TYPE Original Research

PUBLISHED 26 October 2023

DOI 10.3389/fpsyt.2023.1243618

A mixed method examination:

OPEN ACCESS how stigma experienced by
EDITED BY
April Hargreaves,
National College of Ireland, Ireland
autistic adults relates to metrics
REVIEWED BY
So Yoon Kim,
of social identity and social
Duksung Women’s University, Republic
of Korea
Ana Blázquez,
functioning
Hospital Clinic of Barcelona, Spain
*CORRESPONDENCE Alex Marion1 , Karrah Bowman2 , Gina Thomas2 and
Ashley J. Harrison
Ashley.harrison@uga.edu
Ashley J. Harrison2*
1
Medical College of Georgia, Augusta University, Augusta, GA, United States, 2 Department
RECEIVED 21June 2023 of Educational Psychology, University of Georgia, Athens, GA, United States
ACCEPTED 29 September 2023
PUBLISHED 26 October 2023

CITATION
Marion A, Bowman K, Thomas G and
Harrison AJ (2023) A mixed method A recent meta-analysis reveals almost half of autistic individuals experience
examination: how stigma experienced by some form of victimization in their lifetime, including bullying and other forms
autistic adults relates to metrics of social
identity and social functioning.
of stigma. Research among caregivers of autistic individuals demonstrates that
Front. Psychiatry 14:1243618. stigma can have a long-lasting impact on other aspects of a social identity, such
doi: 10.3389/fpsyt.2023.1243618
as self-esteem, but less research has specifically examined this among autistic
COPYRIGHT
adults themselves, in spite of research suggesting these are likely constructs
© 2023 Marion, Bowman, Thomas and
Harrison. This is an open-access article that contribute to the internalization of stigma and subsequent mental health
distributed under the terms of the Creative consequences. The current study used a mixed method approach to assess the
Commons Attribution License (CC BY). The
use, distribution or reproduction in other relation between stigma and several components of social identity and social
forums is permitted, provided the original functioning. More specifically, among 45 autistic young adults, three dimensions
author(s) and the copyright owner(s) are
credited and that the original publication in this
of self-reported stigma (discrimination, disclosure, and positive aspects) were
journal is cited, in accordance with accepted examined in relation to self-esteem, self-efficacy, social satisfaction and adaptive
academic practice. No use, distribution or
social functioning. Quantitative analyses revealed higher reported discriminative
reproduction is permitted which does not
comply with these terms. and disclosure stigma were significantly associated with lower self-efficacy.
Increased experience with all types of stigma were associated with lower social
satisfaction. Greater reported disclosure stigma was also associated with lower
self-esteem. Qualitative interviewing among eight autistic young adults helped
to better understand the nature of stigma and the impact of these experiences.
Thematic analysis of the qualitative data revealed that all of the participants
experienced stigma in the form of exclusion or isolation and that a majority
also experienced verbal bullying. Many of the negative interactions came from
educators, peers, and family members. Most participants indicated that these
stigmatizing interactions directly contributed to decreased social satisfaction,
diminished self-efficacy, and lowered self-esteem. A greater understanding of the
negative consequences of stigma can inform efforts to increase awareness and
acceptance of autism.

KEYWORDS

stigma, autism, social identity, self-esteem, self-efficacy, social satisfaction,

neurodiversity

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1. Introduction 1.2.1. Perpetrators of stigma

A systematic review reported the majority of experienced
1.1. Neurodiversity movement and stigma stigma over the last decade has originated from peers, teachers,
employers/co-workers, and family members (10). Many studies
document that autistic individuals feel misunderstood, rejected,
The autistic community has been at the frontline of
and/or excluded by peers. They also found teachers and employers
the neurodiversity movement, which emphasizes neurological
often make false assumptions about an individual’s abilities and
differences as innate, attributable to the person, and simply
needs. Similarly, a metanalysis focused on experiences of stigma
part of a continuum of human diversity (1). The neurodiversity
in the form of bullying among autistic students and found these
framework has the potential to reduce stigma [social exclusion due
instances occurred most frequently in the inclusive classroom
to differences that are perceived to deviate from societal norms;
setting (8).
(2)], by explaining that the differences between neurotypical and
In addition to the individual level, autistic people report being
neurodiverse individuals are due to biology and outside of one’s
impacted by stigma at a group or societal level. For example,
control (3). This is particularly important to the autism community
media representations of autism are frequently negative, depicting
as these individuals are at heightened risk of experiencing stigma
individuals as dangerous and/or unloved (13). Additionally,
likely because of differences in social functioning and noticeable
one study suggested the news coverage of autism may be
stereotyped behavior, paired with typical physical appearance (4, 5).
unintentionally stigmatizing autistic individuals by including
Thus, autism allies support this movement to help both decrease
stigmatizing cues, such as describing psychiatric symptoms or
the stigmatization of autism and increase the wellbeing of the
social skills deficits which distinguish autistic from allistic children,
autistic individuals through increased community acceptance and
in more than two-thirds of media coverage (14). This same
awareness that the concept of “typical” is driven by societal
narrative extends into autistic adults, in which dehumanizing
standards (1, 5).
language continues to appear (15, 16).
As a result of the neurodiversity movement, more recent
research has focused on the experience of stigma from the
perspective of autistic individuals (6). This research reveals that 1.2.2. Types of experienced stigma
in spite of greater societal acceptance of individual differences Both qualitative and quantitative research provides evidence
through the adoption of neurodiversity framework (7), many that autistic individuals have historically experienced stigma in
autistic adults continue to encounter stigma. Recent meta analyses alignment with most of the primary modalities of stigma defined
revealed that 44 to 67% of autistic adults report experiencing in the literature [i.e., labeling, stereotyping, separation, status
stigma (8, 9). Several contemporary literature reviews reveal that loss, discrimination and misuse of power; (17)]. For example,
autistic individuals continue to experience stigma in many different qualitative interviews documented that autistic individuals
forms and from various sources (5, 10). However, much of the experienced stereotyping, exclusion, and discrimination (18).
research included in these recent literature reviews and meta- A systematic review examining the impact of stigma experienced
analyses include data over a broad period of time, which in many by autistic individuals similarly found evidence for varying types
cases can be over a decade old (5, 8, 10). Thus, more research of experienced stigma, including stereotyping, bullying, and
needs to examine the current perspective of autistic individuals to judgment (10).
better understand the contexts in which stigmatization continues The vast majority of the literature focuses on bullying, which
to occur and the extent of consequences of experienced stigma is discussed by most as “ongoing and deliberate misuse of power
(5, 10). To continue to make gains in stigma reduction, we in relationships through repeated verbal, physical, and/or social
need to better understand the types of stigma autistic adults behavior that intends to cause physical, social, and/or psychological
continue to experience over time and the primary sources. As we harm” (8). This type of stigma can manifest as exclusion (19),
continue working toward shifting societal attitudes, understanding but is often physical in nature (20). The quantitative research is
the widespread impact that stigma has on neurodiverse individuals clear that bullying occurs more readily among autistic individuals
can also help inform approaches to mitigate some of the negative compared to those with other disabilities and compared to
consequences (11). neurotypical peers (19). One study revealed that 36% of autistic
individuals had some lifetime experience of bullying (19) and
another documented that as many as 14% had experienced
cyber bullying (12); however, a more recent metanalysis revealed
1.2. Contextualizing experienced stigma pooled prevalence rates of bullying closer to 67% among autistic
individuals (8). Additional qualitative research emphasized the
The hope is that an adoption of a neurodiversity framework will pervasive nature of experienced stigma among autistic adults
help to reduce stigma experienced by autistic individuals; however, (18). These different types of methodological approaches help
to gauge success with shifting societal attitudes, research needs to to reveal the importance of mixed methods in understanding
focus on frequently assessing the continued scope of experienced more about the types of stigma that continue to occur and
stigma. Further, because research documents that parents might from what perpetrators. A greater understanding of what types
underestimate the extent their children experience stigma (12), it of stigma persist can inform targeted approaches to diminish
is crucial to specifically document the lived experience from the the negative impact of stigma still experienced by so many
perspective of autistic individuals. autistic adults.

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1.3. Consequences of experienced to self-esteem and that self-esteem mediated the relation between
stigma stigma and negative mental health consequences (31). The only
known study to directly quantitatively test the link between stigma
Although the impact of experienced stigma is underrepresented and self-esteem among autistic adults did not find significant
in the literature for autistic adults compared to adults with esteem differences among groups that did and did not experience
bullying but this is a topic that remains under-investigated (32).
other developmental disorders, a growing body of literature has
also begun to document the myriad of negative consequences
1.3.1.2. Social self-efficacy and stigma
among autistic individuals. Growing literature has documented
Although even less well examined in the literature, parents
a relation between stigma and mental health in autism. For
of autistic children report that experiencing stigma led them
example, almost half of adults with Asperger’s syndrome had long
to feel embarrassed and feel less confident in their parenting
term sequelae from prior bullying, such as increased levels of
(33). A later review identified parent confidence as a potential
anxiety (8). Additionally, there is a known relationship between
moderator between experienced stigma and parental mental health
higher levels of experienced bullying and victims’ increased rates
challenges (34). Only one known study specifically links self-
of depression, anxiety, suicidality, and other broad internalizing
efficacy related to socialization and stigma among autistic adults.
symptoms (12, 21). An illuminating recent study examined the time
In this study, a large majority of the autistic sample endorsed
ordered relation between bullying and mental health among autistic
the item, “I can’t contribute anything to society because I have
adolescents and documented that bullying predicted internalizing
autism,” revealing signs of low social self-efficacy among autistic
mental health concerns one year later (22). Less is known about
participants experiencing internalized stigma (35). In spite of
how these stigma experiences convey risk for mental health.
these connections drawn between stigma and self-efficacy, no
known research has directly examined the relation between these
1.3.1. Stigma and social identity consequences constructs among autistic adults using comprehensive assessments.
A systematic review examining the impact of stigma Examining how stigma relates to social identity among autistic
experienced by autistic individuals found evidence for a host adults provides greater evidence for the importance of stigma
of more nuanced negative outcomes including internalization reduction and provides insight into the process of how stigma
of stigma, low self-esteem, negative self-labeling, and concealing internalization likely happens.
their diagnosis (10). These more subtle negative consequences
likely contribute to later negative mental health outcomes. Theory 1.3.2. Stigma and social functioning
suggests that experienced stigma is internalized and converted into Social functioning is a broad concept comprised of multiple
self-stigma, where autistic individuals begin to view themselves factors, including social satisfaction and adaptive social skills.
in a negative light as a result of their negative experiences with Social satisfaction is often assessed by examining constructs such
others (5, 23). Research documents that a meaningful number as loneliness, social adequacy, and peer relations/status (36).
of autistic individuals experience this self-stigma [e.g., (23)]. Examining how personally satisfied an individual is with their
In this process of internalizing stigma, autistic individuals then social interactions helps to understand one’s own perception of
start to view themselves negatively, which results in increased social success (35). Measures of adaptive functioning help to
experiences of shame and fear (5, 10). In alignment with the “Why examine social success from a more objective perspective through
Try? Effect” (24), among autistic individuals, this internalized a comparison of population norms (37, 38). Adaptive behaviors are
stigma is thought to result in negative shifts in social identity (23). real-life skills one performs independently to succeed, and include
These impacted factors of social identity include self-esteem and social adaptive skills or practical behaviors that help an individual
self-efficacy. Self-esteem is defined as how much someone likes socialize in society [e.g., understanding social nuances; (37, 38)].
themself and is related to self-respect, worthiness, and adequacy Socialization was found to be the most impaired adaptive domain
(24, 25). Self-efficacy is how capable one believes themself to be among autistic participants (39).
of successfully accomplishing tasks, and social self-efficacy refers
specifically to the completion of social tasks or interactions (26). 1.3.2.1. Social satisfaction and stigma
In support of this theory, a broader review revealed that In relation to stigma, most studies measure subconstructs of
internalized or self-stigma related to self-esteem and self-efficacy social satisfaction, such as loneliness or feelings of isolation [i.e.,
(27). Although not explicitly studied among autistic adults, self- (36)]. Related to this, autistic participants in a qualitative study
esteem is documented as a mechanism by which stigma contributes reported being outcasted by society due to their differences (18).
to negative mental health outcomes among reviews examining the Participants in this study also revealed that the internalization
implications of experienced stigma among families of individuals of this experienced stigma resulted in social isolation as a
with developmental delays and autism (28–30). Other aspects result of pressure to conform and subsequent avoidance of
of one’s identity, such as self-efficacy, have not been similarly social situations to prevent judgment from others. An additional
examined but are also a likely additional mechanism. study demonstrated that experienced discrimination by autistic
individuals resulted in an expectation of later rejection that
1.3.1.1. Self-esteem and stigma likely renders an individual to feel more uncomfortable in social
Although not directly testing the relation between stigma and situations (40). All of these negative social experiences revealed
self-esteem, a systematic review revealed a relation between self- through qualitative inquiry align with measurement items designed
esteem and social support and loneliness, two experiences related to quantify loneliness/social dissatisfaction (36).
to stigma (5). Relatedly in qualitative research, caregivers of autistic One quantitative study examined the experiences of loneliness
children report that experienced affiliative stigma is directly related and bullying among autistic college students and found that many

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experienced bullying and reported limited social satisfaction [e.g., (4) a better understanding of the specific ways in which stigma
feelings of isolation, feeling left out and limited companionship; relates to social consequences from the perspective of
(19)]. Of note, this study did not examine a relation between these autistic adults.
two constructs and both were measured with a limited number of
items. Although these identified feelings of loneliness and isolation
that arise as a result of stigmatization are likely to lead to low social
satisfaction, this relation has not been specifically examined.
2. Materials and methods
1.3.2.2. Adaptive social functioning and stigma
Autistic individuals’ social adaptive functioning has served 2.1. Procedure
as a predictor of stigma in past research (33) and emerged as
a meaningful predictor of bullying in a metanalysis (8). Yet, This study used a mixed-method complimentary design
impaired social adaptive functioning might also be an outcome of involving an initial quantitative component with a qualitative
experienced stigma. Autistic individuals are already at an increased follow-up (45). A sequential sampling design allowed the
risk for developing a co-occurring disorder, such as anxiety (41). researchers to gain a general understanding of the topic before
Added social stress (e.g., bullying, stigma) can exacerbate or following-up with a deeper exploration of the participants’
elicit internalizing problems for autistic individuals. Internalizing experiences (46). This study was approved by the university’s
problems, such as social anxiety and social withdrawal, have been Institutional Review Board Committee. Autistic individuals were
reported as outcomes in bully victims but also might lead to recruited for the study through various listservs (e.g., university
increased social challenges (42). A link between social anxiety disability resource centers nationwide, state Autism organizations,
and social self-esteem also suggests that higher levels of social etc.) and other online advertisements. Fliers were handed out at
fear, avoidance, and physiological reaction are associated with autism-related events (e.g., conferences, walks, social skills groups),
negative attitudes regarding themselves in social situations (43). posted on campus buildings, and distributed to therapist offices
Given these associations, this study aims to further examine the in the local area.
relationship between stigma and adaptive social functioning in
autistic young adults.
2.2. Participants
1.4. Current study
The quantitative study included 45 autistic adults (23 males,
21 females, 1 gender not reported) from the United States. Initial
Despite the progress made in increasing acceptance through
screener questions required the participants to self-report if they
the neurodiversity movement, autistic individuals still experience
had both a confirmed diagnosis of autism and were 18 years
stigma; however, the extent of these experiences in more recent
or older. The individuals’ ages ranged from 18 to 58 years old
years are not fully documented as many of the published reviews
(M = 25.12, SD = 9.50). Twenty-nine adults were enrolled in
and meta-analyses reflect experiences over a wider or dated time
postsecondary education and 22 held jobs at the time of survey
period. As such, using a mixed method approach, the current
completion. Thirty-three percent of participants lived at home with
study documented a more recent perspective of the stigmatizing
family members, 33.3% lived independently, and 26.7% lived on
experiences experienced by autistic adults, including the types of
campus in university housing. Race and ethnicity was inadvertently
stigma this population continues to endure and from what sources.
This study also aimed to extend the research by examining in-depth not collected as part of the quantitative data collection.
potential social consequences of experienced stigma. After collecting the battery of self-report surveys, participants
The quantitative component of this study measured the were offered the opportunity to participate in an interview.
following: Eight individuals participated in the qualitative follow-up study.
Sampling stopped after thematic saturation was reached across
interviews (47). Participants were between the ages of 19 and 40
(1) how several aspects of perceived/experienced stigma
(discrimination, disclosure, and positive aspects of stigma) (M = 25.13, SD = 8.06), primarily White (75%), and Non-Hispanic
relate to social self-efficacy and self-esteem and or Latino (88%). All participants had some college completed, with
(2) how experienced stigma correlated with measures of social most individuals currently completing an undergraduate degree
functioning, including self-reported adaptive social skills and during the time of the interviews.
social satisfaction.

Qualitative interviews were also conducted with autistic adults, 2.3. Data collection
to add more depth to the understanding of the extent and context of
experienced stigma, as well as the perception of how stigma relates 2.3.1. Quantitative questionnaires
to social identity. Qualitative data allowed for: Participants completed five rating scales in addition to some
demographic questions regarding their academic standing (e.g.,
(3) documentation of types of stigma experiences that autistic graduation year, major) and living situation. Participants were
adults continue to experience and the reported sources of this given the option to complete the questionnaires in person or online.
stigma (44), and The rating scales took approximately 15 to 30 minutes to complete.

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2.3.1.1. Stigma Scale The measure uses a 5-point Likert scale (1 = never to 5 = always),
The Stigma Scale (48) is a 28-item measure that assesses with a higher score indicating less social satisfaction.
perceived and experienced stigma in individuals with mental health
disorders. In this study, the phrase “mental health problems” was 2.3.1.5. ABAS-II
replaced with “autism spectrum disorder” wherever it appeared A widely used adaptive functioning measure, the Adaptive
in the measure. Autistic participants rated their perceived or Behavior Assessment System (ABAS), assesses three constructs
experienced stigma on a 5-point Likert scale (0 = strongly disagree of adaptive behaviors: conceptual, social, and practical (58). The
to 4 = strongly agree) in the following sub-scales: discrimination Social Domain of the Adaptive Behavior Assessment, Second
(12 items; Cronbach’s α = 0.87), disclosure (11 items; Cronbach’s Edition consists of 23 items and was used to measure participants’
α = 0.75), and positive aspects (5 items; Cronbach’s α = 0.79). The perceptions of social skills that help them function in daily living
discrimination subscale assessed more overt types of experienced (59). The instructions specify that participants rate how often they
stigma, such as experienced hostility from others or losing perform the various social behaviors independently on a four-point
opportunities due to others’ biases. The disclosure subscale assessed scale (0 = not able to 3 = always). A social composite score was
negative experiences with disclosing an autism diagnosis or fear calculated and higher scores on the composite reflect more adaptive
surrounding this process. The positive aspects examined any behavior skills based on participants’ self perception. Prior studies
positive experiences as a result of having an autism diagnosis. have demonstrated high internal consistency for the Social domain
For all subscales, higher numbers were associated with greater (60). Similarly, high internal consistency for the Social domain
experienced stigma. This scale has high reported psychometric was reported in the current study (Cronbach’s α = 0.96). In this
support (internal consistency α = 0.87) (48). In the current sample, participant standard scores fell in the Extremely low range
study the internal consistency was similarly solid for the total (0.4th percentile) indicating this sample had notable challenges
stigma score (Cronbach’s α = 0.85), as well as for the individual with adaptive functioning compared to same aged peers.
subscales (see above).
2.3.2. Qualitative interview
2.3.1.2. Adapted rosenberg self-esteem scale Participants’ met one-on-one with a researcher to complete
The Adapted Rosenberg Self-Esteem Scale (49) is a six item a semi-structured interview that lasted between 45 minutes and
measure that assesses an individual’s self-esteem and overall feelings 1 hour. An interview guide was created to establish consistency
of self-worth (25) using a 5-point Likert scale (1 = never true to across interviews and to facilitate discussion with the participant.
5 = always true). A higher score on this measure indicates greater The guide included questions and prompts that related to
self-esteem and feelings of self-worth. The adapted version of the experienced stigma and factors impacted by the stigma experienced
scale was used due to its simplified wording and past use in the (i.e., self-esteem, self-efficacy, and social satisfaction). Examples of
mental health context (49). This is one of the most widely used questions asked include, “Can you tell me a time when you were
measures of self-esteem (50), with a excellent demonstration of treated unfairly?” and “When have the actions or words of others
psychometric support [i.e., (51, 52)]. In the current study, good made you feel as if you can/can’t interact well with people?”
internal consistency was reported (Cronbach’s α = 0.82). Questions were derived from different published measurement
approaches from both the qualitative and quantitative literature.
2.3.1.3. Social self-efficacy subscale Specifically, the interview included questions assessing experiences
The Social Self-Efficacy Subscale consists of six items derived and feelings about receiving a diagnosis aligned with qualitative
from the Self-Efficacy Scale identified as a unique factor (53). research examining similar questions (61, 62). Broader stigma
This subscale is a self-report measure of one’s social competence questions were derived from the Discrimination and Stigma Scale
and the perception of success with completing tasks (54). The [DISC; (63)], as well as The Stigma Scale (48). The inquiry about
measure uses a 5-point Likert scale (1 = strongly disagree to social satisfaction aligned with a qualitative interview assessing
5 = strongly agree) with higher scores indicating greater self- social experiences among autistic adults (56). Social identity theory
efficacy. Previous studies demonstrate strong psychometric support was the framework to guide the second part of the qualitative
for this measure (53). The internal consistency calculated for this interview. More specifically, the interview focused on two aspects
sample (Cronbach’s α = 0.65), although considered in the low range of social identity theoretically impacted by the internalization
by some, is considered in the acceptable range according to multiple of stigma: self-esteem and self-efficacy (23). Interview questions
psychometric experts for a psychological measure used in research assessing self-esteem were derived from both a qualitative interview
[see (55) for a review]. (61) and from the Rosenberg Self-Esteem Scale (49) and the self-
efficacy conversation was guided by items on the Self-efficacy
2.3.1.4. Social satisfaction measure Scale (53).
The social satisfaction measure is a compilation of the social This study was conducted by researchers who identify as non-
distress and companionship sections of the NIH Toolbox Social autistic. As neurotypical researchers, we acknowledge our privilege
Relationships subdomain that assesses how fulfilling individuals in society and recognize the contrast between our experiences and
find their relationships (56). Previous studies have established solid the participants’ experiences. Throughout the research process,
psychometric support for the measure (57). The measure consists we reflected on how our status in society could influence the
of 22 items that factors onto four scales presented in the following development of interview questions, connection with participants,
order: friendship (5 items; Cronbach’s α = 0.86), loneliness (7 items; and interpretation of responses. Alignment with the neurodiversity
Cronbach’s α = 0.95), perceived rejection (5 items; Cronbach’s mindset and a thorough knowledge of the autism stigma literature
α = 0.91), and perceived hostility (5 items; Cronbach’s α = 0.91). was used as a guiding tool throughout this study.

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2.3.3. Analysis plan [e.g., (18)]; thus, a blended approach allowed for both existing
All statistical analyses were conducted using SPSS software and developing codes to emerge. The authors transcribed verbatim
version 26. The statistical significance for the analyses were set audio recordings of the interviews, then coded responses by
at p = 0.05. Using two-tailed bivariate correlational analyses, we identifying and labeling recurring concepts (65) via NVIVO
examined how three types of stigma were related to a range 10. A codebook was developed to categorize concepts derived
of social variables. More specifically, the three types of stigma from participants’ responses into meaningful themes. The original
(disclosure stigma, discriminative stigma, and positive aspects of version of the codebook aligned with the overarching structure of
autism) were included in all of the correlational analyses. We the interview. For example, this included sections aligning with
first examined how stigma was related to several components general inquiry about stigma (i.e., types and sources) and then
of social identity, including self-efficacy and self-esteem. Next, sections about each of the two social identity and social functioning
we examined the relation between stigma and social outcomes, domains. Code operational definitions were added and refined
including the four subdomains of social satisfaction (i.e., friendship, following consensus coding by two team members of several initial
loneliness, rejection, and hostility) and the ABAS social adaptive interviews. Additional codes were added throughout the coding
functioning subdomain. process as relevant and the data was considered saturated after
no novel themes emerged from the coded interviews. Questions
about coding were reconciled through consensus conversations
3. Results among team members.

3.1. Quantitative
3.3. Thematic analysis results
3.1.1. Preliminary analyses
Both the stigma measure and all measures of social functioning Four themes emerged from the data examined (1) type of
demonstrated a normal distribution. For the quantitative measures, experienced stigma, (2) source of stigma, (3) perceived reason for
means and standard deviations for the current sample are reported stigma, and (4) impact of stigma on multiple domains of social
in Table 1. This table also includes published means to allow for functioning. The terms ‘some,’ ‘most,’ and ‘all’ were used to quantify
contextualization of the current data within the broader literature. the number of participants who shared similar experiences. ‘Some’
is defined as less than or equal to half of the participants; ‘most’
3.1.2. Correlation analyses is defined as more than half of the participants (i.e., 5 to 7); and
Table 2 presents the correlations between the stigma types ‘all’ is defined as all eight participants. Pseudonyms and non-binary
and all social identity variables. For the social identity variables, pronouns (they/them/their) are used to personalize the responses
analyses revealed individuals with lower reported self-efficacy had and to maintain confidentiality.
significantly higher reported discriminative and disclosure stigma
(all p’s < or equal to 0.05). However, expressions of positive aspects 3.3.1. Type of stigma
of stigma were not significantly related to higher self-efficacy All participants expressed experiencing some type of stigma.
(p = 0.19). Additionally, lower self-esteem was correlated with Definitions of stigma from the literature highlight that stigma
greater reported disclosure stigma (p < 0.5) and positive aspects is experienced in six primary modalities including, labeling,
of stigma (p < 0.5), but it was not significantly associated with stereotyping, separation, status loss, discrimination and misuse
discriminative stigma (p = 0.37). of power (17). Autistic adults in the current sample provided
Regarding variables assessing social functioning, all four social examples of experienced stigma across most of these modalities (see
satisfaction subdomain scores were significantly associated with Table 3).
higher discriminative stigma (all p’s < 0.01). Similarly, higher
disclosure stigma was significantly associated with lower social 3.3.1.1. Stereotyping
satisfaction in the subdomains of loneliness, rejection, and hostility Some participants shared experiences of others relying on
(all p’s < 0.05), but not friendship (p = 0.32). Positive aspects of stereotypes to make general assumptions about autism. For
stigma were significantly associated with the loneliness subdomain example, Kari explained a time they experienced stigma while
(p = 0.04), but not friendship, rejection, or hostility (all p’s > 0.05). having dinner with their ex-partner’s family: “Umm his stepsister
Lower adaptive social functioning was associated with positive was talking about her ex-boyfriend or something and she was
aspects (p = 0.01), such that people with lower adaptive social like. . . ‘He had Asperger’s like, that’s why he was kind of weird,’ and
functioning scores reported less positive experiences with their then his siblings started joking about it.” Beatriz also explained how
autism diagnosis. others minimized their autism because it did not align with other
autistic exemplars they held (see Table 3).

3.2. Qualitative 3.3.1.2. Separation

When asked to describe a time participants were
The authors used a phenomenological approach in alignment treated unfairly, all indicated experiences of separation or
with the social identity theory to understand the participants’ exclusion from the neurotypical society because of their
lived experiences of personal stigma and explore how stigma behavior and/or autism diagnosis. Some individuals reported
related to their social identity (64). Past studies have examined being made to feel as though they did not fit in with the
the impact of stigma on autistic adults’ identity and wellbeing neurotypical society. For example, Diya shared a time when

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TABLE 1 Descriptive statistics of all quantitative measures.

Variables Minimum Maximum Mean (SD) Other published means

(References)
Stigma
Discrimination 2 44 22.02 (10.27) 29.1 (48)

Disclosure 3 41 20.67 (8.23) 24.7 (48)

Positive Aspects 0 18 6.96 (4.65) 8.8 (48)

Stigma Total 16 95 49.64 (17.00) 62.6 (48)

Social satisfaction
Friendship 5 25 14.67 (5.37) 26.53 (57)

Loneliness 7 35 19.93 (7.88) 12.02 (57)

Rejection 5 25 11.02 (4.52) 16.93 (57)

Hostility 5 25 11.69 (4.81) 16.87 (57)

Self-esteem 11 30 21.80 (4.83) 23.44 (49)

Social adaptive functioning 0 13 4.97 (3.08) 9.9 (75)

Social self-efficacy 6 26 16.98 (4.36) 21.20 (75)

their classmates were talking about how one of their parents that.” Other examples shared by participants regard instances of
work with people on the autism spectrum, explaining how verbal bullying, such as name calling and using “autistic” in a
“they were really talking about them as (if they were) other colloquial manner to refer to something defective (see Table 3).
people.”
3.3.2. Source of stigma
3.3.1.3. Discrimination Overall, participants experienced stigma from nine different
Some participants reported experiences of discrimination. Diya sources, including family members, peers, significant others,
shared about an instance “at a camp that was meant for autistic healthcare professionals, educators, employers, camp counselors,
people” when they felt discriminated against by camp staff: “They acquaintances, and strangers.
isolated me in the nurse’s office and told me that I was using my
disability as an excuse and I was trying to just get attention by 3.3.2.1. Educators
hurting myself and it honestly made me feel worse.” This form Most participants experienced stigma from educators and this
of stigma made Diya feel as if they was not seen as a person, was the most prevalent source among all reported. The type of
and that they “were just looking at (them) because of (their). stigma experienced by educators ranged from singling students
disability.” out because of their autism diagnosis or observed symptoms, to
minimizing the need for legally assigned accommodations. For
3.3.1.4. Misuse of power example, Ali shared an instance in which an educator infringed
Gabriel shared a more intense situation in which a teacher upon the use of extra time:
from their daughter’s school got overly involved in the child’s
care because the teacher did not believe Gabriel and their partner “Um and then there was one time sophomore year where I had
could “protect” their daughter because they were autistic, or like an accommodation to be able to stand in the back of the
“disabled” as described by the teacher. Other examples discussed room if I just needed to like fidget or whatever and this one
in more detail below involve the refusal to provide legitimate teacher called me out and in front of the class and he was in
educational accommodations. a pissy mood that day and just made me sit. . . it was just like I
don’t know kind of made me insecure (and) I know what works
3.3.1.5. Overt bullying and abuse for myself why won’t you let me. I clearly like wasn’t distracting
In addition to these types of less overt aggressions, most anyone.”
participants in this sample also experienced more overt types
of bullying and abuse, including both physical and verbal Although many of the participants described experiencing
bullying/verbal abuse. Eric explained how their “hyper fixations” stigma in high school and in their earlier developmental years,
imposed on their conversations with others. They knew others most of the participants reported still experiencing stigma in
would make “sly comments” about this which resulted in them postsecondary settings as well. Hanna’s experienced stigma from
wanting to “shut up and not talk to people and kinda be by myself.” their research supervisor highlighted the lack of knowledge about
One participant experienced stigma in a physical manner. Ali autism even in higher education: “He still has a lot of like stigma
explained: “I’d get beat up because people didn’t- I mean- people that are not promotive to our relationship, such as um he doesn’t
hated me there in middle school and I think a lot of that just comes understand how much variability there is among all the autistic
down to the fact that I was different, and they didn’t understand people.”

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Marion et al. 10.3389/fpsyt.2023.1243618

TABLE 2 Correlations between stigma and all social variables. and someone used the term “autistic” colloquially to indicate
something negative.
Variable N 1 2 3
Stigma “Like a month ago, um I’m in this group chat for dungeons and
1. Discrimination 45 – dragons and I only know like one person there and he invited
2. Disclosure 45 0.44 – me in, but you know I guess it’s like the internet thing to say oh
3. Positive aspects 45 0.14 0.23 –
no it’s autistic. And I’m like, ‘dude that’s—that’s not cool I have
autism.”’
Social satisfaction
5. Friendship 45 0.50** 0.15 −0.02

6. Loneliness 45 0.52** 0.30* 0.30* 3.3.3. Consequences of stigma

3.3.3.1. Impact of stigma on self-esteem
7. Rejection 45 0.56** 0.40** 0.20
All participants declared their social self-esteem was negatively
8. Hostility 45 0.59** 0.33* 0.21
impacted by experiences of stigma. Stereotypes about autism not
10. Self-esteem 45 −0.14 −0.33* −0.44** only alter others’ understanding about autism, but it seemed that
11. Social adaptive 44 −0.11 −0.27 −0.40** stereotypes also affected participants’ perceptions of themselves.
functioning Diya explained how a camp counselor’s negative views of their
12. Self-efficacy 45 −0.43** −0.37* −0.20 abilities to be independent impacted their self-esteem in the long-
term, as they were questioning their ability to move away for
*p < 0.05 level (2-tailed). **p < 0.01 level (2-tailed).
college:

3.3.2.2. Peers “I just couldn’t do anything I guess um like I was- like the
Most participants also experienced stigma from the peers at stereotypes of like autistic people were kind of playing through
school. Stigma mainly came from acquaintances or classmates, my head like I’m never going to be able to leave my parents I’m
including accounts of demeaning comments or physical bullying. always gonna be stuck here um I can’t do college because it will
One participant described experiencing stigma from a significant
be too overwhelming, and even though I knew all of those were
other after disclosing their autism diagnosis. Kari explained, “When
lies like I was just really depressed and overwhelmed.”
I, you know, disclosed to him about it, you know, right after
we’d started dating, he like thought that I was joking.” Kari
Kari’s social self-esteem was also impacted by experienced
further explained that their significant other would say things that
stigma. They explained how their significant other’s negative
implied that they couldn’t care for themselves because of their
perceptions of their abilities made them “feel like (they were) like
autism diagnosis.
less than a person.”
3.3.2.3. Family members
3.3.3.2. Impact of stigma on social self-efficacy
Family dynamics varied across participants. Unfortunately,
Participants reported variable self-efficacy in a range of
most participants described negative relationships with different
situations requiring socialization, such as in the classroom, at a
family members, while some even explained experiencing stigma
job, or in relationships. Most participants reported that experienced
from their family. Eric shared that their parents would refer to
stigma had a negative impact on their self-efficacy in social
their diagnosis in a “derogatory tone:” “They’ll say something like,
situations. Ali explained how they tended to second guess or
‘you know well I guess it’s your duh, duh, duh diagnosis acting up
analyzed social situations after they occured. For example, when
today.”
they “say something other people will laugh at and then a little bit
later I’ll start thinking about how they’re probably laughing at me
3.3.2.4. Community members
and not with me.”
There were also accounts made by some participants of
experienced stigma in the form of discrimination and misuse of 3.3.3.3. Impact of stigma on social satisfaction
power by community members, such as healthcare providers and In general, most of the participants reported a mix of both
employers. Gabriel explained how they were laid off from a job social satisfaction and dissatisfaction depending on interactions
because of their request for accommodations: with others. Social dissatisfaction was related to experienced stigma
for most participants. For Kari, this decrease in social satisfaction
“The same employers that laid me off um for being disabled. was the result of discrimination and isolation from their team
They said it was because I had requested accommodations for members:
being disabled. They didn’t say it was for being disabled, they
said it was for requesting accommodations and I shouldn’t have “I mean, people can tell that I don’t act normal and I think
requested accommodations. And um yeah that made me feel that I’m a pretty easy target. So people just in general weren’t
kind of ashamed.” super nice to me or like very encouraging. . . I mean it kind of
just drove like a further wedge between me and all these other
Additionally, some participants experienced stigma from
people like, even though I was on the team, I never really felt
acquaintances and strangers. Eric was a victim of stigma
like I was a part of the team”
when playing Dungeons and Dragons, an online video game

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 TABLE 3 Examples of participants’ experienced stigma.
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Marion et al.
Theme Example
Type of stigma
Stereotyping “And so there have been. . .plenty of people who I tell them my diagnosis and I get a ‘oh I would’ve never known’ or ‘you’re nothing like my cousin’s sister’s brother’s ex’s kid.’ And I’m like ‘cool it’s because
I’m not your cousin’s sister’s brother’s ex’s kid’. . . a lot of times it makes me feel like. . .I don’t actually have autism but just that I’m not worthy of being part of like that community.” (Beatriz)

Separation “As far as responding to my diagnosis I mean I never tell anyone about my diagnosis except for like this because I know they will not respond well no one has ever responded well.” (76)
“I don’t want to be like because I’m a student with accommodations or anything, but I was just like she’s just making me feel kind of weird and it’s like you’re not treating other students like this.” (Kari)

Discrimination “Parents got involved. Mom says she’s a nurse says, ‘Oh he’s gonna have a meltdown and you better not have that you know if y’all get married and then you have a child then you gonna take care of the child
all your life because of the autism offspring.’ Dad says, ‘Oh you can’t have a uh you can’t be around him because he might not be able to have a job.”’ (Fatima)
“I wasn’t allowed to talk about my disability at work which is kinda crazy because a lot of my students had disabilities themselves.” (Gabriel)

Misuse of power “Um I was laid off in (county) for being disabled as well because I needed accommodations for my visual processing disorder and so when they needed to lay off half their staff, they can’t fire you for being
disabled but when they have to lay off half their staff, then they can get away with it.” (Gabriel)

Overt bullying and abuse “One time we were like sitting in his truck and he was like, ‘I’m sorry, but this truck is like actually autistic,’ because his truck was acting up.” (Kari)
“Oh yeah, (laugh) I mean like I was picked on a lot in middle school so like then. Um my sister liked to call me freak for a while.” (Beatriz)

Source of stigma
Educators “I was. . . working on a problem on the board and it was taking me a while and (teacher) actually called me a ‘retard’ in front of the whole class for it.” (Ali)

Peers “In high school. . .I was bullied a lot. ‘You’re different, you need to stop thinking about your future.’ This that and the other because I said during my high school years I wanted to go for a Ph.D. and people
looked at me like you’re nuts. I know that was just my social peers.” (Fatima)

Family members “(My sisters) would belittle me about it a few times. Like whenever I was doing something- whenever I’d say something, they didn’t agree with they’d just say, ‘Oh he’s insane.’ And they would just totally
09

discredit me because of (my diagnosis) and that made me feel ashamed that I had something that people could just do that with.” (Ali)
“My family. . . tried to convince me that. . . ‘you can’t be a medical doctor because your motor skills are bad.’ Well, you know I always said. . .’let me prove you wrong’ and I wasn’t told until after I graduated
with my uh bachelor’s is that my parents both told me at graduation that ‘we thought you were gonna flunk out the first semester and you gonna be moving back home.”’ (Fatima)

Community members “There’s a really nice lady in my choir, she would tell me things like- but you have Asperger’s not autism so you’re safe.” (Hanna)
“Yeah when (ADA Coordinator) told me that I took her literally and I took her out of context and walked out on me, I feel very ashamed (of my diagnosis).” (Hanna)

Consequences of stigma
Self-esteem “I pretty systematically get rejected whenever I ask someone out and I don’t know how much of that is autism and how much of that is other things. But yeah. That always makes me lose confidence in
myself.” (Ali)
“It also made me feel really sad because I mean. . . It really hurt my self-confidence because I mean you’re supposed to you know try to earn the respect of your teachers through your work, and they feel like
I was just totally unable to do that.” (Ali)

Social self-efficacy “I realize that when other people respond to my autism diagnosis the wrong way, I usually spend a lot of time and effort in educating them ‘laugh’ Um, I don’t think I stopped anything, I think I become
more committed to making them understand that they can’t say those things.” (Hanna)
“She (social skills tutor) you know did kind of like have a conversation with me and was like look like you do want to be careful with like who you share your diagnosis with in college um because people like

10.3389/fpsyt.2023.1243618
do have biases and they do have stereotypes and you know you’re going into a competitive field and you don’t want that to be the first thing that people know about you. You want them to like make their
own um opinions about you. So, I’ve definitely like been more hesitant to like share my diagnosis and I don’t think that’s something where I’ve been like ashamed of it I’ve just like I’m aware of the realities
of the world and like not everyone like knows you know what autism is or what it means.” (Beatriz)

Social satisfaction “I often feel left out and alone being a grad student with autism.” (Hanna)
frontiersin.org

“I mean, people can tell that I don’t act normal and I think that I’m a pretty easy target. So people just in general weren’t super nice to me or like very encouraging. . . I mean it kind of just drove like a further
wedge between me and all these other people like, even though I was on the team, I never really felt like I was a part of the team” (Kari)

Adaptive socialization “. . .the student alliance meeting. Um I only went to one of them at the beginning of the semester because it was kind of a social thing and I got uncomfortable with it, and I’ve been like too nervous to put
myself back in that situation and go back there.” (18002)
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3.3.3.4. Impact of stigma on adaptive socialization This study also documented a link between experienced stigma
Many individuals indicated that lower adaptive social skills or and metrics of social functioning, such as social satisfaction
autism symptoms contributed to an increase in stigmatization. For and adaptive social skills. Although all of the research questions
example, Fatima shared: “I’m just like not sure how to keep up examining the true impact of stigma would benefit from
with the conversation and butt in the conversation to make myself longitudinal studies, the social success variables are most difficult
relevant and sometimes I end up feeling left out a lot.” Additionally, to interpret with a cross-sectional, correlational design because it is
some participants also reported that their other characteristics of likely that there is a cyclic pattern. Previous research has shown that
autism or autism diagnosis were reasons why they experienced social success is likely both a predictor of experienced stigma and an
stigma. For example, Ali explained how they’re “kinda like off outcome [i.e., (4, 18, 21, 33)]. Qualitative data from this study reveal
in (their) own world sometimes” and can “sometimes. . .come a similar pattern in that participants report that the different social
across weirdly.” Also, Fatima’s parents discouraged them from abilities they possess contributed to greater experiences of stigma
becoming a “medical doctor because (their) motor skills are and that increased stigma led to less overall social satisfaction.
bad.” This confirms the importance on conducting more longitudinal
research in this area to better understand how stigma impacts
quality of life.
The positive aspects subscale of the stigma measure did not
4. Discussion
align with the discrimination and disclosure subscales in terms
of a relation with self-esteem and self-efficacy. As a reminder, on
This study provides a mixed method examination from the
this subscale a higher score indicated that an individual had less
perspective of autistic adults on experienced stigma and how
positive experiences attributable to their autism diagnosis, which
it relates to a range of social outcomes. Results from this study
is an important, but much different, aspect of stigma compared to
replicate previous research demonstrating that autistic individuals
the others measuring more overtly negative experiences. Although
experience high rates of stigma (5, 10). Qualitative data helped
we still anticipated that this metric would significantly relate
to reveal that these individuals experienced a myriad of different
to the social identity indices, it is likely that other participant
types of stigma that come from a wide range of sources. This
characteristics not assessed in this study impacted this relation.
information documents that in spite of the significant strides made
For example, research shows that autistic adults that align with a
by the neurodiversity movement toward reducing stigma (3), most
neurodiversity movement mindset (3, 66) and those with a stronger
autistic adults in this sample report still experiencing stigmatizing
affiliation to their autistic identity (67) have a more positive
interactions in recent years in employment, postsecondary
self-esteem and a positive social identity. Future research would
education, and from peers. This study highlights the need for
benefit from including other protective and predictive factors in
more specific trainings in workplace and educational settings
the model to determine among what groups and in what context
to increase awareness of the different types of implicit and
stigma most likely leads to internalization and subsequent mental
explicit stigma people often engage in and continue to grow
health concerns.
alignment with a neurodiversity mindset to shift the culture toward
more acceptance.
With regard to the negative consequences of stigma, the
current study also expands the literature [e.g., (5, 35)] by 4.1. Limitations and future directions
specifically examining the relation between experienced stigma and
components of the social identity theory thought to contribute There were several limitations of this study that are
to an internalization of stigma: self-efficacy and self-esteem. important to note. One key limitation is that primarily autistic
Quantitative results revealed individuals reporting higher amounts individuals with higher cognitive abilities participated, such as
of experienced stigma had significantly lower self-efficacy and self- those attending college or maintaining full-time employment.
esteem. Delving into these associations in more detail, interviewees This limits the ability to generalize findings to the entire
revealed that the misconceptions held by others about autism autism population, including those with lower intellectual
often resulted in them feeling more negative about themselves functioning and proliferates the issue that autistic individuals
or “less than a person.” Stigmatizing experiences resulted in with higher support needs are underrepresented in the
low expressed self-efficacy in social situations and employment autism literature (68). Because individuals with intellectual
seeking. While not explicitly examined in this study, these disabilities also face stigma in society (69), future research
findings help to elucidate how experienced stigma transitions should also recruit participants with autism and co-occurring
to self-stigma and ultimately, mental health concerns among intellectual disability to understand if they have unique
autistic individuals (5, 10, 23, 24, 28–30). Because systemic stigma experiences.
acceptance continues to spread at a pace that might be insufficient As participants were recruited through various methods to
to help autistic adults that might have already endured a complete an online survey about autism and experienced stigma,
great deal of stigma, understanding more about the potential selection bias could have influenced results (70). Perhaps only
mechanism between experienced stigma and later mental health those who felt as if they experienced stigma participated in the
consequences helps to understand that more resources should focus study, leaving out others with different experiences. The nature
at present on helping to bolster self-esteem and self-efficacy among of phenomenological research also limits the generalizability of
neurodiverse populations. findings (71). Although the qualitative interviews served as a

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Marion et al. 10.3389/fpsyt.2023.1243618

follow-up to better understand and apply deeper meaning to the of the consequences and how we might help to ameliorate
quantitative results (45), participants’ lived experiences are unique these is essential.
to the individual and cannot appropriately explain all autistic
adults’ experiences.
Another limitation to the study is the lack of racial and ethnic
diversity in the qualitative sample and a failure to document
Data availability statement
the demographic composition of the quantitative sample, which
The raw data supporting the conclusions of this article will be
prohibited researchers from controlling for demographic factors
made available by the authors, without undue reservation.
in the analyses. The fact that mainly white, non-Hispanic
autistic individuals participated in the qualitative interviews
limits the understanding of intersectionality of identities. For
example, Black autistic individuals experience racial discrimination Ethics statement
from society, in addition to ableism from their community
[see (72) for a review]. As the majority of the research has The studies involving humans were approved by the
focused on the relation between cultural and affiliate stigma University of Georgia Institutional Review Board. The studies were
[e.g., (29)], future research should specifically explore stigma conducted in accordance with the local legislation and institutional
among autistic adults with a more diverse intersection of requirements. The participants provided their written informed
identities to better understand if different groups have unique consent to participate in this study.
stigma experiences.
Finally, there were limitations in the sample size and reliability
analysis. Specifically, the small sample size of the quantitative
study limited the ability to perform more complex quantitative Author contributions
analyses. Future research should employ methods that allow for
an examination of social identity variables as mediators between AM and AH contributed to the conception and design of
stigma and reported symptoms of psychopathology and those the study. AH supervised AM during the development of the
that examine more cyclical patterns in how social ability might codebook and interview protocol. AM collected with majority of
serve as a potential predictor and outcome of stigma. Most the quantitative and qualitative data, with help from KB, GT, and
importantly longitudinal research is needed to really examine AH. KB, GT, and AH analyzed the quantitative data. KB and
whether the experienced stigma over time is a causal factor AH identified themes in the qualitative data. All authors wrote
in contributing to lower social identity and social success. sections of the manuscript, contributed to manuscript revisions,
Furthermore, the lower Cronbach’s alpha that was calculated on and approved the submitted version.
the Social Self-Efficacy subscale limits our confidence that the
subscale accurately measures social self-efficacy; however, a 0.6
alpha is considered moderately acceptable or satisfactory in some Acknowledgments
literature for the use of psychology measurement in research [see
(55) for a review]. Margaret Dore, Elisabeth Sweeny, and all of the participants
who graciously share their stories and experiences.

5. Conclusion
Author disclosure
The pervasive and prolonged nature of stigma experienced
by autistic individuals indicates that efforts to impart change
There is clear indication that autistic adults prefer identify-first
continue to be insufficient. As rates of autism continue to rise
language [e.g., (74)]. Despite the disagreement among professionals
and more supports are put into place, more autistic adults
about the use of identify-first versus person-first language, we opted
are predicted to enter post-secondary education or professional
to use identify-first language (i.e., autistic individuals) to align with
settings (73) thus, we need approaches to reduce stigma in
autistic adults’ preference as the participants in this study. The use
childhood and adult context. By examining how stigma relates
of this language is consistent with APA guidance https://apastyle.
both social outcomes and core features of one’s social identity
apa.org/style-grammar-guidelines/bias-free-language/disability#:
we can continue to alert the public to the importance of
$\sim$:text=Avoid%20language%20that%20uses%20pictorial,
engaging in stigma reduction efforts in educational institutions
AIDS%E2%80%9D%20or%20%E2%80%9Cperson%20with%20a.
or workplaces and to develop and implement more appropriate
support structures for autistic students or employees to mitigate
these negative experiences. This research helps to underscore
the importance of continued efforts to help improve societal Conflict of interest
attitudes about autism through great acceptance to reduce
harmful stigma and to help mitigate the subsequent negative The authors declare that the research was conducted in the
social consequences (7). Also, given that many autistic adults absence of any commercial or financial relationships that could be
have already encountered stigma, understanding the extent construed as a potential conflict of interest.

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Marion et al. 10.3389/fpsyt.2023.1243618

Publisher’s note organizations, or those of the publisher, the editors and the
reviewers. Any product that may be evaluated in this article, or
All claims expressed in this article are solely those of the claim that may be made by its manufacturer, is not guaranteed or
authors and do not necessarily represent those of their affiliated endorsed by the publisher.

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