Skin diseases comprise one of the largest disease burdens worldwide and may be associated with anxiety, low self-esteem, or depression, having a profound impact on quality of life. Given their visible nature, skin diseases often provoke negative reactions resulting in stigma and discrimination. References to stigma have been documented throughout history in religious scriptures contributing to the belief that leprosy was a punishment and that those afflicted should be segregated from society. Other key conditions associated with disease-related stigma are albinism, psoriasis and vitiligo. For centuries, misconceptions have led to laws and practices oppressing and persecuting individuals for having a specific skin disorder undermining basic human rights, professional opportunities and development.1
The first descriptions of vitiligo, a non-infectious, depigmenting skin condition with an estimated global prevalence of 0.5–2%, date back to more than 3500 years ago.2 In some communities, despite the ancient recognition, vitiligo continues to be confused with leprosy, particularly in people with a darker skin tone.3 In India, the stigma associated with vitiligo is so deeply-rooted, that women with vitiligo are often prohibited from marriage.4 In Brazil, persons with vitiligo are disqualified or rejected from specific public professions. For the purpose of this perspective, we evaluated the most recent job announcements of the Brazilian Armed Forces, Police Forces, and Fire Department, which recruited candidates for various positions from across the country. We accessed the public website http://www.pciconcursos.com.br/ for job announcements and searched clauses that exclude patients with vitiligo from applying for a public job vacancy.
A total of 97 job descriptions, dating between 2009 and 2022, were found, of which 55 (56.7%) excluded people with vitiligo from holding positions in the aforementioned governmental institutions including administrative functions, combat officers, medical doctors, and others. This practice dates back to 1967, during the Brazilian Military Regime, when the ‘General Instructions for the Health Evaluation of Conscripts in the Armed Forces (IGISC)’ was implemented. These instructions list diseases, including vitiligo and leprosy, forbidding those affected to participate in the Military Service of the Armed Forces.5 Even less than a year ago, in 2022, the restriction was acknowledged as 'best scientific practice' by the Brazilian Civil Police of the Federal District,6 although it is widely known that vitiligo is not transmissible nor a disabling disease.2
In 1958, the International Labour Organization, a United Nations agency that mandates worldwide social and economic justice, prohibited all forms of discrimination and exclusion in employment and invalidated legislation that was not based on equal opportunities.7 Ironically, the Brazilian government ratified this document before the release of the IGISC, which as stated above, prohibited people with vitiligo from holding military positions.8 In India, similar rejections are seen: a candidate cannot have any hyper- or hypopigmentated lesions on the skin to be eligible for the army.9
In contrast, vitiligo is not considered a disqualifying condition for the Armed Forces of the United States of America, United Kingdom, and members of the European Union. In Canada, a risk management assessment is incorporated in the eligibility criteria with the purpose of translating medical employment limitations into a stratified Risk Assessment Matrix. Based on scientific evidence, this tool is capable of predicting the recurrence rate of a medical condition and its potential impact on operational procedures fostering transparency, accountability, and equality.10
In conclusion, stigma and discrimination based on skin conditions have been described throughout history transcending cultures, politics, and time trends. The discriminatory practices currently present within Brazilian public institutions highlight the intolerance that persists until today and play a role in amplifying prejudicial attitudes and negative stereotypes towards minority groups, impacting employment opportunities and well-being. We advocate for safeguarding individual and social rights of persons living with skin diseases, promoting health equity, dignity, and justice for all.
Contributors
LPS: literature search, data collection, data analysis, data interpretation, drafting of manuscript.
MLG: literature search, data interpretation, drafting of manuscript.
IF: conceived and designed the analysis, writing.
GD: study design, data analysis, data interpretation, writing.
All authors provided valuable input and critically revised the manuscript. All authors reviewed and approved the final version of the manuscript.
Declaration of interests
LPS, MLG, IF, GD: We declare no competing interests.
Acknowledgments
We acknowledge Dr. Esther Freeman for her useful input into the development of this article.
References
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