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

Abstract 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, R 2 = 0.59; women: AUC = 0.71, HL p = 0.21, Brier = 0.12, R 2 = 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.