A/HRC/21/42 for ascertaining whether human rights obligations are met. It requires States to go beyond enacting legislation, to take positive action to meet their obligations effectively, and to make a legitimate and reasonable effort to prevent and combat stigma. 59. Since stigma is so complex and so deeply engrained in society, permeating different spheres, preventing and combating it requires holistic approaches and systemic solutions: (a) Stigma must be addressed at different levels, to ensure change at the level of individual behaviours, as well as at the broader social and cultural levels. It is crucial to recognize the extent to which States perpetuate stigma and address this at the institutional and structural levels; (b) While States are the primary duty bearers under international human rights law, non-State actors also have responsibilities and can be held accountable for human rights abuses. They should be part of any efforts to combat stigma; (c) Addressing stigma requires working with the stigmatized as well as with the stigmatizers, while recognizing that there is significant overlap. Those who experience stigmatization due to a certain attribute are just as likely as the majority population to stigmatize others; (d) Strategies need to cover prevention and address existing stigma, as well as provide for redress for the stigmatized and punishment for the perpetrators where stigmatization results in human rights violations. A. Participation and empowerment 60. Meaningful participation of stigmatized individuals in crafting measures to combat stigma in relation to water and sanitation is absolutely essential. In order to ensure meaningful participation States must guarantee access to information in relevant languages and formats and targeted to different ages and population groups. For example, since stigma relating to some diseases is often reinforced by a lack of scientific information on ways to prevent, treat or transmit diseases, a critical aspect is to run public health campaigns and ensure that all individuals can seek and receive accurate and trustworthy information. Empowerment should be the key strategy, with those experiencing stigma having space to combat prejudices and discrimination. 61. In the context of sex workers, the Durbar Mahila Samanwaya Committee, a grassroots sex workers‘ collective in India, began organizing self-regulatory boards made up of its staff, doctors, advocates, national human rights commissioners, local politicians and officials, and sex workers themselves in a number of red-light districts. Their objectives included mitigating violence against sex workers, but also brought about improvements in access to water and sanitation.43 62. In order to combat stigma effectively, it is essential to address both its external and internalized dimensions. People who are stigmatized often feel embarrassment and shame, so they remain silent and are incapable of combatting stigma working against them. Where stigmatized people lack voice and agency, empowering them to know and claim their rights is crucial. This requires States to ensure access to information on rights and mechanisms to claim them, as well as to information on issues such as menstruation and hygiene. A 43 16 on the Elimination of Discrimination against Women, general recommendation No. 19 (1992) on violence against women, para. 9. Anna-Louise Crago, Our Lives Matter: Sex Workers Unite for Health and Rights (New York, Open Society Institute, 2008), pp. 36 ff.