**4. The role of valid theory in ethical and scientifically sound research**

Despite the detailed theoretical focus of this chapter, a wholistic identity approach to epidemiologic research, of which the IP framework is one example, has practical application for clarifying gender-related differences in health. One of the most significant assertions of the IP framework is that epidemiologic research should embrace a more nuanced approach to social determinants of health and health disparities research, specifically as related to assumptions of homogeneity in social group differences in health. This paper has presented strong evidence that concepts of gender and race are conceptually far more complex than is often operationalized in many epidemiologic analyses. Furthermore, the health implications of adverse social experiences associated with gender and race are heavily dependent on psychosocial characteristics that are rarely measured in epidemiologic studies.

The inclusion of sound theoretical foundations is necessary to ethically and rigorously address these concerns. The IP framework calls for reconsidering some standard methodologies of epidemiologic research. Because the white male referent presents a number of conceptual problems, using stratified analyses can circumvent many of the biases to which research questions based on multi-gender, multi-racial, or multi-ethnic samples are vulnerable. Stratified analyses can also avoid the pitfall of including variables for complex social constructs such as gender or race in regression models, as recent literature has described notable limitations and conceptual inconsistencies in this approach [15, 16].

In addition to implications for improving the rigor of scientific research, the increased application of well-developed theory to research into the causes of social group differences in health has ethical implications as well. Outside of the academic settings in which health research frequently occurs, epidemiologic findings have significant impact of the health and lives of real people. What we discover about the causes of gender differences in health informs the policies and societal changes intended to alleviate unnecessary and unjust suffering. A failure to fully consider all available evidence is a failure to meet the lofty ideals of epidemiology as a discipline —to identity the causes of disease in order to eradicate.

#### **5. Conclusions**

In this chapter, I have addressed the necessity and challenge of incorporating sound theory into epidemiologic research on the causes of gender differences in health. Intersectionality Theory has in many ways served as a springboard for the growing collaboration of epidemiology with social science. Still, although the use of interdisciplinary theory in epidemiologic research has increased substantially within the last decade, there is much room for improving the application of theory to everything from developing research questions to the selection of confounders to the interpretation of results. Moreover, much of the research employing an

discrimination they report. Rather, these findings indicate that structural barriers, such as reduced access to high-quality medical care, may have a much more compelling effect on the cardiovascular health of black women than stress stemming from encounters with interpersonal discrimination, as has been previously argued

The settings in which reported discrimination impacted CVH among black men in this study indicate that members of this group may be more susceptible to the direct physiological impact of perceived subordinate status than black women. This may be because racism targeted at black men has historically been more ostensibly violent [97], or due to other psychosocial and cultural factors influencing the distinct coping methods of these groups [10, 64, 97]. The observed patterns in the associations of reported discrimination with CVH indicate that reminders of marginalized status may be experienced as more stressful among black men than black women and therefore may be more likely to act on CVH through direct physiological mechanisms in addition to creating barriers to health and social resources in this

One explanation for the patterns observed in this study is that interpersonal discrimination may act as an "identity trigger" consistent with claims of the Jedi Public Health framework [42]. The authors suggest that identity triggers, or elements of the social environment that trigger awareness of one's social status, are one mechanism through which structured inequities act to differentially impact on health and lead to health disparities. The unequal social conditions in which black and white women and men are situated influence the type and saturation of identity triggers each of these groups will encounter, as well as available coping resources [39, 111], within and across various social settings [42]. According to this framework, experiences of discrimination pose a setting-specific disease risk for each gendered race group. We suggest further that perceived experiences of interpersonal discrimination can act as identity cues, even in the absence of actual occurrences of discrimination, which might partially explain the associations we found among white women and men. Identity triggers and the perceived coping resources [39] particular to black and white women and men may act to specify conditions under which experiences of interpersonal discrimination will have a measurable

Hierarchical social conditions create power dynamics between marginalized and

dominant status groups which influence how inequity will be experienced on a personal basis by members of both types of groups [7, 10, 97, 114]. Experiences of discrimination based on gendered race that occur in the context of medical care, education, or in interactions with law enforcement, for example, can bring to bear historically structured power imbalances through heightened awareness of one's stigmatized status in the form of race consciousness [99, 115]. Instances of interpersonal discrimination in these specific settings may be uniquely stressful for marginalized persons both because of the likelihood of recurrence and a perceived

On the other hand, the settings in which awareness of unequal social status might be triggered among dominant group members—whether or not a discriminatory interaction actually occurred—and the resources they believe are available for coping with the accompanying stress, likely differ. These perceptions of social status triggered by interpersonal discrimination lead to between-group differences in the types of social contexts in which experiencing discrimination will contribute to deteriorated CVH. This interplay is consistent with our findings that although a higher percentage of black men reported encountering discriminatory treatment in public or on the street than in any other setting, this setting was the only one in which exposure was not associated with poorer CVH within this group. In contrast,

lack of opportunities for retribution [39, 42, 111].

[4, 98].

*Quality of Life - Biopsychosocial Perspectives*

group.

impact on CVH.

**36**

intersectional approach struggles to deeply engage the health implications of concepts like socially constructed gendered race. While there is acknowledgement of the external social processes which shape the health of groups in different socially defined categories, little attention is given to how internal identity processes also play a pivotal role in determining health. This oversight is largely due to a resistance within the field of epidemiology to grapple with complex social psychological phenomena such as the influence of social group identity on population-level differences in health.

The persistence of documented health disparities over the last century despite longstanding calls for social, economic, and political reform as well as substantial advances in our understanding of the role of social determinants in health indicates, as the IP framework theorizes, that these policies and the decision-makers behind them are resistant to change. Reservoirs of infection, source populations which stubbornly harbor pathogenic identity beliefs even as changing discourse variably decreases or increases the acceptability of social prejudice, ensure that interventions

*Health Disparities at the Intersection of Gender and Race: Beyond Intersectionality Theory…*

*DOI: http://dx.doi.org/10.5772/intechopen.92248*

In light of these observations, the IP framework suggests that because pathogenic identity beliefs perpetuate the pathogenic social environments in which they flourish, interventions must target the environment, agent, and host simultaneously. Eradicating health disparities therefore requires an additional approach that acts in conjunction with efforts to deconstruct problematic institutions and policies, and efforts to create identity-safe cultures. In the case of identity pathology, environmental interventions, which have been well-described in extant theory [1, 37], involve abolishing the policies and practices which maintain and promote inequity within social institutions and the inequitable distribution of healthimpacting resources. Agent interventions require shifting the cultural and social norms in which pathogenic beliefs flourish and are transmitted, as proposed by the Jedi Public Health Framework [42]. Host interventions, which the IP framework newly proposes, target the identity beliefs which make individuals particularly susceptible to the effects of inequitable social conditions on the cognitions and behaviors that directly and indirectly influence their own health as well as the

Although the IP framework uses the example of race and gender hierarchy among black and white women and men, application of the framework extends well beyond these particular groups and examples of structural inequity. As the objective of the framework is to highlight the substantial role of identity processes in health outcomes, the principles of the IP framework can be adapted to describe the effects of any inequitable social contexts on the physical and psychological well-being of any populations exposed to those contexts. The IP framework may be particularly useful for examining the understudied health impacts of structural inequity among groups such as those with varying physical abilities or native populations whose

The framework is densely theoretical and draws from a number of disciplines in

outlining complex mechanisms from structural inequities to health inequities. Despite its ambitious reach, the core concepts of the framework are readily applicable to health research. Through suggesting adjustments to analytic methods, outlining testable causal mechanisms, and proposing an evidence-based intervention, the IP model orients health researchers toward another channel for more ethical and rigorous investigation the causes of and solutions to unjust gender

suffering has been systematically made invisible.

focusing only on shifting policy will do little to yield lasting social equity.

health of others.

disparities in health.

**39**

For this reason, I have argued in this chapter for the necessity of moving beyond intersectional approaches to health disparities research. The use of a wholistic identity approach to understanding social group differences in health requires the engagement of wide array theories which each provide important but distinct elements of the larger mechanisms by which structural inequity produces social group differences in health. One wholistic identity theory, the Identity Pathology model, is built on such an interdisciplinary conceptualization of health disparities.

According to Identity Pathology theory, embedded in socially constructed identities are beliefs that moderate whether and how exposure to chronic adverse social conditions, for example experiences of interpersonal discrimination, will generate disease. When individuals are socialized with identities built on pathogenic identity beliefs, they are more susceptible to a number of physical and mental illnesses. Pathologized identities act to foster disease through dictating cognitive and behavioral practices—stressor appraisal, health behaviors, etc.—that yield distinct pathologies in the context of unequal social conditions. The IP framework argues that gendered racial identities constructed in the context of inequitable social conditions create unique manifestations of health and disease among black and white women and men, contributing to gender differences in health that will vary across race in a manner that may not be adequately captured in current interpretations of Intersectionality Theory.

Fundamentally, many theories on social determinants of health, including Intersectionality Theory, predicate the health of the socially marginalized—whether that be on the basis of gendered race, socioeconomic status, etc.—on a set of resources of which they are systematically deprived. In some ways, these theories carry undercurrents of an adversarial tone by situating the "disadvantaged" as those who have everything to gain from social change against the "privileged" who are at risk for a corresponding loss. As such, any improvements in the health of members of marginalized groups are necessarily dependent on the decisions of those who retain power over the distribution of these resources, individuals who have little incentive to relinquish their positions of authority (perceived and actual) or enact more inclusive policies [28].

In *The Health Gap*, Marmot observes: "Being at the wrong end of inequality is disempowering, it deprives people of control over their lives. Their health is damaged as a result. And the effect is graded–the greater the disadvantage the worse the health" [116]. This observation, while not incorrect, seems to suggest, almost tacitly, unintentionally perhaps, that at the "right" end of inequality, individuals are artificially empowered. I consider whether the focus on external resources to the exclusion of internal resources of health is another form of disempowering marginalized persons. To act on the idea that the marginalized many cannot even enjoy health without the permission of the advantaged few feels, at its core, like another practice of structural violence.

If structural inequities and the unequal health outcomes such conditions cause are to be truly deconstructed, intervention must entail more than efforts to change social and economic policies which were intentionally established to ensure that power and resources remain under the control of white men [10, 26, 28, 34].

#### *Health Disparities at the Intersection of Gender and Race: Beyond Intersectionality Theory… DOI: http://dx.doi.org/10.5772/intechopen.92248*

The persistence of documented health disparities over the last century despite longstanding calls for social, economic, and political reform as well as substantial advances in our understanding of the role of social determinants in health indicates, as the IP framework theorizes, that these policies and the decision-makers behind them are resistant to change. Reservoirs of infection, source populations which stubbornly harbor pathogenic identity beliefs even as changing discourse variably decreases or increases the acceptability of social prejudice, ensure that interventions focusing only on shifting policy will do little to yield lasting social equity.

In light of these observations, the IP framework suggests that because pathogenic identity beliefs perpetuate the pathogenic social environments in which they flourish, interventions must target the environment, agent, and host simultaneously. Eradicating health disparities therefore requires an additional approach that acts in conjunction with efforts to deconstruct problematic institutions and policies, and efforts to create identity-safe cultures. In the case of identity pathology, environmental interventions, which have been well-described in extant theory [1, 37], involve abolishing the policies and practices which maintain and promote inequity within social institutions and the inequitable distribution of healthimpacting resources. Agent interventions require shifting the cultural and social norms in which pathogenic beliefs flourish and are transmitted, as proposed by the Jedi Public Health Framework [42]. Host interventions, which the IP framework newly proposes, target the identity beliefs which make individuals particularly susceptible to the effects of inequitable social conditions on the cognitions and behaviors that directly and indirectly influence their own health as well as the health of others.

Although the IP framework uses the example of race and gender hierarchy among black and white women and men, application of the framework extends well beyond these particular groups and examples of structural inequity. As the objective of the framework is to highlight the substantial role of identity processes in health outcomes, the principles of the IP framework can be adapted to describe the effects of any inequitable social contexts on the physical and psychological well-being of any populations exposed to those contexts. The IP framework may be particularly useful for examining the understudied health impacts of structural inequity among groups such as those with varying physical abilities or native populations whose suffering has been systematically made invisible.

The framework is densely theoretical and draws from a number of disciplines in outlining complex mechanisms from structural inequities to health inequities. Despite its ambitious reach, the core concepts of the framework are readily applicable to health research. Through suggesting adjustments to analytic methods, outlining testable causal mechanisms, and proposing an evidence-based intervention, the IP model orients health researchers toward another channel for more ethical and rigorous investigation the causes of and solutions to unjust gender disparities in health.

intersectional approach struggles to deeply engage the health implications of concepts like socially constructed gendered race. While there is acknowledgement of the external social processes which shape the health of groups in different socially defined categories, little attention is given to how internal identity processes also play a pivotal role in determining health. This oversight is largely due to a resistance within the field of epidemiology to grapple with complex social psychological phenomena such as the influence of social group identity on population-level differ-

For this reason, I have argued in this chapter for the necessity of moving beyond

intersectional approaches to health disparities research. The use of a wholistic identity approach to understanding social group differences in health requires the engagement of wide array theories which each provide important but distinct elements of the larger mechanisms by which structural inequity produces social group differences in health. One wholistic identity theory, the Identity Pathology model, is built on such an interdisciplinary conceptualization of health disparities. According to Identity Pathology theory, embedded in socially constructed identities are beliefs that moderate whether and how exposure to chronic adverse social conditions, for example experiences of interpersonal discrimination, will generate disease. When individuals are socialized with identities built on pathogenic identity beliefs, they are more susceptible to a number of physical and mental illnesses. Pathologized identities act to foster disease through dictating cognitive and behavioral practices—stressor appraisal, health behaviors, etc.—that yield distinct pathologies in the context of unequal social conditions. The IP framework argues that gendered racial identities constructed in the context of inequitable social conditions create unique manifestations of health and disease among black and white women and men, contributing to gender differences in health that will vary across race in a manner that may not be adequately captured in current interpretations of

Fundamentally, many theories on social determinants of health, including Intersectionality Theory, predicate the health of the socially marginalized—whether that be on the basis of gendered race, socioeconomic status, etc.—on a set of resources of which they are systematically deprived. In some ways, these theories carry undercurrents of an adversarial tone by situating the "disadvantaged" as those who have everything to gain from social change against the "privileged" who are at risk for a corresponding loss. As such, any improvements in the health of members of marginalized groups are necessarily dependent on the decisions of those who retain power over the distribution of these resources, individuals who have little incentive to relinquish their positions of authority (perceived and actual) or enact

In *The Health Gap*, Marmot observes: "Being at the wrong end of inequality is disempowering, it deprives people of control over their lives. Their health is damaged as a result. And the effect is graded–the greater the disadvantage the worse the health" [116]. This observation, while not incorrect, seems to suggest, almost tacitly, unintentionally perhaps, that at the "right" end of inequality, individuals are artificially empowered. I consider whether the focus on external resources to the exclusion of internal resources of health is another form of disempowering marginalized persons. To act on the idea that the marginalized many cannot even enjoy health without the permission of the advantaged few feels, at its core, like another

If structural inequities and the unequal health outcomes such conditions cause are to be truly deconstructed, intervention must entail more than efforts to change social and economic policies which were intentionally established to ensure that power and resources remain under the control of white men [10, 26, 28, 34].

ences in health.

*Quality of Life - Biopsychosocial Perspectives*

Intersectionality Theory.

more inclusive policies [28].

practice of structural violence.

**38**

*Quality of Life - Biopsychosocial Perspectives*

**References**

2010;**1186**(1):5-23

[1] Adler NE, Stewart J. Health

disparities across the lifespan: Meaning, methods, and mechanisms. Annals of the New York Academy of Sciences.

*DOI: http://dx.doi.org/10.5772/intechopen.92248*

feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. University of Chicago Legal Forum. 1989;**1989**(1):139-167

[12] Williams DR, Kontos EZ, Viswanath K, Haas JS, Lathan CS, MacConaill LE, et al. Integrating multiple social statuses in health disparities research: The case

[11] Reynolds AL, Pope RL. The complexities of diversity: Exploring multiple oppression. Journal of Couseling and Development. 1991;**70**

of lung cancer. Health Services Research. 2012;**47**(3):1255-1277

[13] Robinson WR, Gordon-Larsen P, Kaufman JS, Suchindran CM, Stevens J. The female-male disparity in obesity prevalence among black American young adults: Contributions of

sociodemographic characteristics of the childhood family. American Journal of Clinical Nutrition. 2009;**89**(4):1204-1212

[14] Bey GS, Ulbricht CM, Person SD. Theories for race and gender differences in management of social identity-related stressors: A systematic review. Journal of Racial and Ethnic Health Disparities. 2019;**6**(1):117-132. DOI: 10.1007/

s40615-018-0507-9

[15] Jackson JW, Williams DR, VanderWeele TJ. Disparities at the intersection of marginalized groups. Social Psychiatry and Psychiatric Epidemiology. 2016;**51**(10):1349-1359

methods to questions in social psychiatry and psychiatric

York, NY: Basic Books; 2019

139-142

[16] Schwartz S. Commentary: On the application of potential outcomes-based

epidemiology. Social Psychiatry and Psychiatric Epidemiology. 2017;**52**(2):

[17] Metzl JM. Dying of Whiteness. New

(1):174-180

*Health Disparities at the Intersection of Gender and Race: Beyond Intersectionality Theory…*

[2] Krieger N. Methods for the scientific study of discrimination and health: An ecosocial approach. American Journal of Public Health. 2012;**102**(5):936-944

[3] Kawachi I, Daniels N, Robinson D. Health disparities by race and class: Why both matter. Health Affairs. 2005; **24**(2). DOI: 10.1377/hlthaff.24.2.343

[4] Williams DR, Mohammed SA. Racism and health I: Pathways and scientific evidence. American

10.1177/0002764213487340

[6] Marmot M, Allen JJ. Social

University Press; 2011

(Suppl 4):S517-S519

643-710

**41**

Behavioral Scientist. 2013;**57**(8). DOI:

[5] Krieger N. Epidemiology and the People's Health. New York, NY: Oxford

determinants of health equity. American Journal of Public Health. 2014;**104**

[7] Krieger N. Discrimination and health inequities. International Journal of Health Services Research. 2014;**44**(4):

[8] Harrell JP, Hall S, Taliaferro J. Physiological responses to racism and discrimination: An assessment of the evidence. American Journal of Public

[9] Vandiver BJ, Fhagen-Smith P, Cokley KO, Cross WE, Worrell FC. Cross's nigrescence model: From theory

[10] Crenshaw K. Demarginalizing the intersection of race and sex: A black

Health. 2003;**93**(2):243-248

to scale to theory. Journal of Multicultural Counseling and Development. 2001;**29**:174-200
