**3.2 Application of IP theory to investigating gendered racial differences in cardiovascular health**

Recently published work applies the IP framework to the study of gendered racial variation in the association of discrimination with cardiovascular health (CVH). This emerging body of research makes a compelling case for considering the role of wholistic identity in assessing the manner by which structural inequity contributes to unjust and unnecessary gender differences in health. Persistent gendered racial differences in the prevalence and severity of cardiovascular disease (CVD) in the U.S. highlight the necessity for a stronger theoretical foundation in understanding the role of discrimination in yielding social group disparities in CVD [21, 22, 80].

The age-adjusted likelihood of a CVD diagnosis is approximately equal for black and white men [65, 66], but black women are nearly twice as likely as white women in the same age group to develop CVD [65, 66]. Black women are also more likely than white women or black men to develop cardiometabolic precursors to CVD [96]. Among other risk factors [7, 10], researchers frequently attribute this increased risk among black women to a greater likelihood of experiencing racial and gender discrimination [12, 95]. Unlike the large gender disparity among whites, however, black women and men report comparable exposure to interpersonal gender and racial discrimination [21, 97] even as black men develop CVD at a faster rate than black women [65, 66].

Due to these prominent disparities in cardiovascular outcomes between black and white women and men, researchers have examined social group-specific exposures as potential contributors to these inequities [98]. Consistent with the dominant biomedical, individual-level orientation of epidemiological research [7], the literature has largely focused on interpersonal racial discrimination as a driver of poorer CVH within these groups [7, 22, 98, 99]. Often conceptualized as a proxy for structural discrimination, or, alternatively, as a mechanism through which structural discrimination acts on health, interpersonal discrimination provides an accessible method for investigating social determinants of health [7]. The underlying assumption for the majority of studies examining interpersonal discrimination appears to be that the stress associated with experiencing discriminatory interactions has a detrimental effect on CVH, directly through chronic activation of the stress response system, or indirectly through promoting poor health behaviors, which in turns increases risk for cardiovascular morbidity and mortality [7, 22, 100]. As such, populations more likely to encounter these experiences (e.g. women compared with men in the case of gender discrimination) will exhibit poorer health behaviors, experience higher rates of cardiometabolic dysfunction, and necessarily have a greater burden of disease.

In line with this reasoning, previous studies have linked reported racial discrimination to sedentary behavior, smoking, hypertension, obesity, and incident CVD within black and white populations [21, 100–103]. Because the prevalence of reported interpersonal racial discrimination is substantially higher among black persons than whites [7, 23] these findings have generally been interpreted through

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

the lens of differential exposure rather than vulnerability [16]. That is, a higher prevalence of disease theorized to correspond with a higher prevalence of exposure, rather than with differential vulnerability to the effects of exposure [7, 99]. Consequently, consensus has leaned toward an association of reported racial discrimination with the disproportionate rate of cardiovascular morbidity and mortality among blacks [7, 98, 99].

Admittedly, researchers have emphasized relevant differences in the effects of exposure depending on the basis of discrimination [98, 102] (racial versus weight, for example), the frequency of discrimination [98], demographic characteristics such as the age or gender of the individual to whom the discrimination is directed [103], and how individuals respond to stress [21, 104]. Even still, few have theoretically considered the nature of these differences and whether the reasons for these differences have implications for the exposure-disease relationship; even fewer have taken these potential implications into account during analysis.

Further, while the consequences of structural and interpersonal discrimination are documented more frequently among women [20, 95], recent evidence showing no association of reported gender discrimination with incident CVD [21], along with other recent findings inconsistent with previous evidence [94], calls into question unidimensional conceptualizations of discrimination as a cause of poorer CVH. A focus on differential exposure to interpersonal discrimination as underlying gendered racial disparities in CVH may prevent identification of other relevant group-specific characteristics such as varying *susceptibility* to the health effects of perceiving discrimination [7, 12, 62, 63, 105]. For example, a recent study assessing the effect of cumulative unfair treatment on subclinical CVD among a multi-ethnic sample of women found an association only among white women [106]. Such evidence supports the argument that while women and black persons are more likely to experience both structural and interpersonal gendered racial discrimination, men and white persons may be more susceptible to the health consequences of perceiving interpersonal discrimination as a result of group-specific internal resources [29, 80, 107].

Previous findings also suggest that the magnitude of stress discriminatory experiences cause and whether responses to these experiences exacerbate or reduce the risk of CVD depends on the context in which they occur [100, 104, 106]. Therefore, in addition to the challenge of capturing variation in the subjective identity characteristics that might render interpersonal discrimination detrimental to CVH, as well as the complex psychological processes by which individuals attribute discriminatory experiences, it is also necessary to consider how the setting in which discrimination is reported reflects access to both internal and external psychosocial resources that may independently relate to CVH differently for different gendered race groups. Everyday experiences of discriminatory treatment not only encompass individual acts but also the complex relation of acts that will be specific to specific social contexts, as argued by some critical race theorists [12]. The particular relationship between individual and context bears important implications for the physiological impact of perceived discriminatory interactions.

Further, the context of reported discrimination, such as at school, at work, by the police or courts, or while seeking healthcare, may provide insight into distinct effect pathways operating among different gendered race groups. While discrimination may act directly on CVH through repeated activation of the stress response system for some, others may be more susceptible to the indirect effects of interpersonal discrimination such as barriers to quality health care [98, 100, 108].

The complex relationships of these psychosocial exposures with CVD among black and white women and men connoted in the literature point to a need for further consideration of how and in whom discrimination operates to affect risk for disease [7].

Importantly, the IP framework does not assert that compounded inequities necessarily translates to greater likelihood of a specific disease outcome among multiply marginalized groups. Instead, the framework argues that the lived experience of race and gender in a society which advantages some groups in certain ways while disadvantaging others in different ways [12, 95] based on these identities yields variation in the efficacy of health-protective factors. This variation in turn manifests as a differential vulnerability to disease across gendered race groups.

**3.2 Application of IP theory to investigating gendered racial differences**

Recently published work applies the IP framework to the study of gendered racial variation in the association of discrimination with cardiovascular health (CVH). This emerging body of research makes a compelling case for considering the role of wholistic identity in assessing the manner by which structural inequity contributes to unjust and unnecessary gender differences in health. Persistent gendered racial differences in the prevalence and severity of cardiovascular disease (CVD) in the U.S. highlight the necessity for a stronger theoretical foundation in understanding the role of discrimination in yielding social group disparities in CVD

The age-adjusted likelihood of a CVD diagnosis is approximately equal for black and white men [65, 66], but black women are nearly twice as likely as white women in the same age group to develop CVD [65, 66]. Black women are also more likely than white women or black men to develop cardiometabolic precursors to CVD [96]. Among other risk factors [7, 10], researchers frequently attribute this

increased risk among black women to a greater likelihood of experiencing racial and gender discrimination [12, 95]. Unlike the large gender disparity among whites, however, black women and men report comparable exposure to interpersonal gender and racial discrimination [21, 97] even as black men develop CVD at a faster

Due to these prominent disparities in cardiovascular outcomes between black and white women and men, researchers have examined social group-specific exposures as potential contributors to these inequities [98]. Consistent with the dominant biomedical, individual-level orientation of epidemiological research [7], the literature has largely focused on interpersonal racial discrimination as a driver of poorer CVH within these groups [7, 22, 98, 99]. Often conceptualized as a proxy for structural discrimination, or, alternatively, as a mechanism through which structural discrimination acts on health, interpersonal discrimination provides an accessible method for investigating social determinants of health [7]. The underlying assumption for the majority of studies examining interpersonal discrimination appears to be that the stress associated with experiencing discriminatory interactions has a detrimental effect on CVH, directly through chronic activation of the stress response system, or indirectly through promoting poor health behaviors, which in turns increases risk for cardiovascular morbidity and mortality [7, 22, 100]. As such, populations more likely to encounter these experiences (e.g. women compared with men in the case of gender discrimination) will exhibit poorer health behaviors, experience higher rates of cardiometabolic dysfunction, and necessarily

In line with this reasoning, previous studies have linked reported racial discrimination to sedentary behavior, smoking, hypertension, obesity, and incident CVD within black and white populations [21, 100–103]. Because the prevalence of reported interpersonal racial discrimination is substantially higher among black persons than whites [7, 23] these findings have generally been interpreted through

**in cardiovascular health**

*Quality of Life - Biopsychosocial Perspectives*

rate than black women [65, 66].

have a greater burden of disease.

**30**

[21, 22, 80].

Evidence suggests that the multifaceted nature of the interpersonal discrimination experience operates within distinct social groups to differentially influence CVH in a manner not frequently captured in epidemiologic studies [22, 98, 99, 103]. Inconsistencies in the literature may be attributable, in part, to an inadequate conceptualization, measurement, and analysis of interpersonal discrimination in relation to CVH across demographically diverse populations.

entitlements they believe they are due as a result of their manhood. Similarly, reporting of multiple encounters with racial discrimination by white persons likely indicates encounters in which these individuals believe they were deprived of entitlements due to them as white persons. Regardless of the accuracy of their reporting, the perception of what members of dominant status groups consider discrimination can be stressful enough to have a measurable impact on their cardiovascular health. This effect may be exacerbated by their recognizing the inconsistencies of their perceptions with the way that society defines experiences of

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

Moreover, even among those whom the occurrence, perception, and reporting of discrimination overlap with high accuracy, differences in beliefs about the significance of being perceived and treated as inferior by another group will influence the stressfulness of perceiving discrimination. Finally, identity beliefs associated with gendered race also shape how individuals will cope with the reality of being perceived and treated as inferior, thereby creating another source of variability in the effect of reported interpersonal discrimination on CVH. Because increased exposure to social stressors among marginalized groups may yield an array of adaptive coping strategies that are protective against the health consequences of psychosocial adversity, the IP model predicts, perhaps counterintuitively, that the association between reports of racial and gender discrimination and declining CVH to be stronger among members of dominant status groups. The IP framework also posits that the susceptibility to direct versus indirect effects of discrimination on CVH are primarily a function of an individual's cumulative social experiences and

will therefore manifest differentially across gendered race groups.

Given these hypotheses, two studies [29, 80] examined the relationship of reported interpersonal discrimination with CVH among black and white women and men using 30 years of longitudinal data from the Coronary Artery Risk Development in Young Adults study. The first study evaluated whether the associations of reported interpersonal experiences of racial and gender discrimination simultaneously compared with racial or gender discrimination alone, or no discrimination, with cardiovascular health 23 years later was stronger among white men than other groups. The second study explored variation in the relationship between simultaneously reported

racial and gender discrimination and future CVH across eight social settings.

The studies identified important characteristics of the relationships between reported racial and gender discrimination and cardiovascular health (CVH) in black and white women and men. The first study identified differences in the associations between reported gender and racial discrimination and CVH, suggesting differential vulnerability (**Table 4**). Compared with reporting no discrimination, reporting any racial discrimination predicted higher CVH scores among black women, while no statistically significant associations were found among black men. Among white women, reporting any gender discrimination predicted higher CVH scores than reporting no discrimination. For white men, predicted CVH scores were higher for those reporting any racial discrimination, and lower for those reporting racial and gender discrimination in at least two settings, than in those reporting no

These findings contrasted with those describing a link between racial discrimination and poorer cardiovascular health among black persons [7, 99, 101]. Though inconsistent, the literature has demonstrated associations of reported racial discrimination with CVD risk factors including diet, hypertension, smoking, sedentary behavior, obesity, and inflammation [50, 101, 103, 109], as well as social predictors of CVD such as marital status, socioeconomic position, and education, in both black women and men [7, 23]. In this study, we did not find a statistically significant association between racial discrimination and poorer CVH within these groups.

discrimination.

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

discrimination.

**33**

The Identity Pathology framework provides a useful model for investigating these inconsistencies in the relationship of discrimination with CVD (see **Figure 1**). While not solely applicable to CVD, the model is useful for clarifying inconsistencies in the literature on interpersonal discrimination and CVD because it specifies the conditions under which—and in whom—reported experiences of interpersonal discrimination will be measured as damaging to CVH and lead to the development of disease. As applied to CVD disparities and interpersonal discrimination, the model makes three central assertations.

First, that in order to more accurately capture the effects of interpersonal discrimination on cardiovascular health and health disparities, multiple aspects of the discrimination experience must be considered in the design, analysis, and interpretation of health-related studies. Secondly, the IP framework posits that experiences of interpersonal discrimination are fundamentally based in historically structured inequities that impact on each dimension of the discrimination process in healthrelevant ways. Finally, the model purports that the precision with which reported experiences map onto perceptions and intentionally or implicitly driven acts of discrimination depend on a variety of psychosocial characteristics, one of the most important of which is an individual's beliefs about their gendered racial identity. In other words, the contribution of discrimination to disparities in CVH may extend beyond gendered racial variation in *exposure* to gendered racial differences in the effect of perceiving interpersonal discrimination.

The IP model argues that this variability in effect across gendered race groups can be attributed to differing manifestations of identity pathology. Due to the relationship between identity pathology and the experience of interpersonal discrimination, the experience being captured in reported discrimination among different gendered race groups must necessarily be different. For men reporting frequent experiences of gender discrimination, these experiences are less likely to reflect objective encounters with discrimination as traditionally conceptualized and are more likely to signify that these men feel they are being deprived of the

#### **Figure 1.**

*Application of the emerging identity pathology framework to describe potential pathways from intersecting axes of structured racism and sexism to cardiovascular disease.*

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

entitlements they believe they are due as a result of their manhood. Similarly, reporting of multiple encounters with racial discrimination by white persons likely indicates encounters in which these individuals believe they were deprived of entitlements due to them as white persons. Regardless of the accuracy of their reporting, the perception of what members of dominant status groups consider discrimination can be stressful enough to have a measurable impact on their cardiovascular health. This effect may be exacerbated by their recognizing the inconsistencies of their perceptions with the way that society defines experiences of discrimination.

Moreover, even among those whom the occurrence, perception, and reporting of discrimination overlap with high accuracy, differences in beliefs about the significance of being perceived and treated as inferior by another group will influence the stressfulness of perceiving discrimination. Finally, identity beliefs associated with gendered race also shape how individuals will cope with the reality of being perceived and treated as inferior, thereby creating another source of variability in the effect of reported interpersonal discrimination on CVH. Because increased exposure to social stressors among marginalized groups may yield an array of adaptive coping strategies that are protective against the health consequences of psychosocial adversity, the IP model predicts, perhaps counterintuitively, that the association between reports of racial and gender discrimination and declining CVH to be stronger among members of dominant status groups. The IP framework also posits that the susceptibility to direct versus indirect effects of discrimination on CVH are primarily a function of an individual's cumulative social experiences and will therefore manifest differentially across gendered race groups.

Given these hypotheses, two studies [29, 80] examined the relationship of reported interpersonal discrimination with CVH among black and white women and men using 30 years of longitudinal data from the Coronary Artery Risk Development in Young Adults study. The first study evaluated whether the associations of reported interpersonal experiences of racial and gender discrimination simultaneously compared with racial or gender discrimination alone, or no discrimination, with cardiovascular health 23 years later was stronger among white men than other groups. The second study explored variation in the relationship between simultaneously reported racial and gender discrimination and future CVH across eight social settings.

The studies identified important characteristics of the relationships between reported racial and gender discrimination and cardiovascular health (CVH) in black and white women and men. The first study identified differences in the associations between reported gender and racial discrimination and CVH, suggesting differential vulnerability (**Table 4**). Compared with reporting no discrimination, reporting any racial discrimination predicted higher CVH scores among black women, while no statistically significant associations were found among black men. Among white women, reporting any gender discrimination predicted higher CVH scores than reporting no discrimination. For white men, predicted CVH scores were higher for those reporting any racial discrimination, and lower for those reporting racial and gender discrimination in at least two settings, than in those reporting no discrimination.

These findings contrasted with those describing a link between racial discrimination and poorer cardiovascular health among black persons [7, 99, 101]. Though inconsistent, the literature has demonstrated associations of reported racial discrimination with CVD risk factors including diet, hypertension, smoking, sedentary behavior, obesity, and inflammation [50, 101, 103, 109], as well as social predictors of CVD such as marital status, socioeconomic position, and education, in both black women and men [7, 23]. In this study, we did not find a statistically significant association between racial discrimination and poorer CVH within these groups.

Evidence suggests that the multifaceted nature of the interpersonal discrimination experience operates within distinct social groups to differentially influence CVH in a manner not frequently captured in epidemiologic studies [22, 98, 99, 103]. Inconsistencies in the literature may be attributable, in part, to an inadequate conceptualization, measurement, and analysis of interpersonal discrimination in relation to CVH

The Identity Pathology framework provides a useful model for investigating these inconsistencies in the relationship of discrimination with CVD (see **Figure 1**). While not solely applicable to CVD, the model is useful for clarifying inconsistencies in the literature on interpersonal discrimination and CVD because it spec-

interpersonal discrimination will be measured as damaging to CVH and lead to the development of disease. As applied to CVD disparities and interpersonal discrimi-

First, that in order to more accurately capture the effects of interpersonal discrimination on cardiovascular health and health disparities, multiple aspects of the discrimination experience must be considered in the design, analysis, and interpretation of health-related studies. Secondly, the IP framework posits that experiences of interpersonal discrimination are fundamentally based in historically structured inequities that impact on each dimension of the discrimination process in healthrelevant ways. Finally, the model purports that the precision with which reported experiences map onto perceptions and intentionally or implicitly driven acts of discrimination depend on a variety of psychosocial characteristics, one of the most important of which is an individual's beliefs about their gendered racial identity. In other words, the contribution of discrimination to disparities in CVH may extend beyond gendered racial variation in *exposure* to gendered racial differences in the

The IP model argues that this variability in effect across gendered race groups can be attributed to differing manifestations of identity pathology. Due to the relationship between identity pathology and the experience of interpersonal discrimination, the experience being captured in reported discrimination among different gendered race groups must necessarily be different. For men reporting frequent experiences of gender discrimination, these experiences are less likely to reflect objective encounters with discrimination as traditionally conceptualized and

are more likely to signify that these men feel they are being deprived of the

*Application of the emerging identity pathology framework to describe potential pathways from intersecting axes*

ifies the conditions under which—and in whom—reported experiences of

across demographically diverse populations.

*Quality of Life - Biopsychosocial Perspectives*

nation, the model makes three central assertations.

effect of perceiving interpersonal discrimination.

*of structured racism and sexism to cardiovascular disease.*

**Figure 1.**

**32**


emotional states [27, 112]. The relatively low percentage of black women who reported experiencing no racial or gender discrimination did so despite a considerable body of evidence to the contrary, indicating a measure of denial or "tough it out" mentality in this group [27] distinct from the evidence-based reasons that a much greater proportion of white men would report no exposure. Even within gendered race groups, the meaning of reported exposure to discrimination may vary. As proposed in the IP framework, white men reporting few experiences of racial discrimination may subscribe to identity paradigms distinct from those in their group reporting both racial and gender discrimination in multiple settings. The framework posits that among white persons, reported experiences of racial discrimination in only one setting (e.g. at school) may be more likely to meet objective standards of discriminatory treatment. Accordingly, better CVH scores among white men who reported only racial discrimination would not be inconsistent with a protective effect of reporting interpersonal experiences of discrimination that meet objective measures. That is, white men who reported only exposure to racial discrimination were likely the white men for whom the overlap of the occurrence, perception, and reporting of discrimination was relatively accurate. As the IP model predicts, in such cases, there is likelihood that reported discrimination will be measured as protective of CVH. That the positive effect on CVH among white men reporting only racial discrimination persisted even after adjusting for SES further

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

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

Study 2 revealed that simultaneously reported racial and gender discrimination were differentially associated with CVH depending on gendered race and setting (**Table 2**). Among black women, with one exception, reported instances of interpersonal discrimination were not associated with CVH or were associated with a higher CVH score while the opposite findings were observed among the three other gendered race groups. For black men, simultaneously reported discrimination in four of the eight settings was significantly associated with poorer CVH. Associations across settings also differed between white women and men. For white women, reported racial discrimination by the police or courts or while seeking housing was associated with lower CVH scores, while among white men, self-reports of racial and gender discrimination in public or at work were associated with a lower CVH score. For all groups, reporting discriminatory experiences while receiving medical care had a negative impact on future CVH, although effect estimates did not reach

That the settings in which reported racial and gender discrimination were associated with poorer CVH differed among black and white women and men is consistent with disparate effect pathways for these groups that may be linked to gendered race-specific external and internal characteristics. The findings suggest that for black women, interpersonal experiences of discrimination are more likely to act indirectly on CVH by deterring access to health-influencing resources such as medical care, a mechanism that has been demonstrated in previous research [113]. Black women who reported racial and gender discrimination while receiving medical care were the only individuals of their gendered race group to experience a decline in CVH associated with reported discrimination; reported exposure in other settings was measured as either protective or had no influence on CVH. Rather than yielding a greater vulnerability to the negative health consequences of psychosocial stress as might be intuitively concluded, these findings suggest that black women may more readily adapt to hostile social environments such that the effects of recurrent interpersonal discrimination on the stress response system [64], or on certain health-related behaviors that preempt cardiovascular disease [103], are minimized in comparison to other gendered race groups. These results do not suggest that black women are immune to the physiological impacts of the

supports this assertation.

**35**

statistical significance among white women and men.

*\*p <sup>&</sup>lt; 0.05. <sup>a</sup>*

*Cardiovascular health scores are calculated based on data collected in year 30 or the last follow-up using six components: body mass index, total cholesterol, systolic blood pressure, fasting glucose, smoking status, and physical activity. Higher scores indicate better health. b Models are adjusted for age and geographic location.*

#### **Table 4.**

*Adjusted difference in cardiovascular health Scorea for categories of reported racial and/or gender discrimination by gendered Raceb : CARDIA, 1992–2016.*

Other cross-sectional analyses [100, 110] and the only study prospectively examining the relationships of racial discrimination with incident CVD exclusively among black women and men have also failed to find a connection [94]. Taken together, these findings offer evidence that traditionally accepted risk factors may be poorer predictors of CVD among black persons. Accordingly, while interpersonal racial discrimination may increase the likelihood that black women and men develop cardiometabolic risk factors for CVD, other factors integral to the experience of multiply marginalized identities may have a much more substantial impact on the development of CVD in these groups. As these other potential risk factors remain under studied [7, 95], the long history of investigating interpersonal discrimination as a cause of poorer health has done little to expand an understanding of CVD disparities between black and white women and men.

In addition to suggesting alternative causes of higher CVD morbidity and mortality among marginalized groups, the IP model theorizes that discrepancies between the occurrence, perception, and reporting of interpersonal discrimination contribute to the observed variability in the associations of reported racial and gender discrimination with CVH among black and white women and men (see **Figure 1**). The model suggests that for some gendered race groups in certain places and settings, reported discrimination is more likely to reflect interactions that meet objective standards of inequitable treatment. In these cases, acknowledging experiences that actually occur may be beneficial for health, while denying may lead to increased stress and stress-related pathology regardless of one's gendered race group [50, 111]. From building social networks based on shared experiences to enabling the development of healthier coping behaviors [27, 109], recognizing and acknowledging the discrimination one encounters may allow for chronic stress relief that reduces risk for CVD associated with discrimination exposure [50, 111]. Reported experiences of racial and gender discrimination may thus be measured as protective among those against whom such experiences actually occur.

To fully account for the results of this study in the context of IP theory, it is important to note that across the four gendered race groups, reporting or not reporting exposure likely signify different health-relevant psychological and

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

emotional states [27, 112]. The relatively low percentage of black women who reported experiencing no racial or gender discrimination did so despite a considerable body of evidence to the contrary, indicating a measure of denial or "tough it out" mentality in this group [27] distinct from the evidence-based reasons that a much greater proportion of white men would report no exposure. Even within gendered race groups, the meaning of reported exposure to discrimination may vary. As proposed in the IP framework, white men reporting few experiences of racial discrimination may subscribe to identity paradigms distinct from those in their group reporting both racial and gender discrimination in multiple settings. The framework posits that among white persons, reported experiences of racial discrimination in only one setting (e.g. at school) may be more likely to meet objective standards of discriminatory treatment. Accordingly, better CVH scores among white men who reported only racial discrimination would not be inconsistent with a protective effect of reporting interpersonal experiences of discrimination that meet objective measures. That is, white men who reported only exposure to racial discrimination were likely the white men for whom the overlap of the occurrence, perception, and reporting of discrimination was relatively accurate. As the IP model predicts, in such cases, there is likelihood that reported discrimination will be measured as protective of CVH. That the positive effect on CVH among white men reporting only racial discrimination persisted even after adjusting for SES further supports this assertation.

Study 2 revealed that simultaneously reported racial and gender discrimination were differentially associated with CVH depending on gendered race and setting (**Table 2**). Among black women, with one exception, reported instances of interpersonal discrimination were not associated with CVH or were associated with a higher CVH score while the opposite findings were observed among the three other gendered race groups. For black men, simultaneously reported discrimination in four of the eight settings was significantly associated with poorer CVH. Associations across settings also differed between white women and men. For white women, reported racial discrimination by the police or courts or while seeking housing was associated with lower CVH scores, while among white men, self-reports of racial and gender discrimination in public or at work were associated with a lower CVH score. For all groups, reporting discriminatory experiences while receiving medical care had a negative impact on future CVH, although effect estimates did not reach statistical significance among white women and men.

That the settings in which reported racial and gender discrimination were associated with poorer CVH differed among black and white women and men is consistent with disparate effect pathways for these groups that may be linked to gendered race-specific external and internal characteristics. The findings suggest that for black women, interpersonal experiences of discrimination are more likely to act indirectly on CVH by deterring access to health-influencing resources such as medical care, a mechanism that has been demonstrated in previous research [113]. Black women who reported racial and gender discrimination while receiving medical care were the only individuals of their gendered race group to experience a decline in CVH associated with reported discrimination; reported exposure in other settings was measured as either protective or had no influence on CVH. Rather than yielding a greater vulnerability to the negative health consequences of psychosocial stress as might be intuitively concluded, these findings suggest that black women may more readily adapt to hostile social environments such that the effects of recurrent interpersonal discrimination on the stress response system [64], or on certain health-related behaviors that preempt cardiovascular disease [103], are minimized in comparison to other gendered race groups. These results do not suggest that black women are immune to the physiological impacts of the

Other cross-sectional analyses [100, 110] and the only study prospectively examining the relationships of racial discrimination with incident CVD exclusively among black women and men have also failed to find a connection [94]. Taken together, these findings offer evidence that traditionally accepted risk factors may be poorer predictors of CVD among black persons. Accordingly, while interpersonal racial discrimination may increase the likelihood that black women and men develop cardiometabolic risk factors for CVD, other factors integral to the experience of multiply marginalized identities may have a much more substantial impact on the development of CVD in these groups. As these other potential risk factors remain under studied [7, 95], the long history of investigating interpersonal discrimination as a cause of poorer health has done little to expand an understanding of CVD

**Black women Black men White women White men**

0.1 (0.3, 0.5) 0.0 (0.5, 0.5) 0.2 (0.2, 0.6) 0.2 (0.6, 0.1)\*

0.2 (0.1, 0.6) 0.3 (0.7, 0.1) 0.0 (0.4, 0.4) 0.6 (1.1, 0.1)

ß (95% CI) ß (95% CI) ß (95% CI) ß (95% CI)

None ref. ref. ref. ref.

Any racial only 0.4 (0.0, 0.8)\* 0.1 (0.5, 0.4) 0.3 (1.2, 0.6) 0.4 (0.1, 0.8)\* Any gender only 0.3 (0.8, 0.2) 0.2 (0.6, 1.0) 0.3 (0.0, 0.6)\* 0.0 (0.4, 0.3)

*Cardiovascular health scores are calculated based on data collected in year 30 or the last follow-up using six components: body mass index, total cholesterol, systolic blood pressure, fasting glucose, smoking status, and physical*

*Adjusted difference in cardiovascular health Scorea for categories of reported racial and/or gender*

*: CARDIA, 1992–2016.*

In addition to suggesting alternative causes of higher CVD morbidity and mor-

To fully account for the results of this study in the context of IP theory, it is important to note that across the four gendered race groups, reporting or not reporting exposure likely signify different health-relevant psychological and

tality among marginalized groups, the IP model theorizes that discrepancies between the occurrence, perception, and reporting of interpersonal discrimination contribute to the observed variability in the associations of reported racial and gender discrimination with CVH among black and white women and men (see **Figure 1**). The model suggests that for some gendered race groups in certain places and settings, reported discrimination is more likely to reflect interactions that meet objective standards of inequitable treatment. In these cases, acknowledging experiences that actually occur may be beneficial for health, while denying may lead to increased stress and stress-related pathology regardless of one's gendered race group [50, 111]. From building social networks based on shared experiences to enabling the development of healthier coping behaviors [27, 109], recognizing and acknowledging the discrimination one encounters may allow for chronic stress relief that reduces risk for CVD associated with discrimination exposure [50, 111]. Reported experiences of racial and gender discrimination may thus be measured as protective

disparities between black and white women and men.

Discrimination (year 7)

Any racial or gender, in <2 settings

Both racial and gender, in ≥2 settings

*activity. Higher scores indicate better health.*

*discrimination by gendered Raceb*

*Models are adjusted for age and geographic location.*

*Quality of Life - Biopsychosocial Perspectives*

*\*p <sup>&</sup>lt; 0.05. <sup>a</sup>*

**Table 4.**

*b*

**34**

among those against whom such experiences actually occur.

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 [4, 98].

"in public or on the street" was one of the two settings in which white men who reported experiencing racial and gender discrimination experienced declining CVH. Given the historical contexts in which white men's social status afforded a measure of public and occupational deference, for some white men instances when this deference is absent or challenged in settings such as on the street or at work may be more likely to be perceived as discriminatory and more stressful than encounters perceived as discriminatory in other settings, an explanation that is consistent with

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

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

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 con-

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

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

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

the findings of this study.

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

that are rarely measured in epidemiologic studies.

ceptual inconsistencies in this approach [15, 16].

—to identity the causes of disease in order to eradicate.

**5. Conclusions**

**37**

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 group.

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 impact on CVH.

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

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

"in public or on the street" was one of the two settings in which white men who reported experiencing racial and gender discrimination experienced declining CVH. Given the historical contexts in which white men's social status afforded a measure of public and occupational deference, for some white men instances when this deference is absent or challenged in settings such as on the street or at work may be more likely to be perceived as discriminatory and more stressful than encounters perceived as discriminatory in other settings, an explanation that is consistent with the findings of this study.
