**3. Evidence supporting the necessity of a wholistic approach to health disparities research**

#### **3.1 Current evidence supporting both intersectional and wholistic identity approaches**

Extant epidemiological literature in accordance with an intersectional framework has identified gendered racial differences among black and white women and men in lung cancer treatment and mortality [12]; in the protective effects of income on depression [62]; in the association of depression with mortality [63]; and in the link between chronic stress and depression [64] among other exposure-health combinations. Yet, the results of these studies may also be viewed as evidence for the need of a wholistic identity approach.

The IP model builds on Intersectionality Theory in asserting that gendered racialization yields identity pathologies distinct to different gendered race groups, even among those not dually marginalized. Social hierarchies act to create unequal access to health-impacting resources, but it the convergence of each element of an individual's wholistic identity that accounts for the unique manifestations of disease caused by identity pathology across different social groups. In this section, I present evidence for the concomitantly protective and harmful effects of these gendered race-specific identity pathologies that can partially explain patterns of disease observed across gendered race groups in the United States.

For the purposes of demonstrating the application of IP theory to the epidemiology of gendered racial health disparities, I use the example of the socially constructed identity which has been the focus of this chapter thus far, gendered race, among four groups who occupy different tiers within a historically grounded social hierarchy: U.S.-born black and white women and men. Taking a snapshot of the pathologies (which fit accepted notions of disease) endemic to each of these

social resources do so along specific axes—inequitably, across races, genders, socioeconomic positions, abilities, sexual orientations, etc. Groups at the junctions of these axes are multiply advantaged or disadvantaged; disparities in health outcomes manifest at social intersections are, according to Intersectionality Theory, testament to the existence of a synergistic effect [10]. Internal identity processes that influence health in myriad ways, from stressor appraisal to behavior, have similarly been conceptualized in intersectional terms. The concept of dimensions outlined in Multidimensional identity theory also conjures an axial formulation of distinct identities. The intersection of these identities shapes how the external environment is experienced internally [11, 41], and subsequently, how social exposures impact

A wholistic identity approach challenges the notion of both intersecting identities and intersecting axes of oppression. Intersectionality Theory calls attention to the locations where the distinct mechanisms of social hierarchies such as racism and patriarchy overlap to dictate social and health outcomes [10]. A wholistic identity approach instead argues that because racism is inherently gendered and sexism is

decomposed into distinct measurable units. The impact of either on the outcomes of individuals targeted by these systems therefore has less to do with the number of marginalized social group categories under which individuals fall and more so with the sociocultural paradigms unique to specific social groups which shape the internalization of, and response to, adverse social experiences. As such, while acknowledging the influence of social context and experience on the content and salience of specific identities, the argument put forth here is that individuals do not experience oppression in an axial fashion, but rather through a wholistic identity lens. That is, experiences of inequity are filtered simultaneously through each element of selfconcept which predominates an individual's identity in a manner with direct implications for how such experiences will impact on health. While perhaps appearing problematically theoretical, this concept of wholistic identity as a determinant of health can be readily applied to improve current understandings of gender differ-

One newly emerging wholistic identity approach is the Identity Pathology (IP) model, an infectious disease framework for the effects of structural inequity on health. The triad paradigm of disease causation which sits at the foundation of infectious disease epidemiology describes interactions between an environment, a host, and a pathogenic agent [56]. The IP framework incorporates the three elements of the infectious disease triad to conceptualize the health-impacting interaction between structural inequity, individuals subscribing to socially constructed identities, and pathogenic identity beliefs. Conceptualizing identity beliefs as a pathogen that spreads through social interaction over time in a contagious manner to cause specific disease patterns across socially defined groups is an innovative approach to characterizing the causal pathways from structural inequity to disease. Contagion modeling of social determinants of health has been useful in explaining and predicting the effects of other social exposures, such as gun violence [57]. The IP model goes beyond identifying the contagious nature of socially driven health outcomes to directly characterizing the fundamental infectious elements underlying

According to IP theory, structural inequity serves as a breeding ground for the multilevel processes which yield unequal health outcomes. Through the construction and hierarchical organization of race and gender, as well as the disproportionate distribution of social and material resources across these categories, the ubiquitous nature of structural inequity lends itself to the nourishment of belief systems and

associated behaviors which produce population-level disease patterns.

inherently racialized, any effects of racism or sexism on health cannot be

on health.

*Quality of Life - Biopsychosocial Perspectives*

ences in health.

**24**

the spread of pathogenic social exposures.

groups at middle age (45–55), we see that black women are more likely to be afflicted by cardiometabolic conditions such as obesity and uncontrolled hypertension than the other groups [65]; black men, prostate cancer (compared with white men) and cardiovascular disease [65–67]; white women, prescription opioid abuse and depressive symptomatology (MDD) [17, 68]; and white men, alcoholism and suicide [17, 69, 70]. The IP framework asserts that these disease patterns result directly from the ways in which each of these group experience identity pathology as dictated by their gendered race.

The identity pathologies of white males and black females differ from those of black males and white females, and present with different symptomatology. White males occupy both racially and gender superordinate social positions, and are therefore more likely to be socialized to adopt identity paradigms which rely primarily on socially constructed relational self-worth. Without exposure to the subordinate status that conditions adoption of identity paradigms embedded with increased risk of internalization and chronic inflammation, white males are more likely to exhibit symptoms of recurrent identity stress through externalized controlreinforcing behaviors, which have been discussed at length. Subscribing to socially constructed white male identity paradigms not only increases susceptibility to antisocial tendencies attributable to pathologized whiteness, including lack of empathy, feelings of entitlement, and behaviors to reinforce feelings of control, but also externalizing disorders driven by pathogenic masculinity that manifest through violent or aggressive behavior toward self and others. As the practice of white male identity also requires the perpetuation of the structural violence that enables members of this group access to a disproportionate share of social and material resources, white males subscribing to these identity paradigms are also less susceptible to the physical disorders such as cardiovascular disease promoted by material

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

On the other hand, dominant narratives of white and male identity which distance whiteness from poverty [71] ensure that certain groups of white men are particularly susceptible to the health consequences of identity pathology. With increased dependence on superior status for a sense of self-worth [17, 28], not being afforded the expected privileges of white male membership can exacerbate the negative health effects of poverty. Poor white men, for example, face increased risk of depression, and substance abuse may serve as a form of coping [17, 77] for those white men not succumbing to other self-destructive compulsions of identity

In contrast, the dual occupancy of subordinate social positions may reduce the risk of psychopathology among black women, while conferring an increased risk for cardiometabolic disorder. As both female and non-white, their dually marginalized positions might predict that black female identity paradigms manifest a propensity for disorders such as depression as an expression of chronic stress. Identity pathology theory, however, contrasts the external social circumstances in which black women are situated with the internal resources characteristic of this group. The necessity for adapting to multi-faceted forces of structural violence may have enabled the development of psychological durability within black female identity paradigms that is protective against psychological symptoms of toxic stress. So, while occupying both racially and gender subordinate tiers might predict higher risk of psychological manifestations of depression among black women, the greater necessity for the development of effective coping strategies may actually act to

Not permitted access to social privilege or higher social status as a result of their

confer psychological resilience and reduce risk in this group [64, 79].

women, and white men, but not black women (**Table 2**) [80].

race or gender, evidence suggests that black women have been compelled to develop alternative standards of value in order to build self-worth. In this way deprived of access to sources of socially constructed self-esteem, black women subscribing to dominant black female identity paradigms are likely to appraise potential identity threats in a manner distinct from other groups. Specifically, acute, interpersonal experiences of identity threat may be perceived as less threatening. Previous research grounded in IP theory indicates, which will be later examined in more detail, that reported lifetime gender and racial discrimination in certain settings is associated with poorer cardiovascular health among black men, white

deprivation.

**27**

pathology such as suicide [17, 77, 78].

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

Most individuals are categorized as possessing at least one privileged and one marginalized identity. Queer or poor white men, for example, experience discordant social identities, as heteronormativity and classism rank these statuses as inferior [19, 71] even as their race and gender grant certain privileges. However, as previously noted, the immutable physical attributes assigned to gender and race lend a permanence and identifiability that make social processes particularly susceptible to discrimination based on these characteristics. Gendered racial identities are therefore particularly influential in shaping the manifestation of identity pathology.

As the theories covered in this chapter outline, female and black persons occupy subordinate social positions in the U.S. gendered racial hierarchy. Those who are both female and white, or male and black, however, occupy both subordinate (female and black) and dominant (white and male) positions and therefore can experience a particular kind of dissonance associated with simultaneous disempowerment and privilege. Because of this incongruence between the socially constructed racial and gender identities of white females and black males, these groups likely share underlying identity pathologies distinct from those of black women and white men. However, sociocultural influences as well as the influences of other centralized identities on coping can lead to distinct manifestations of identity pathology even among white women and black men.

Shared identity pathologies in which self-worth is predicated on an unattainable, but desired social status underlies prevalent diseases among white women and black men. The increased cardiovascular disease risk (as well as other chronic inflammatory diseases like prostate cancer) [72] in black men has been shown to correlate with John Henryism, a type of goal-striving stress caused by a refusal to succumb to racial or economic barriers to the practice of a socially defined masculinity among members of this group [73]. Similarly, the IP model asserts that white women's increased risk for inflammatory-based internalizing disorders such as depression are caused by an increased likelihood of self-blame and denial of social inequity. As the social value granted by whiteness is diminished through gender marginalization, opioid addiction becomes a method of avoidant coping consistent with the socialized internalization of female persons.

In this manner, black men and white women can perceive similar barriers to the benefits of their advantaged social positions. For some black men, racism prevents the full practice of socialized concepts of masculinity, leading to social deprivation, identity threat, and the cognitions and health behaviors that increase risk for cardiovascular disease [27, 73]. Likewise, for some white women, gender discrimination impedes access to the full perceived benefits of whiteness, leading to social marginalization, identity threat, and the cognitions and health behaviors that predispose members of this group to inflammatory-based depressive disorders. These hypotheses are supported by emerging evidence of a link between cardiovascular disease and depression [48, 74, 75], making a case for the assertations that (a) black men and white women may share identity pathologies that manifest distinctly based on sociocultural contexts, and (b) ostensibly dissimilar symptoms of illness may stem from shared disease origins [49, 76].

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

The identity pathologies of white males and black females differ from those of black males and white females, and present with different symptomatology. White males occupy both racially and gender superordinate social positions, and are therefore more likely to be socialized to adopt identity paradigms which rely primarily on socially constructed relational self-worth. Without exposure to the subordinate status that conditions adoption of identity paradigms embedded with increased risk of internalization and chronic inflammation, white males are more likely to exhibit symptoms of recurrent identity stress through externalized controlreinforcing behaviors, which have been discussed at length. Subscribing to socially constructed white male identity paradigms not only increases susceptibility to antisocial tendencies attributable to pathologized whiteness, including lack of empathy, feelings of entitlement, and behaviors to reinforce feelings of control, but also externalizing disorders driven by pathogenic masculinity that manifest through violent or aggressive behavior toward self and others. As the practice of white male identity also requires the perpetuation of the structural violence that enables members of this group access to a disproportionate share of social and material resources, white males subscribing to these identity paradigms are also less susceptible to the physical disorders such as cardiovascular disease promoted by material deprivation.

On the other hand, dominant narratives of white and male identity which distance whiteness from poverty [71] ensure that certain groups of white men are particularly susceptible to the health consequences of identity pathology. With increased dependence on superior status for a sense of self-worth [17, 28], not being afforded the expected privileges of white male membership can exacerbate the negative health effects of poverty. Poor white men, for example, face increased risk of depression, and substance abuse may serve as a form of coping [17, 77] for those white men not succumbing to other self-destructive compulsions of identity pathology such as suicide [17, 77, 78].

In contrast, the dual occupancy of subordinate social positions may reduce the risk of psychopathology among black women, while conferring an increased risk for cardiometabolic disorder. As both female and non-white, their dually marginalized positions might predict that black female identity paradigms manifest a propensity for disorders such as depression as an expression of chronic stress. Identity pathology theory, however, contrasts the external social circumstances in which black women are situated with the internal resources characteristic of this group. The necessity for adapting to multi-faceted forces of structural violence may have enabled the development of psychological durability within black female identity paradigms that is protective against psychological symptoms of toxic stress. So, while occupying both racially and gender subordinate tiers might predict higher risk of psychological manifestations of depression among black women, the greater necessity for the development of effective coping strategies may actually act to confer psychological resilience and reduce risk in this group [64, 79].

Not permitted access to social privilege or higher social status as a result of their race or gender, evidence suggests that black women have been compelled to develop alternative standards of value in order to build self-worth. In this way deprived of access to sources of socially constructed self-esteem, black women subscribing to dominant black female identity paradigms are likely to appraise potential identity threats in a manner distinct from other groups. Specifically, acute, interpersonal experiences of identity threat may be perceived as less threatening. Previous research grounded in IP theory indicates, which will be later examined in more detail, that reported lifetime gender and racial discrimination in certain settings is associated with poorer cardiovascular health among black men, white women, and white men, but not black women (**Table 2**) [80].

groups at middle age (45–55), we see that black women are more likely to be afflicted by cardiometabolic conditions such as obesity and uncontrolled hypertension than the other groups [65]; black men, prostate cancer (compared with white men) and cardiovascular disease [65–67]; white women, prescription opioid abuse and depressive symptomatology (MDD) [17, 68]; and white men, alcoholism and suicide [17, 69, 70]. The IP framework asserts that these disease patterns result directly from the ways in which each of these group experience identity pathology

Most individuals are categorized as possessing at least one privileged and one marginalized identity. Queer or poor white men, for example, experience discordant social identities, as heteronormativity and classism rank these statuses as inferior [19, 71] even as their race and gender grant certain privileges. However, as previously noted, the immutable physical attributes assigned to gender and race lend a permanence and identifiability that make social processes particularly susceptible to discrimination based on these characteristics. Gendered racial identities are therefore particularly influential in shaping the manifestation of identity

As the theories covered in this chapter outline, female and black persons occupy subordinate social positions in the U.S. gendered racial hierarchy. Those who are both female and white, or male and black, however, occupy both subordinate (female and black) and dominant (white and male) positions and therefore can experience a particular kind of dissonance associated with simultaneous disempowerment and privilege. Because of this incongruence between the socially constructed racial and gender identities of white females and black males, these groups likely share underlying identity pathologies distinct from those of black women and white men. However, sociocultural influences as well as the influences of other centralized identities on coping can lead to distinct manifestations of

Shared identity pathologies in which self-worth is predicated on an unattainable, but desired social status underlies prevalent diseases among white women and black men. The increased cardiovascular disease risk (as well as other chronic inflammatory diseases like prostate cancer) [72] in black men has been shown to correlate with John Henryism, a type of goal-striving stress caused by a refusal to succumb to racial or economic barriers to the practice of a socially defined masculinity among members of this group [73]. Similarly, the IP model asserts that white women's increased risk for inflammatory-based internalizing disorders such as depression are caused by an increased likelihood of self-blame and denial of social inequity. As the social value granted by whiteness is diminished through gender marginalization, opioid addiction becomes a method of avoidant coping consistent with the social-

In this manner, black men and white women can perceive similar barriers to the benefits of their advantaged social positions. For some black men, racism prevents the full practice of socialized concepts of masculinity, leading to social deprivation, identity threat, and the cognitions and health behaviors that increase risk for cardiovascular disease [27, 73]. Likewise, for some white women, gender discrimination impedes access to the full perceived benefits of whiteness, leading to social marginalization, identity threat, and the cognitions and health behaviors that predispose members of this group to inflammatory-based depressive disorders. These hypotheses are supported by emerging evidence of a link between cardiovascular disease and depression [48, 74, 75], making a case for the assertations that (a) black men and white women may share identity pathologies that manifest distinctly based on sociocultural contexts, and (b) ostensibly dissimilar symptoms of illness may

identity pathology even among white women and black men.

ized internalization of female persons.

stem from shared disease origins [49, 76].

**26**

as dictated by their gendered race.

*Quality of Life - Biopsychosocial Perspectives*

pathology.


(**Table 3**) [64]. Furthermore, there is indication that the underlying neurobiology of depression differs among black women compared with black men, white women, and white men (**Table 1**) [49, 87]. The depressive response to deprivation among black women, rather than being a function of a perceived threat to deeply held selfconcepts that promotes sustained inflammation, as IP theory argues is more likely to be the case among black men and white women, may be based more in a situation-appropriate response to the uniquely disadvantaged social conditions in which black women are disproportionately situated. So, while the prevalence of depressive symptoms may be substantial among black women, these symptoms may be indicative of a response that is distinct from the pathology manifest in depressive symptoms among other groups. Evidence that adjusting for socioeconomic status eliminates the gender disparity in depression among black persons but

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

These potential psychological benefits do not come without physical costs, however. Where black women may be psychologically resilient, they are likely to be physically vulnerable; high rates of obesity, hypertension, and poor maternal/neonatal outcomes in this group reflect a unique adaptation to structural inequity metabolically, rather than psychologically, exhibiting pathology. In addition to the structural racism and sexism that concentrates economic deprivation and limits the

capacity for health-promoting behaviors within black female populations [10, 82, 85], black female identity paradigms demand what could be argued as a pathological minimization of self-care in efforts to be valued as caregiver [84, 89]. As Superwoman Schema theory suggests, in prioritizing the needs of others, black women often bear an extensive familial and community burden without complaint at the cost of their own emotional and physical needs [84]. Adherence to these gendered race-specific identity paradigms predisposes black women to automated coping such as emotional eating [90, 91], other risk-factors for obesity such as postpartum weight retention [92], and other health-impacting behaviors such as low health services utilization [93]. Furthermore, another form of identity pathology characterized by a failure to acknowledge the existence, or negative psychological impacts, of structural inequity can lead to denial and internalization which may

not white [88] further supports this theory.

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

lead to premature disease and mortality [29, 94].

*Health and Nutrition Examination Survey, 2005–2010.*

Depression, % (SE)

Low AL<sup>b</sup> (0–3)

High AL (4–9)

*a*

*b*

*c*

**29**

*\**p *< 0.05. \*\**p *< 0.0001.*

**Table 3.**

**All (***n* **= 6431) Black women**

**(***n* **= 980)**

**White women (***n* **= 2147)**

7.3 (0.5) 14.6 (1.3) 8.5 (0.7) 7.1 (0.8) 4.9 (0.6)

6.1 (0.5) 13.4 (1.4) 6.9 (0.7) 6.1 (0.9) 4.3 (0.6)

11.8 (1.2) 17.1 (3.0) 15.3 (1.9) 10.1 (2.0) 7.4 (1.5)

Crude 2.1 (1.6, 2.7)\*\* 1.3 (0.8, 2.2) 2.4 (1.7, 3.4)\*\* 1.7 (1.0, 3.0)\* 1.8 (1.0, 3.0)\* Adjusted<sup>c</sup> 1.7 (1.3, 2.2)\*\* 1.1 (0.6, 2.0) 2.1 (1.5, 3.0)\*\* 1.7 (1.0, 2.9)\* 1.4 (0.8, 2.5)

*Results are from five separate logistic regression models; one for the total sample and one for each gendered race group.*

*Depression in relation to Allostatic load by gendered race Group<sup>a</sup> among Black and white US adults: National*

*Allostatic load, calculated as a composite of nine cardiovascular, metabolic, and immune biomarkers.*

*Adjusted for five age groups and five groups of ratio of household income to the US poverty threshold.*

**Black men (***n* **= 1028)**

**White men (***n* **= 2276)**

*a All models are adjusted for age and study center.*

*b Health scores are calculated based on data collected in year 30 or the last follow-up after year 7, using six components with a total possible 12 points: body mass index, total cholesterol, systolic blood pressure, fasting glucose, smoking status, and physical activity. Higher scores indicate better health.*

*c At year 7, discrimination "at home" was excluded from the race or color scale; "by the police or courts" and "getting housing" were excluded from the gender scale.*

*\*p < 0.05*

#### **Table 2.**

*Adjusted<sup>a</sup> difference in cardiovascular health Score<sup>b</sup> at year 30 of the CARDIA study across settings of simultaneously reported racial and gender discrimination at year 7, ß (95% CI): 1992–2016.*

This psychological resilience among black women may be grounded in an ability to redefine standards of value in a manner that challenges the very notion of socially constructed subordinance. Contrary to what many psychological theories once predicted, members of stigmatized groups tend to have comparable levels of selfesteem with non-stigmatized groups [81]. Researchers attributed these surprising findings to the use of self-protecting mechanisms by members of stigmatized groups such as "selectively devaluing, or regarding as less important for their selfdefinition, those performance dimensions on which they or their group fare(s) poorly, and selectively valuing those dimensions on which they or their group excel (s)" [81]. Dominant sociocultural narratives rank black women at the bottom in most highly regarded social dimensions—physical beauty, intellectually capability, etc. [82], but celebrate their caregiving, selfless, mothering natures [83, 84]. However, rather than devaluing the dimensions in which society ranks them poorly as identity stigma predicts, many black women appear to have developed alternative social rating systems which do not predicate socially valued traits on dominant group standards [79, 82].

Furthermore, their professions, voting patterns, and activism demonstrate that black women have identified a source of self-worth inherent to the practice of caring for and about others [85]. In this way, by enabling a greater sense of selfefficacy in which black women feel capable of determining for themselves standards against which their value will be measured [82], multifaceted forces of disempowerment may confer individuals subscribing to dominant black female identity paradigms a measure of protection against the psychological manifestations of the very chronic identity threat they cause.

In support of this hypothesis, research demonstrates that allostatic load, a measure of cumulative physiological dysregulation stemming from chronic stress that precedes and correlates highly with many chronic diseases [86], is associated with depression among black men and white women, but not black women or white men *Health Disparities at the Intersection of Gender and Race: Beyond Intersectionality Theory… DOI: http://dx.doi.org/10.5772/intechopen.92248*

(**Table 3**) [64]. Furthermore, there is indication that the underlying neurobiology of depression differs among black women compared with black men, white women, and white men (**Table 1**) [49, 87]. The depressive response to deprivation among black women, rather than being a function of a perceived threat to deeply held selfconcepts that promotes sustained inflammation, as IP theory argues is more likely to be the case among black men and white women, may be based more in a situation-appropriate response to the uniquely disadvantaged social conditions in which black women are disproportionately situated. So, while the prevalence of depressive symptoms may be substantial among black women, these symptoms may be indicative of a response that is distinct from the pathology manifest in depressive symptoms among other groups. Evidence that adjusting for socioeconomic status eliminates the gender disparity in depression among black persons but not white [88] further supports this theory.

These potential psychological benefits do not come without physical costs, however. Where black women may be psychologically resilient, they are likely to be physically vulnerable; high rates of obesity, hypertension, and poor maternal/neonatal outcomes in this group reflect a unique adaptation to structural inequity metabolically, rather than psychologically, exhibiting pathology. In addition to the structural racism and sexism that concentrates economic deprivation and limits the capacity for health-promoting behaviors within black female populations [10, 82, 85], black female identity paradigms demand what could be argued as a pathological minimization of self-care in efforts to be valued as caregiver [84, 89]. As Superwoman Schema theory suggests, in prioritizing the needs of others, black women often bear an extensive familial and community burden without complaint at the cost of their own emotional and physical needs [84]. Adherence to these gendered race-specific identity paradigms predisposes black women to automated coping such as emotional eating [90, 91], other risk-factors for obesity such as postpartum weight retention [92], and other health-impacting behaviors such as low health services utilization [93]. Furthermore, another form of identity pathology characterized by a failure to acknowledge the existence, or negative psychological impacts, of structural inequity can lead to denial and internalization which may lead to premature disease and mortality [29, 94].


*a Results are from five separate logistic regression models; one for the total sample and one for each gendered race group. b Allostatic load, calculated as a composite of nine cardiovascular, metabolic, and immune biomarkers. c Adjusted for five age groups and five groups of ratio of household income to the US poverty threshold.*

*\**p *< 0.05.*

*\*\**p *< 0.0001.*

#### **Table 3.**

*Depression in relation to Allostatic load by gendered race Group<sup>a</sup> among Black and white US adults: National Health and Nutrition Examination Survey, 2005–2010.*

This psychological resilience among black women may be grounded in an ability to redefine standards of value in a manner that challenges the very notion of socially constructed subordinance. Contrary to what many psychological theories once predicted, members of stigmatized groups tend to have comparable levels of selfesteem with non-stigmatized groups [81]. Researchers attributed these surprising findings to the use of self-protecting mechanisms by members of stigmatized groups such as "selectively devaluing, or regarding as less important for their selfdefinition, those performance dimensions on which they or their group fare(s) poorly, and selectively valuing those dimensions on which they or their group excel (s)" [81]. Dominant sociocultural narratives rank black women at the bottom in most highly regarded social dimensions—physical beauty, intellectually capability, etc. [82], but celebrate their caregiving, selfless, mothering natures [83, 84]. However, rather than devaluing the dimensions in which society ranks them poorly as identity stigma predicts, many black women appear to have developed alternative social rating systems which do not predicate socially valued traits on dominant

**Setting<sup>c</sup> Black women Black men White women White men**

Getting a job 0.0 (0.3, +0.3) 0.3 (0.6, 0.0)\* 0.6 (1.3, +0.1) 0.5 (1.1, +0.1)

At work +0.1 (0.2, +0.4) 0.4 (0.7, 0.1)\* 0.4 (0.9, +0.1) 1.0 (1.6, 0.3)\* At school +0.3 (0.0, +0.6)\* 0.4 (0.8, 0.0)\* 0.1 (0.6, +0.5) 0.3 (1.1, +0.4)

At home +0.1 (0.3, +0.4) 0.1 (0.6, +0.4) 0.2 (0.5, +0.1) 0.2 (0.7, +0.3)

*Health scores are calculated based on data collected in year 30 or the last follow-up after year 7, using six components with a total possible 12 points: body mass index, total cholesterol, systolic blood pressure, fasting glucose, smoking status,*

*At year 7, discrimination "at home" was excluded from the race or color scale; "by the police or courts" and "getting*

*Adjusted<sup>a</sup> difference in cardiovascular health Score<sup>b</sup> at year 30 of the CARDIA study across settings of simultaneously reported racial and gender discrimination at year 7, ß (95% CI): 1992–2016.*

+0.2 (0.0, +0.5)\* 0.0 (0.3, +0.3) +0.1 (0.2, +0.5) 0.5 (1.0, 0.1)\*

0.1 (0.3, +0.2) 0.2 (0.5, +0.1) 1.5 (2.5, 0.4)\* 0.4 (1.5, +0.7)

0.5 (0.9, 0.1)\* 0.7 (0.9, 0.1)\* 1.5 (3.8, +0.7) 1.1 (2.7, +0.5)

0.1 (0.2, +0.4) 0.1 (0.4, +0.2) 1.1 (2.0, 0.3)\* 0.3 (0.9, +0.4)

Furthermore, their professions, voting patterns, and activism demonstrate that

In support of this hypothesis, research demonstrates that allostatic load, a measure of cumulative physiological dysregulation stemming from chronic stress that precedes and correlates highly with many chronic diseases [86], is associated with depression among black men and white women, but not black women or white men

black women have identified a source of self-worth inherent to the practice of caring for and about others [85]. In this way, by enabling a greater sense of selfefficacy in which black women feel capable of determining for themselves standards against which their value will be measured [82], multifaceted forces of disempowerment may confer individuals subscribing to dominant black female identity paradigms a measure of protection against the psychological manifestations

group standards [79, 82].

**28**

In public/on the street

Getting housing

Receiving medical care

*a*

*b*

*c*

*\*p < 0.05*

**Table 2.**

By the police or courts

*All models are adjusted for age and study center.*

*Quality of Life - Biopsychosocial Perspectives*

*housing" were excluded from the gender scale.*

*and physical activity. Higher scores indicate better health.*

of the very chronic identity threat they cause.

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.

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

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

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

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 phys-

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 interper-

The complex relationships of these psychosocial exposures with CVD among black

sonal discrimination such as barriers to quality health care [98, 100, 108].

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].

iological impact of perceived discriminatory interactions.

among blacks [7, 98, 99].

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

resources [29, 80, 107].

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