**1.2 Why gender and race?**

important contributors—the most important contributors, one could argue—to these racial and ethnic gaps in health status were often overlooked in epidemiologic

tions in which individuals live and work [1, 2, 4, 6], a lack of well-developed theoretical context to health disparities research frequently yields data, results, and interpretations that obfuscate the complex mechanisms underlying social group disparities in health [7]. Wide-spread assumptions of racial homogeneity [8, 9], for example, echo biological essentialism, masking important within-race gender or socioeconomic differences in disease risk, pathogenesis, prognosis, and treatment efficacy, even in those studies which acknowledge social determinants of health. Theory emerging from the social science and social psychological disciplines is

often borne of extensive grappling with these complex causal webs. Intersectionality Theory [10] and Multidimensional Identity Theory [11] are among many theoretical frameworks which outline compelling social and psychological explanations for disparate health outcomes along what are frequently conceptualized as "dimensions" of identity—race, gender, socioeconomic status, and other social group designations. From studies of genetic risk, heath service utilization, and health behaviors to the health-impact of identity processes and coping responses, research grounded in these intersectional theories indicates that socially constructed categories such as race can be further divided into meaningfully distinct categories such as "gendered race" with important implications for accurately assessing the

Despite being one of the most increasingly used social theories in epidemiologic research, much of the theoretical nuance of Intersectionality Theory is often lost in application. The frequent oversimplification of theory manifests, in part, as a growing trend in efforts to decompose the relative contributions of intersecting exposures such as race and socioeconomic status [15]. Aside from the uncertain utility of such findings in addressing social group disparities in health, these methods reflect an interpretation that is in many ways counter to the central claims of Intersectionality Theory—that the effects of such exposures can somehow be separated [16]. The relationship between epidemiologic research and social psychological theory is even more tenuous. Very few studies even consider the populationlevel health implications of internal identity processes, whose effects on health can

in many ways be even more difficult to capture than the consequences of compounded external social processes such as racial, gender, and socioeconomic

To address the challenge of improving the utility of theory in understanding gender differences in health, I advocate for a conceptualization of social and psychosocial exposures that moves beyond "intersection" toward a "wholistic" identity approach. This approach emphasizes how the external social factors that shape health are experienced by individuals who not separately gendered, raced, or classed, but who each have a wholistic identity developed out of the unique social experience determined by these constructs which influences how external contexts are internally mediated and manifest in health. I argue that such an approach could circumvent the temptation of attempting to quantify the relative contributions of specific dimensions of oppression when far more integral to understanding social group health differences is characterizing the internal and external barriers and resources unique to different social groups. A wholistic identity approach not only aids in elucidating how the lived experience of one's social status as determined by a unique combination of race, gender, etc., affects health, but would also allow for a more ethical and scientifically sound conduct of epidemiologic research if employed

causes of, and solutions for, health disparities [12–14].

Even as epidemiologists increasingly consider the causal role of the social condi-

research [5].

*Quality of Life - Biopsychosocial Perspectives*

inequity.

with greater frequency.

**18**

A question that often arises in epidemiologic research drawing from Intersectionality Theory is how the selection for study of any two identity categories, frequently gender and race, can be justified under the concept of inseparability of identity. In this chapter, I use gender and race as one example to explore the validity of a wholistic identity approach in epidemiologic research. Importantly, of the many designations which demarcate social groups in the U.S., there is strong evidence that gender and race exert a substantial, unique influence on health [14, 17, 18]. Despite the ongoing debate of whether race or socioeconomic status contributes more to poorer health outcomes among black persons in the USA [3], the social categories of gender and race share a number of factors not characteristic of other social constructs.

First, they are arguably two of the most visible and socially reinforced demographic traits. Whether approaching from an external social resource framework or an internal identity framework, the readily recognizable nature of race and gender means that individuals are more frequently subject to interpersonal discrimination based on these characteristics than other types of discrimination [18–22]. Such experiences can have far-reaching consequences for health, from chronic physiological dysregulation associated with toxic stress [22, 23] to receipt of subpar medical care [23] and increased barriers to protective social factors such as stable, safe housing or occupations [24]. With the structurally rooted, pervasive nature of racial and gender discrimination, the visibility of race and gender ultimately yields an overrepresentation of black persons and women among the poor and disadvantaged [3]. In this way, regardless of the magnitude of the effect of socioeconomic status on health, race and gender are determinants of socioeconomic status and therefore can be conceptualized as further upstream on the causal pathway from structural to health inequity.

Secondly, many social psychological and anthropological theories of race, as well as feminist theory, argue that cues for race and gender are more prevalent in the social environment than cues for any other social designation [19, 25, 26]. That is, more cultural elements, whether dress styles or styles of worship, are racialized and gendered than given any other social group categorization. In the context of hierarchical racial and gender structures, the prevalence of these constant reminders of what constitutes blackness and whiteness, or femininity and masculinity, renders race and gender particularly influential on how susceptible individuals are to the health consequences of their groups' perceived inferiority or superiority [17, 18, 27–29].

As will be discussed further in the following section, the majority of theories rejecting biological determinism describe the central, causal role for structural inequity in the poorer health outcomes of racial and ethnic minorities and women [4, 10, 18, 20, 24]. Health outcomes can be neither ethically nor rigorously examined outside of the sociopolitical and sociocultural contexts in which the populations of interest are located. Arguably, in the U.S. as elsewhere, the long history of violence against racial and ethnic minorities and women is unapparelled in its pervasiveness and brutality [26, 30], violence executed with the express purpose of establishing and maintaining white and male supremacy [10, 26, 30, 31]. Given this history and the degree to which racial and gender violence became embedded within the structure of U.S. social institutions [10, 26, 30, 31], it can be reasonably inferred that race and gender will have a more measurable impact on the health outcomes attributed to such inequity than other social designations.

Throughout this chapter, I will use the increasingly popular term "gendered race", therefore, to reinforce the need for a wholistic identity approach in epidemiologic research on health disparities. The term captures the concomitant elements of socially assigned gender and race categories that cannot be decomposed, neither within an individual's self-concept nor in the manner which social inequities operate to structure privilege and marginalization based on these characteristics.

largely a function of the social meaning assigned to gender. These definitions carry value constructed by structural, institutionalized gender prejudice as well as cultural traditions that are heavily based in binary, hierarchical concepts of gender [19, 25]. The value assigned to gender is also dependent on other social designations such as race. In fact, perhaps contributing to persistent conflicting evidence on the magnitude and causes of gender differences in health is an assumption of consistency in gender effects on health across racial groups. Any efforts to clarify the causes of gender-related differences in health must necessarily engage the historical contexts in which these health-determining social designations are constructed. These analyses may yield additional, accessible intervention targets on gendered

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

**2.2 Social, anthropological, and social psychological perspectives on social**

that influence the political practices which deprive other groups of access.

Social Identity [41] and Multidimensional Identity [11] theories exist in parallel with these frameworks, describing how the construction of social group identity, likewise informed by intersecting axes of structured oppression, designates advantage and disadvantage across social groups. Identity triggers, what the Jedi Public Health framework [42] terms the overt and covert cues embedded within the social environment which reinforce shared social ideologies, connect structural-level identity outputs with individual-level identity inputs. The Social Signal Transduction Theory of Depression [43] proposes specific ways in which these individuallevel identity signals are transduced through psychoneuroendocrinological pathways that ultimately lead to disease. In this way, these frameworks each provide important but distinct elements of the larger machination by which structural inequity shapes the external social processes and internal identity processes that

To truly engage these theories in a manner that is meaningful for researchers to

understand the health significance of social hierarchies, the historical contexts which have defined concepts such as gender and race, and the ways in which these constructs become biology [38], must be carefully analyzed. Legal sanction of rape, physical assault, and other forms of wide-spread abusive behavior against women has deep historical roots in the U.S. as globally [18, 19, 30]. These practices are only one element of a social environment in which female persons have been subject to gender-based dehumanization so pervasive and persistent as to appear not only

Beyond sanctioning violence in ways that left little possibility for reprise or protection, legal disempowerment of women occurred in a variety of other ways. Among them include inheritance and land ownership prohibitions, and denial of voting rights. Historical analyses also reveal the ways in which the practice of

A vast store of sociological and anthropological literature describes the racial, gender, and economic inequity inherent to the hierarchical social structure of the United States (e.g. [10, 19, 25, 26, 34–36]), as well as the ways in which such social environments are inextricably linked with health [1, 6, 7, 37, 38]. Intersectionality Theory [10], Ecosocial Theory [2], and the Environmental Affordances model [39] specifically emphasize the compound effect of multiple forms of structured inequity intersecting to influence the disproportionate distribution of social, material, and natural resources across dominant status and marginalized populations. Social dominance theory [40] further suggests that structured inequity is supported through "legitimizing myths", or consensually shared ideologies which position certain groups as beneficiaries of these health-impacting resources while also promoting narratives

health disparities.

**group differences in health**

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

yield social group differences in health.

unavoidable but a product of nature [18, 19, 30].

**21**

#### **1.3 Chapter goals**

Far from being the first to advocate for the increased use of theory in epidemiologic research, the primary objective of this chapter is to argue for a wholistic identity approach that moves beyond concepts of intersecting social forces of oppression as determinants of health. Examining health disparities across gendered race groups through the rich perspectives emerging from the social science and social psychological disciplines, I contribute a novel interdisciplinary interpretation which underscores the need for considering both external social processes and internal identity processes in understanding and addressing the causes of gender differences in health. This chapter provides an overview of current evidence for gender differences in health which vary across race, outlining support for one wholistic identity framework, Identity Pathology theory, and its utility in the optimal execution of ethical epidemiologic research. The chapter concludes with recommendations for the inclusion of a wholistic identity approach in epidemiologic and statistical methods, as well as health intervention development.

It is important to note that the research explored in this chapter is based on cisgender identities (gender identities which are consistent with sex assigned at birth), and do not address how gendered race operates in the lived experiences of trans or gender non-conforming individuals to impact on health.
