**2. Theoretical frameworks for social group differences in health**

#### **2.1 Biologically driven vs. socially constructed differences in health**

The distinction between biologically and socially defined categories, while rarely considered theoretically or analytically in epidemiologic research, is integral to understanding how the wholistic effect of gender and race on health extend beyond the individual contributions of either construct. Sex, a biological category, influences physiological processes through the accumulation of hormones, gene expression, and reproduction determined by the presence or absence of the X chromosome. Gender, a sociocultural category, informs identity concepts, exposure to and appraisal of stressors, behaviors, and access to care—all factors whose physiological significance is also dependent on the external contexts in which identity is experienced.

As sex and gender are often conflated in health research [32], it is all the more difficult to tease out the individual contributions of each to specific patterns of health, disease, and mortality, particularly given their interdependent nature. For example, testosterone, a naturally produced hormone is present on average at higher concentrations in males [33], is associated with aggressive behavior. Culturally designated masculinity often reinforces aggression in males [31], leading to increased production of testosterone [33]. In this way, the interplay between sex and gender renders efforts to disentangle their individual effects on populationlevel health differences particularly challenging.

Despite the difficulty of distinguishing health outcome differences attributable to gender and sex, focusing on eliminating those differences that are unnecessary and therefore unjust—can serve as a useful target for epidemiologic research. Because gender is a sociocultural construct, gender differences in health are also

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

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.

#### **2.2 Social, anthropological, and social psychological perspectives on social group differences in health**

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 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 yield social group differences in health.

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

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

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.

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

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

The distinction between biologically and socially defined categories, while rarely

chromosome. Gender, a sociocultural category, informs identity concepts, exposure to and appraisal of stressors, behaviors, and access to care—all factors whose physiological significance is also dependent on the external contexts in which identity is

As sex and gender are often conflated in health research [32], it is all the more difficult to tease out the individual contributions of each to specific patterns of health, disease, and mortality, particularly given their interdependent nature. For example, testosterone, a naturally produced hormone is present on average at higher concentrations in males [33], is associated with aggressive behavior. Culturally designated masculinity often reinforces aggression in males [31], leading to increased production of testosterone [33]. In this way, the interplay between sex and gender renders efforts to disentangle their individual effects on population-

Despite the difficulty of distinguishing health outcome differences attributable to gender and sex, focusing on eliminating those differences that are unnecessary and therefore unjust—can serve as a useful target for epidemiologic research. Because gender is a sociocultural construct, gender differences in health are also

considered theoretically or analytically in epidemiologic research, is integral to understanding how the wholistic effect of gender and race on health extend beyond the individual contributions of either construct. Sex, a biological category, influences physiological processes through the accumulation of hormones, gene expres-

and statistical methods, as well as health intervention development.

**2. Theoretical frameworks for social group differences in health**

**2.1 Biologically driven vs. socially constructed differences in health**

sion, and reproduction determined by the presence or absence of the X

gender non-conforming individuals to impact on health.

level health differences particularly challenging.

**1.3 Chapter goals**

*Quality of Life - Biopsychosocial Perspectives*

experienced.

**20**

medicine has been used to subjugate female persons [44, 45], not in the least by employing psychiatric diagnoses to discredit resistance to oppressive social and cultural norms [44, 46]. Decades of research have accumulated substantial evidence [10, 18, 30, 34] that like black persons, women's exposure to violence, exploitation, and abuse by men while being simultaneously deprived of the physical, political, or legal means to defend themselves or prevent misogynistic violence has resulted in a greater propensity for appraising trauma through a lens of powerlessness.

The structural violence employed to enforce female subordination also conditions females to see violence committed against them as consequences of their own behaviors [19, 30], which can promote the learned helplessness that drives internalization. The widely practiced tradition of female denigration following experiences of gender-based violence increases the likelihood of females' perceptions of their own complicity in traumatic experiences, and likely contributes to the increased vulnerability to internalization observed in this group [18, 19, 30]. The sense of helplessness fostered by a lack of social and legal repercussions for males' physical and sexual aggression toward females, as well as pervasive denigrating responses to female victims of gender-based violence, has promoted internalization in a space where any outward expression of discontent might yield further abuse.

These experiences of gendered dehumanization carry compelling implications for gender differences in health. As has long been argued, there is strong evidence that socially reinforced gender hierarchies directly influence female susceptibility to internalizing psychopathologies like depression and post-traumatic stress disorder (PTSD) [18, 47]. Research highlights a key role for chronic exposure to negative circumstances, or "strain", in women's predisposition toward depressive symptoms [18, 19]. The source of this gender-specific strain is often identified in unique experiences associated with lack of social power as well as societal norms and expectations of women [18, 19]. Accordingly, the IP framework argues that the experience of being a female person in a male-dominated society [rather than solely inherent biological traits of the female sex], increases susceptibility to specific types of psychological and physical disorders associated with the physiological conditioning of subordinate status. Similar to the manner by which race becomes biology [38], so too, does gender become biology.

experience of chronic strain. Still, previous research has identified stress correlates of perceived dominance, showing increased pituitary–adrenal responsiveness to psychological stressors in socially dominant males [52]. This limited evidence suggests that those in dominant positions can also experience higher levels of stress as a function of their status. However, chronic exposure to dominant-status stress likely acts to shape brain physiology and manifestations of identity-based trauma in ways distinct from the chronic stress generated by subordinate social status [53–55]. Where subordinate social status promotes internalizing disorders, dominant status promotes externalizing disorders characterized by antisocial behavior. Social dominance orientation (SDO) measures the degree of preference for inequality among social groups, a personality trait that negatively correlates with empathy, tolerance, and altruism [40], and promotes reduced activity in the brain regions associated with the ability to feel concern for the pain of others [53]. In studies measuring variation in SDO, both male and white persons were found to have significantly higher orientation, suggesting that white males are more likely than either female or black persons to both promote and subscribe to legitimizing myths (rape myths of victim culpability, for example) that enable justification of their dominance-reinforcing behavior [40]. Because high SDO also correlates with low empathy, it is likely that experiences of inequity among those whose race and gender are ranked as superior can yield a proclivity for antisocial behaviors. This propensity is manifest in gendered racial disparities in suicide risk, perpetration of rape, pedophilic child molestation, and mass violence, and risk for Anti-Social

*Adjusted<sup>a</sup> odds of depression<sup>b</sup> with high-risk allostatic load and biomarker levels by gendered race in National*

*.*

*Results are from four separate regression models. The reference category for the biomarkers in each model is "low-risk". <sup>d</sup>*

*Models adjusted for PIR (ratio of household income to the US poverty threshold), age, and all biomarkers.*

**Biomarker Black women White women Black men White men** Systolic BP 1.2 (0.6, 2.5) 1.1 (0.6, 2.0) 1.7 (1.1, 2.7)\* 1.4 (0.8, 2.5) Diastolic BP 1.1 (0.6, 2.1) 1.3 (0.8, 2.2) 1.2 (0.8, 1.9) 1.3 (0.8, 2.1) Pulse 1.1 (0.7, 1.6) 1.5 (1.1, 2.2)\* 1.2 (0.6, 2.4) 1.8 (1.1, 2.9)\* BMI 0.8 (0.5, 1.2) 1.1 (0.7, 1.7) 1.1 (0.6, 2.0) 0.9 (0.6, 1.3) Total cholesterol 1.6 (1.0, 2.7)\* 1.1 (0.8, 1.5) 1.0 (0.5, 2.0) 0.8 (0.4, 1.3) HDL cholesterol 1.2 (0.6, 2.3) 1.1 (0.7, 1.7) 1.7 (0.9, 3.4) 1.3 (0.8, 1.9) Glyco-hemoglobin 1.1 (0.8, 1.7) 1.0 (0.6, 1.7) 0.9 (0.5, 1.6) 0.8 (0.5, 1.4) Serum Albumin 0.9 (0.6, 1.3) 1.0 (0.7, 1.6) 1.7 (1.0, 2.9)\* 1.3 (0.7, 2.5) CRP 0.8 (0.6, 1.1) 1.7 (1.1, 2.6)\* 0.9 (0.5, 1.5) 1.8 (1.1, 2.8)\* High-risk AL<sup>d</sup> 1.1 (0.6, 2.0) 2.1 (1.5, 3.0)\* 1.7 (1.0, 2.9)\* 1.4 (0.8, 2.5) *Abbreviations: BP, blood pressure; BMI, body mass index; HDL, high-density lipoprotein; CRP, c-reactive protein.*

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

**2.3 Beyond Intersectionality: identity pathology, a wholistic identity approach**

Intrinsic to the concept of intersection is the existence of distinction that two distinct elements, at some point, intersect. This is the basis on which Intersectionality Theory is built. As described, the structural institutions that distribute

Personality disorder.

**23**

*a*

*b*

*\*p <0.05*

**Table 1.**

*PHQ-9 scores of* <sup>≥</sup>*10. <sup>c</sup>*

*AL scores of* ≥*4 were considered "high-risk".*

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

*Health and Nutrition Examination Survey 2005–2010, OR (95% CI)c*

Growing literature on the role of inflammation in depression [48] supports this argument. The Social Signal Transduction Theory of Depression [43] offers a comprehensive framework for understanding the processes through which chronic stress associated with social identity threat can lead to depression. The framework outlines how inflammatory processes chronically triggered in response to social isolation, rejection, and marginalization stemming from subordinate social status can increase risk for several conditions, including rheumatoid arthritis, asthma, obesity, and depression. As a function of their subordinate social status, those who identify (and are identified) as female are therefore at increased risk for the identity threat which can cause sustained activation of the immune system's inflammatory response. In accordance with this theory, women and black persons are consistently found to have higher levels of inflammation than men and white persons, respectively [49, 50]. These racial and gender disparities in inflammation may underlie the increased risk for conditions such as depression, which has been increasingly linked to chronic inflammation [43, 48, 49, 51], among women (see **Table 1**). In conjunction with increasing psychological susceptibility through socialized helplessness, socially constructed subordinance can thus also act physiologically to increase female vulnerability to disorders that may be better classified as internalizing symptomatology.

While the association between subordinate status and toxic stress is welldocumented, less attention is devoted to the impact of higher-status on the

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


*Abbreviations: BP, blood pressure; BMI, body mass index; HDL, high-density lipoprotein; CRP, c-reactive protein. a Models adjusted for PIR (ratio of household income to the US poverty threshold), age, and all biomarkers. b PHQ-9 scores of* <sup>≥</sup>*10. <sup>c</sup>*

*Results are from four separate regression models. The reference category for the biomarkers in each model is "low-risk". <sup>d</sup> AL scores of* ≥*4 were considered "high-risk".*

*\*p <0.05*

#### **Table 1.**

medicine has been used to subjugate female persons [44, 45], not in the least by employing psychiatric diagnoses to discredit resistance to oppressive social and cultural norms [44, 46]. Decades of research have accumulated substantial evidence [10, 18, 30, 34] that like black persons, women's exposure to violence, exploitation, and abuse by men while being simultaneously deprived of the physical, political, or legal means to defend themselves or prevent misogynistic violence has resulted in a

*Quality of Life - Biopsychosocial Perspectives*

greater propensity for appraising trauma through a lens of powerlessness.

biology [38], so too, does gender become biology.

izing symptomatology.

**22**

The structural violence employed to enforce female subordination also conditions females to see violence committed against them as consequences of their own behaviors [19, 30], which can promote the learned helplessness that drives internalization. The widely practiced tradition of female denigration following experiences of gender-based violence increases the likelihood of females' perceptions of their own complicity in traumatic experiences, and likely contributes to the increased vulnerability to internalization observed in this group [18, 19, 30]. The sense of helplessness fostered by a lack of social and legal repercussions for males' physical and sexual aggression toward females, as well as pervasive denigrating responses to female victims of gender-based violence, has promoted internalization in a space where any outward expression of discontent might yield further abuse. These experiences of gendered dehumanization carry compelling implications for gender differences in health. As has long been argued, there is strong evidence that socially reinforced gender hierarchies directly influence female susceptibility to internalizing psychopathologies like depression and post-traumatic stress disorder (PTSD) [18, 47]. Research highlights a key role for chronic exposure to negative circumstances, or "strain", in women's predisposition toward depressive symptoms [18, 19]. The source of this gender-specific strain is often identified in unique experiences associated with lack of social power as well as societal norms and expectations of women [18, 19]. Accordingly, the IP framework argues that the experience of being a female person in a male-dominated society [rather than solely inherent biological traits of the female sex], increases susceptibility to specific types of psychological and physical disorders associated with the physiological conditioning of subordinate status. Similar to the manner by which race becomes

Growing literature on the role of inflammation in depression [48] supports this argument. The Social Signal Transduction Theory of Depression [43] offers a comprehensive framework for understanding the processes through which chronic stress associated with social identity threat can lead to depression. The framework outlines how inflammatory processes chronically triggered in response to social isolation, rejection, and marginalization stemming from subordinate social status can increase risk for several conditions, including rheumatoid arthritis, asthma, obesity, and depression. As a function of their subordinate social status, those who identify (and are identified) as female are therefore at increased risk for the identity threat which can cause sustained activation of the immune system's inflammatory response. In accordance with this theory, women and black persons are consistently found to have higher levels of inflammation than men and white persons, respectively [49, 50]. These racial and gender disparities in inflammation may underlie the increased risk for conditions such as depression, which has been increasingly linked to chronic inflammation [43, 48, 49, 51], among women (see **Table 1**). In conjunction with increasing psychological susceptibility through socialized helplessness, socially constructed subordinance can thus also act physiologically to increase female vulnerability to disorders that may be better classified as internal-

While the association between subordinate status and toxic stress is welldocumented, less attention is devoted to the impact of higher-status on the

*Adjusted<sup>a</sup> odds of depression<sup>b</sup> with high-risk allostatic load and biomarker levels by gendered race in National Health and Nutrition Examination Survey 2005–2010, OR (95% CI)c .*

experience of chronic strain. Still, previous research has identified stress correlates of perceived dominance, showing increased pituitary–adrenal responsiveness to psychological stressors in socially dominant males [52]. This limited evidence suggests that those in dominant positions can also experience higher levels of stress as a function of their status. However, chronic exposure to dominant-status stress likely acts to shape brain physiology and manifestations of identity-based trauma in ways distinct from the chronic stress generated by subordinate social status [53–55].

Where subordinate social status promotes internalizing disorders, dominant status promotes externalizing disorders characterized by antisocial behavior. Social dominance orientation (SDO) measures the degree of preference for inequality among social groups, a personality trait that negatively correlates with empathy, tolerance, and altruism [40], and promotes reduced activity in the brain regions associated with the ability to feel concern for the pain of others [53]. In studies measuring variation in SDO, both male and white persons were found to have significantly higher orientation, suggesting that white males are more likely than either female or black persons to both promote and subscribe to legitimizing myths (rape myths of victim culpability, for example) that enable justification of their dominance-reinforcing behavior [40]. Because high SDO also correlates with low empathy, it is likely that experiences of inequity among those whose race and gender are ranked as superior can yield a proclivity for antisocial behaviors. This propensity is manifest in gendered racial disparities in suicide risk, perpetration of rape, pedophilic child molestation, and mass violence, and risk for Anti-Social Personality disorder.

#### **2.3 Beyond Intersectionality: identity pathology, a wholistic identity approach**

Intrinsic to the concept of intersection is the existence of distinction that two distinct elements, at some point, intersect. This is the basis on which Intersectionality Theory is built. As described, the structural institutions that distribute

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 on health.

Transgenerational effects of trauma [58, 59] ensure that even prior to socialization, individuals are vulnerable to particular kinds of identity imprintation, making identity an ideal vector for pathogenic beliefs. Within an environment of structural inequity, what begins as an involuntary process of gendered racial socialization eventually leads to the development of identity paradigms capable of housing the pathogenic beliefs which infect and predispose individuals to various manifestations of pathology. The IP framework argues that the interconnectedness of social, psychological, neurological, and physiological processes renders every individual susceptible to the disruptive effects of identity on biological homeostasis. Whether through transgenerational epigenetic pathways [59], direct neurological pathways [43], or indirect behavioral pathways [60, 61], identity beliefs can chronically disrupt homeostasis and produce

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

The IP model is distinct from Intersectionality theory in that it hypothesizes the concept of identity pathology, which describes a disease-prone state characterized by certain acquired beliefs about individual or group identity that are inherently pathological. Constructed in the context of structured inequities such as institutional gendered and classed racism, these identity beliefs are informed by unique experiences of individuals defined simultaneously by multiple social group designations and may partially account for the types of chronic diseases prevalent among different socially defined groups. The IP concept applies infectious disease modeling to the integration of the aforementioned theoretical frameworks in situating the adoption of socially constructed identities as a mediator of the disease patterns

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

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

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 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

For the purposes of demonstrating the application of IP theory to the epidemi-

ology 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

disease, a phenomenon which the framework terms *identity pathology*.

observed across different socially defined groups.

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

the need of a wholistic identity approach.

observed across gendered race groups in the United States.

**disparities research**

**approaches**

**25**

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

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 the spread of pathogenic social exposures.

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.

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

Transgenerational effects of trauma [58, 59] ensure that even prior to socialization, individuals are vulnerable to particular kinds of identity imprintation, making identity an ideal vector for pathogenic beliefs. Within an environment of structural inequity, what begins as an involuntary process of gendered racial socialization eventually leads to the development of identity paradigms capable of housing the pathogenic beliefs which infect and predispose individuals to various manifestations of pathology. The IP framework argues that the interconnectedness of social, psychological, neurological, and physiological processes renders every individual susceptible to the disruptive effects of identity on biological homeostasis. Whether through transgenerational epigenetic pathways [59], direct neurological pathways [43], or indirect behavioral pathways [60, 61], identity beliefs can chronically disrupt homeostasis and produce disease, a phenomenon which the framework terms *identity pathology*.

The IP model is distinct from Intersectionality theory in that it hypothesizes the concept of identity pathology, which describes a disease-prone state characterized by certain acquired beliefs about individual or group identity that are inherently pathological. Constructed in the context of structured inequities such as institutional gendered and classed racism, these identity beliefs are informed by unique experiences of individuals defined simultaneously by multiple social group designations and may partially account for the types of chronic diseases prevalent among different socially defined groups. The IP concept applies infectious disease modeling to the integration of the aforementioned theoretical frameworks in situating the adoption of socially constructed identities as a mediator of the disease patterns observed across different socially defined groups.
