**1.1 Brief overview of health disparities research in the United States**

Throughout the history of the United States, disparities in health outcomes between racial groups and individuals of differing ethnic backgrounds have been well documented [1, 2]. Consistently, black and Indigenous persons, and those of Hispanic ethnicity have had poorer overall health, higher rates of both chronic and infectious disease, and increased risk of mortality compared with persons of European ancestry [1–4]. For decades, investigations into the causes of these unequal health outcomes largely operated under an implicit—and at times explicit—biological determinism framework [5]. Because of this narrow theoretical scope,

important contributors—the most important contributors, one could argue—to these racial and ethnic gaps in health status were often overlooked in epidemiologic research [5].

**1.2 Why gender and race?**

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

social constructs.

health inequity.

**19**

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

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

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

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 conse-

quences of their groups' perceived inferiority or superiority [17, 18, 27–29].

ined 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

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 exam-

Even as epidemiologists increasingly consider the causal role of the social conditions 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 causes of, and solutions for, health disparities [12–14].

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 inequity.

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 with greater frequency.

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