Discrimination

Discrimination is a socially structured action that is unfair or unjustified and harms individuals and groups.^{1, 2, 3, 4} Discrimination can be attributed to social interactions that occur to protect more powerful and privileged groups at the detriment of other groups.^{3, 4} While not all stressful experiences negatively affect health, or occur because of discrimination, many do impact health and can be related to discrimination.⁵

This summary attempts to show how discrimination, as defined above, can adversely affect health in various populations.

The impact of discrimination occurs at both structural and individual levels. Structural discrimination refers to macro-level conditions (e.g., residential segregation) that limit “opportunities, resources, and well-being” of less privileged groups.⁶ Individual discrimination refers to negative interactions between individuals in their institutional roles (e.g., health care provider and patient) or as public or private individuals (e.g., salesperson and customer) based on individual characteristics (e.g., race, gender, etc.).⁷ Individual and structural discrimination can cause either intentional or unintentional harm, whether or not it is perceived by the individual.^{3, 8} Discrimination can be understood as a social stressor that has a physiological effect on individuals (e.g., irregular heartbeat, anxiety, heartburn) that can be compounded over time and can lead to long-term negative health outcomes.⁵

Discrimination is often measured by either everyday or major discriminatory events.^{9, 10} Everyday discrimination taps into more ongoing and routine experiences of unfair treatment.^{9, 11} Some examples of everyday discrimination include being treated with less courtesy or respect than other people, receiving poorer service than other people at restaurants or stores, or being threatened or harassed.^{9, 11} Major discriminatory events capture important or more significant experiences of unfair treatment.^{9, 10} Some examples of major discrimination include being unfairly dismissed from a job, being unfairly prevented from moving into a neighborhood because a landlord or realtor refused to sell or rent, or being unfairly denied a bank loan.^{9, 10}

Major discriminatory events are often the result of structural discrimination that can negatively affect individuals and communities. Residential segregation, disparities in access to quality education, and disparities in incarceration rates are some specific forms of structural discrimination.^{12, 13, 14, 15, 16} Residential segregation is a form of structural discrimination in the housing market. Residential segregation is a major cause of differences in health status between African American and white people because it can determine the social and economic resources for not only individuals and families, but also for communities.¹⁶ Residential segregation also affects disparities in access to quality education.^{13, 17} Most school districts generate their income locally through property taxes, so residential segregation by income translates into very different possibilities for funding across school districts.^{13, 18} Children who enroll in low-quality schools with limited health resources, increased safety concerns, and low teacher support are more likely to have poorer physical and mental health.¹²

Another example of structural discrimination is variance in the implementation of criminal justice policy. Some of these variances include the rates at which racial/ethnic minorities are arrested, convicted, and incarcerated for criminal offenses.^{19, 20, 21} Research shows that some of the racial disparities seen in the incarceration rate may be heavily influenced by state and federal policies such as “3 strikes,” mandatory minimum sentences, and life without parole.²¹ These state and federal policies impact incarceration rates for racial/ethnic minorities and in turn may have negative impacts on families, housing, employment, political participation, and health.^{13, 14, 15, 21, 22}

Along with the examples of structural discrimination provided above, individual discrimination may have high physical and emotional health costs.^{5, 23, 24, 25} Research suggests that repeated experiences of discrimination may cause the body to be more physically sensitive in stressful or potentially stressful social situations.^{5, 24} Routine discrimination can be a chronic stressor and increase vulnerability to physical illness.²⁵ As with other forms of sustained stress, discrimination “may lead to wear and tear on the body.”⁵

Discrimination is a fairly common experience; 31% of U.S. adults report at least 1 major discriminatory occurrence in their lifetime, and 63% report experiencing discrimination everyday.³ Experiencing discrimination may be related to health behaviors that have clear associations with particular disease outcomes, such as smoking^{26, 27} or alcohol abuse.²⁸ It may also be related to not participating in health-promoting behaviors, such as cancer screening, diabetes management, and condom use.^{5, 29, 30, 31}

Various forms of discrimination impact different population groups, including racial/ethnic minorities,^{23, 32, 33} women,^{8, 34, 35} lesbian, gay, bisexual, and transgender (LGBT) individuals,^{36, 37, 38, 39, 40} older adults,^{3, 41} and people with disabilities.^{42, 43, 44}

Discrimination on the basis of race (commonly referred to as racism) has been linked to disparities in health outcomes for racial/ethnic minorities.³² Racism has been linked to low birth weight, high blood pressure, and poor health status.^{23, 33} Further, the 2015 National Healthcare Disparities Report indicated that white patients receive better quality of care than 36.7% of Hispanic patients, 41.1% of black patients, 32.4% of American Indian/Alaska Native patients, and 20.3% of Asian and Pacific Islander patients.⁴⁵ This differential quality of care may be based on racial discrimination.^{32, 45}

Experiences of discrimination based on gender have been shown to have negative health impacts for women.^{8, 34, 35} One study found that after adjusting for other influences, levels of unhappiness, loneliness, and depression are about 30% higher for women who reported experiencing recent discrimination compared to those who did not.⁸ Additionally, in a national sample of U.S. women ages 18 to 55, perceived discrimination was associated with lower likelihood of self-reported excellent/very good health.³⁴ Another study with a sample of U.S. women found that reports of discrimination due to physical appearance or gender were strongly related to reduced self-reported receipt of Pap smears, mammography, and clinical breast exams.³⁵ These findings suggest that perceived discrimination may be related to reduced utilization of health care services and worse self-reported health for women.^{34, 35}

LGBT individuals also endure frequent exposure to discrimination.^{36, 37, 38, 39} Research has found that LGBT people reported more lifetime and day-to-day experiences with discrimination when compared to heterosexual individuals.³⁶ Evidence suggests that adolescents who identify as LGBT are more likely than heterosexual adolescents to exhibit symptoms of emotional distress, including depressive symptoms, suicidal ideation, and self-harm.³⁷ Elevated risk of emotional distress among LGBT adolescents may be related to the stress of having a stigmatized identity.^{37, 38} Specifically, LGBT adolescents may be in settings where they experience social rejection and isolation, decreased social support, and verbal or physical abuse.^{37, 39, 40}

Older adults and people with disabilities are especially vulnerable to experiences of discrimination.^{3, 41, 42, 43} In 2010, about 56.7 million people in the United States (19% of the population) had a disability.⁴⁴ “A history of discrimination and institutionalization” for people with disabilities has caused health inequalities in this population.⁴³ Adults with disabilities are more likely to report their health to be fair or poor than people without disabilities.⁴⁵ Specifically, 50.8% and 31.5% of adults with complex activity limitation (e.g., work limitation, self-care limitation) and basic actions difficulty (e.g., movement difficult, cognitive difficulty, seeing or hearing difficulty), respectively, reported their health to be fair or poor compared to 3.4% of adults with no disability.⁴⁵ Adults with disabilities are 2.5 times more likely to report skipping or delaying health care because of cost.⁴⁷ People with disabilities consistently report higher rates of obesity, lack of physical activity, and smoking.⁴⁵ These disparities in health could also be the result of insufficient or no health insurance coverage, patient choice, or inaccessible transportation.⁴²

The health vulnerabilities of older adults may amplify the health effects of discrimination.⁴¹ One study found that experiences of discrimination are frequent among the elderly population, with 63% and 31% of older adults reporting everyday discrimination and major discriminatory events, respectively.³ Discrimination based on age was most common.³ After controlling for general stress, everyday discrimination still had effects on emotional health, such as depressive symptoms and self-reported health in older adults.³ Although older adults perceive lower levels of discrimination as they get older, they are more likely to associate experiences of discrimination with their age.³

Although categories such as race or gender alone may influence how individuals experience discrimination, it is equally important to understand how being a part of several affected groups simultaneously (e.g., by race, gender, and place of birth) can impact experiences of discrimination. For example, black women are differentially situated economically, socially, and politically—and may experience discrimination differently—than other women or black men; this may affect health outcomes.^{7, 33, 48, 49} Specifically, racial discrimination as a psychosocial stressor may increase the risk of preterm and low birth weight deliveries for black women.^{33, 50, 51}

Given the health impacts of discrimination on various populations, there is an ongoing need for innovative research methods, improved instrumentation, and new approaches for identifying all types of discrimination and its impact on health and health care.³² Additional research is needed to increase the evidence base on the effects of discrimination on health outcomes or disparities. This additional evidence will help facilitate public health efforts to address discrimination as a social determinant of health.

Disclaimers:

•  This summary of the literature on discrimination as a social determinant of health is a narrowly defined review that may not address all dimensions of the issue.^{i, ii} Please keep in mind that the summary is likely to evolve as new evidence emerges or as additional research is conducted.
•  There is no standard definition or singular perspective of discrimination in the literature. The purpose of this summary is to provide a synthesis of the definitions and approaches to the issue of discrimination and its impact as a social determinant on health outcomes and disparities.