About This Literature Summary

This summary of the literature on Discrimination as a social determinant of health is a narrowly defined examination that is not intended to be exhaustive and may not address all dimensions of the issue. Please note: The terminology used in each summary is consistent with the respective references. For additional information on cross-cutting topics, please see the Access to Foods That Support Healthy Dietary Patterns, Housing Instability, Incarceration, and Quality of Housing literature summaries. 

Literature Summary

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 Stressful experiences related to discrimination can negatively impact health.5 Discrimination, especially racial discrimination, has also been known to cause symptoms of trauma.6,7,8 

This summary discusses types of structural discrimination (e.g., residential segregation, disparities in access to quality education, and disparities in incarceration) and individual discrimination (e.g., discrimination based on race, gender, sexuality, gender identity, disability, and age). 

Levels of Discrimination

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.9 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.).10 Individual and structural discrimination can cause either intentional or unintentional harm, whether or not it is perceived by the individual.3,11 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 can occur as everyday discrimination or as major discriminatory events.12,13 Everyday discrimination taps into more ongoing and routine experiences of unfair treatment.12,14 Major discriminatory events capture important or more significant experiences of unfair treatment.12,13  

Structural Discrimination

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.15,16,17,18,19

Residential segregation is a form of structural discrimination in the housing market. Redlining is a form of discrimination where individuals living in neighborhoods mainly populated by certain racial/ethnic groups are denied loans.20 Basing credit lending decisions on property location has created a legacy of urban areas experiencing chronic health inequities.21 In one study there was an association found between redlining and poor mental health, a nondermatological cancer diagnosis, and a lack of health insurance.21 Another study found that small-for-gestational-age birth, prenatal mortality, and preterm birth have a higher prevalence in redlined neighborhoods than in other areas.22 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.19 

Residential segregation also affects disparities in access to quality education.16,23 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.16,24 Children who enroll in poor-quality schools with limited health resources, increased safety concerns, and low teacher support are more likely to have poorer physical and mental health.15 Another example of structural discrimination is variance in the implementation of criminal justice policy. Some of these variances include the rates at which some racial/ethnic groups are arrested, convicted, and incarcerated for criminal offenses.25,26,27 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.27 These state and federal policies impact incarceration rates for some racial/ethnic groups and in turn may have negative impacts on families, housing, employment, political participation, and health.16,17,18,27,28 

Individual Discrimination

Along with the examples of structural discrimination provided above, individual discrimination may have high physical and emotional health costs.5,29,30,31 Some examples of individual 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.12,14 Research suggests that repeated experiences of discrimination may cause the body to be more physically sensitive in stressful or potentially stressful social situations.5,30 Routine discrimination can be a chronic stressor and increase vulnerability to physical illness.31 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 percent of U.S. adults report at least 1 major discriminatory occurrence in their lifetime, and 63 percent report experiencing discrimination every day.3 While only 8 percent of all U.S. adolescents report experience with racial/ethnic discrimination, there is significant variation between White (2 percent), non-Hispanic Black (17.1 percent), and Hispanic (11.0 percent) youths.32 Experiencing discrimination may be related to health behaviors that have clear associations with particular disease outcomes, such as smoking33,34 or alcohol abuse.35 It may also be related to not participating in health-promoting behaviors, such as cancer screening, diabetes management, and condom use.5,36,37,38 Various forms of discrimination impact different population groups, including certain racial/ethnic groups,29,39,40 women,11,41,42 lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals,43,44,45,46,47 people with disabilities,48,49,50 and older adults.3,51

Discrimination Based on Race

Discrimination on the basis of race (commonly referred to as racism) has been linked to disparities in health outcomes for some racial/ethnic groups.39 Racism has been linked to low birth weight, high blood pressure, and poor health status.29,40 For example, infant mortality rates among the non-Hispanic Black population is 11.11 infant deaths out of 1,000 live births while the overall rate in the United States is 5.96 infant deaths per 1,000 live births.52 Further, the 2019 National Healthcare Disparities Report indicated that White patients receive better quality of care than 40.6 percent of Black patients, 40.5 percent of American Indian/Alaska Native patients, 34.5 percent of Hispanic patients, and 28.6 percent of Asian and Pacific Islander patients.53 This differential quality of care may be based on racial discrimination.39,53

Discrimination Based on Gender    

Experiences of discrimination based on gender (commonly referred to as sexism) have been shown to have negative health impacts for women.11,41,42 Gender refers to “the cultural roles, behaviors, activities, and attributes expected of people based on their sex” while sex is “an individual’s biological status as male, female, or something else assigned at birth.”54 One study found that after adjusting for other influences, levels of unhappiness, loneliness, and depression are about 30 percent higher for women who reported experiencing recent discrimination compared with those who did not.11 Additionally, in a national sample of U.S. women ages 18 to 55 years, perceived discrimination was associated with lower likelihood of self-reported excellent/very good health.41 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.42 These findings suggest that perceived discrimination may be related to reduced utilization of health care services and worse self-reported health for women.41,42

Discrimination Based on Sexuality and Gender Identity

People who identify as LGBTQ also endure frequent exposure to discrimination due to sexual orientation and gender identity (commonly referred to as sexualism).43,44,45,46 Sexual orientation refers to “a person’s sexual and emotional attraction to another person (i.e., lesbian, gay, bisexual, etc.)” while gender identity refers to an “individual’s sense of their self as man, woman, transgender, or something else.”54 Research has found that LGBTQ people reported more lifetime and day-to-day experiences with discrimination when compared with heterosexual individuals.43 Evidence suggests that adolescents who identify as LGBTQ are more likely than heterosexual adolescents to exhibit symptoms of emotional distress, including depressive symptoms, suicidal ideation, and self-harm.44 Elevated risk of emotional distress among LGBTQ adolescents may be related to the stress of having a stigmatized identity.44,45 Specifically, LGBTQ adolescents may be in settings where they experience social rejection and isolation, decreased social support, and verbal or physical abuse.44,46,47 Additionally, research has found that transgender individuals’ increased risk of discrimination and violence contribute to high rates of suicide attempts among this population — some of the highest of any marginalized group.55

Discrimination Toward People With Disabilities

People with disabilities are especially vulnerable to experiences of discrimination (commonly referred to as ableism).48,49 In 2014, about 85.3 million people in the United States (27.2 percent of the population) had a disability (minor to more severe).50 “A history of discrimination and institutionalization” for people with disabilities has caused health inequalities in this population.49 Adults with disabilities are more likely to report their health to be fair or poor than people without disabilities.53,56 Specifically, 50.8 percent and 31.5 percent 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 with 3.4 percent of adults with no disability.53,55 Adults with disabilities are 2.5 times more likely to report skipping or delaying health care because of cost.57 People with disabilities consistently report higher rates of obesity, lack of physical activity, and smoking.55 These disparities in health could also be the result of insufficient or no health insurance coverage, patient choice, or inaccessible transportation.48

Discrimination Based on Age

The health vulnerabilities of older adults may amplify the health effects of discrimination (commonly referred to as ageism).58 One study found that experiences of discrimination are frequent among the elderly population, with 63 percent and 31 percent of older adults reporting everyday discrimination and major discriminatory events, respectively.3 Discrimination based on age was the most common type of discrimination.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

Intersectionality Within Discrimination

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.10,40,59,60 Specifically, racial discrimination as a psychosocial stressor may increase the risk of preterm and low-birth-weight deliveries for Black women.40,61,62

Gaps in Research

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.39 Cumulative and structural consequences of racism are hard to determine through traditional research methods. Innovative advancements in examining this area of discrimination are needed for future examinations.16 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.

Citations

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38.

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