Measures of Racism, Sexism, Heterosexism, and Gender Binarism for Health Equity Research: from Structural Injustice to Embodied Harm—An Ecosocial Analysis
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PU41CH03_Krieger ARjats.cls March 17, 2020 8:42 Annual Review of Public Health Measures of Racism, Sexism, Heterosexism, and Gender Binarism for Health Equity Research: From Structural Injustice to Embodied Harm—An Ecosocial Analysis Nancy Krieger Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts 02115, USA; email: [email protected] Annu. Rev. Public Health 2020. 41:37–62 Keywords First published as a Review in Advance on gender identity, health equity, heterosexism, racism, sexism, structural November 25, 2019 injustice The Annual Review of Public Health is online at publhealth.annualreviews.org Abstract https://doi.org/10.1146/annurev-publhealth- Racism. Sexism. Heterosexism. Gender binarism. Together, they comprise 040119-094017 intimately harmful, distinct, and entangled societal systems of self-serving Copyright © 2020 by Annual Reviews. domination and privilege that structure the embodiment of health inequities. This work is licensed under a Creative Guided by the ecosocial theory of disease distribution, I synthesize key fea- Access provided by 196.40.24.243 on 11/16/20. See copyright for approved use. Commons Attribution 4.0 International Annu. Rev. Public Health 2020.41:37-62. Downloaded from www.annualreviews.org License, which permits unrestricted use, tures of the specified “isms” and provide a measurement schema, informed distribution, and reproduction in any medium, by research from both the Global North and the Global South. Metrics provided the original author and source are credited. See credit lines of images or other discussed include (a) structural, including explicit rules and laws, nonex- third-party material in this article for license plicit rules and laws, and area-based or institutional nonrule measures; and information. (b) individual-level (exposures and internalized) measures, including explicit self-report, implicit, and experimental. Recommendations include (a)ex- panding the use of structural measures to extend beyond the current primary emphasis on psychosocial individual-level measures; (b) analyzing exposure in relation to both life course and historical generation; (c) developing mea- sures of anti-isms; and (d) developing terrestrially grounded measures that can reveal links between the structural drivers of unjust isms and their toll on environmental degradation, climate change, and health inequities. 37 PU41CH03_Krieger ARjats.cls March 17, 2020 8:42 INTRODUCTION Racism. Sexism. Heterosexism. Gender binarism. Each of these seemingly abstract terms encom- passes very real and intimately harmful and distinct societal systems of self-serving domination and privilege (13, 67, 74) that are created by people and structure health inequities (99)—that is, unjust, unnecessary, and preventable differences in health status between social groups (26, 194). Accounting for the avoidable and inequitable suffering these “isms” cause requires measures of ex- posure that are attuned to (a) the explicit and tacit rules that codefine the social groups at issue and the polarities of superior/inferior and normal/deviant they encompass and (b) clarifying not only who is harmed but who gains, socially and materially, from these divisions (13, 99). It also requires challenging biological essentialism and situating human power relations in the larger context of life on Earth (57, 61, 65, 97, 117). These may appear to be obvious statements. However, prior to the 1990s, only scant research measured the impact of discrimination and health, and research conducted since then, largely in the Global North, has chiefly used individual-level measures of self-reported experiences of discrimination (91, 99, 157, 196) (Supplemental Table 1). Only in the past 10 years has a body of research emerged regarding the health impact of what variously is referred to as structural or institutional discrimination (8, 58, 77, 99, 196), albeit using a confusing welter of heterogeneous social metrics. Only a small fraction of this work has addressed environmental racism (43, 182); even less has focused on global climate change (57, 162) (Supplemental Table 1). Accordingly, in this review I focus first on first principles for thinking through what measur- ing isms entails—whether for the isms I was invited to address or those beyond the scope of this review—and why this can vary, not only across different types of injustice and in different soci- etal contexts, but also over time, depending on advances and setbacks in collective efforts to build equitable societies. Drawing on the ecosocial theory of disease distribution (91, 93, 97), I synthe- size key features of these isms (Table 1) and provide a measurement schema (Table 2), which together inform my discussion of concrete examples of such research from the Global North and the Global South (Table 3). My sources include both literature I have engaged with during the past 35 years as a US social epidemiologist (90–99, 109) and new material I have reviewed for this article (see search terms in Supplemental Table 2). As shown in the examples below, the availability of apt measures—and, more often, their absence—means that there is a grave need for better work worldwide to improve the conceptual and methodological rigor, as well as the scope and inclusiveness, of these much-needed metrics. Access provided by 196.40.24.243 on 11/16/20. See copyright for approved use. ON ISMS AND HEALTH EQUITY: CONCEPTS Annu. Rev. Public Health 2020.41:37-62. Downloaded from www.annualreviews.org AND KEY CONSIDERATIONS All Isms Combine Belief and Action, but Not All Involve Injustice The first point is that isms are not things. The term “ism” is a suffix that forms nouns ofaction (153). Sometimes the action involved occurs without human agency, as in the case of “magnetism” (153). More commonly, however, an ism is a connected system of ideas, beliefs, and practices con- ceived by people with purpose in mind (153). Providing guidance for action, isms can be religious, ecclesiastical, philosophical, political, or social and can variously be articulated through explicit institutions or via doctrines or principles that are not institutionally based, per se (153). Famil- iar examples listed in the Oxford English Dictionary (OED) include, for the former, “Buddhism, Calvinism, Catholicism,...Conservatism, Epicureanism, Judaism,...Liberalism...Platonism, Positivism, Presbyterianism, Protestantism, Puritanism,...Quakerism...Ta o i s m ...Whiggism” (153, italics in origi- nal); illustrating the latter is a fascinating list encompassing “agnosticism, altruism, animism, atheism, 38 Krieger PU41CH03_Krieger ARjats.cls March 17, 2020 8:42 Table 1 Key specific and shared features of unjust isms: core beliefs about targeted versus privileged groups, biology, and health status—and contrasting views of challenging anti-isms Feature Racism Sexism Heterosexism Gender binarism Fallacious Racial supremacy is a natural fact Male supremacy is a Heterosexuality is Gender identity that unjust Humans are biologically divided natural fact the only natural conforms to biological premise(s) into discrete “races” The status and roles sexual orientation sex at birth is the only Some “races” are biologically of men and Same-sex desire, natural gender superior women (and boys behavior, and identity The remaining “races” are and girls) naturally identity are Nonconforming gender biologically inferior follow from unnatural (and, by identities are Biological superiority sets the differences in their extension, deviant unnatural (and, by basis for political, economic, biology due to and immoral) extension, deviant) social, and cultural supremacy being different biological sexes Privileged “Superior race(s)” Men and boys Heterosexuals Cisgender persons who group Usually, but not always, defined conform to their as “white,” because designation society’s dominant depends on societal context gender norms Typically reflects histories of conquest and establishment of political regimes and economies dependent on both the enslavement of others and settler-colonialism Targeted group “Inferior race(s)” Women and girls Persons who self- Persons who Usually, but not always, groups identify as or are self-identify defined as “black,” and also categorized as as or are categorized “Indigenous,” because lesbian, gay, as transgender, gender designation depends on bisexual, or queer fluid, or genderqueer, societal context (with terminology with terminology Typically reflects histories of varying by societal varying by societal invasion, enslavement, and context) context and language settler-colonialism (e.g., hijra in India, muxes in Mexico, and travesties in South America) Supporting White supremacy Misogyny Homophobia Transphobia Access provided by 196.40.24.243 on 11/16/20. See copyright for approved use. beliefs and “Blood” (“race”-based) Religious Religious Religious fundamental- Annu. Rev. Public Health 2020.41:37-62. Downloaded from www.annualreviews.org institutional nationalism fundamentalism fundamentalism ism ideologies Religious fundamentalism Reliance on “Biological race” treated as an Biological sex treated as a strictly binary category whose natural binary biological essential natural category expression is heterosexual, cisgender, and gender-conforming essentialism Erroneous Observed differences in health status between targeted and privileged groups fundamentally driven by innate beliefs (and presumed genetic) biological differences health, including presumed