The Role of Minority Stress in Health Disparities

Minority stress refers to the way that individuals from underrepresented or stigmatized groups experience a number of stressors that directly relate to a minority identity. When the concept of minority stress was initially proposed by a researcher in 1995, it was defined as a form of stress derived from minority status. With respect to gay men, in particular, the chronic stress related to stigmatization was seen as taking the form of:

1. Internalized homophobia, which is essentially discriminatory beliefs directed at one's self for one's homosexuality.
2. Expectations of rejection and discrimination
3. Experiences of discrimination

Who May Experience Minority Stress

Despite the focus on sexual and gender minorities in the initial research, minority stress is not limited to those groups. Minority stress can be experienced by

• People of color (internalized racism)
• Gender diverse children and adults (internalized transphobia)
• Muslims, Sikhs, and other non-majority religious individuals
• Individuals with disabilities
• Other groups seen as different in the local society

Minority stress is both additive and intersectional. In other words, individuals who are members of multiple minority groups often experience greater minority stress than those individuals who are only members of one minority group. In addition, people with intersectional identities may experience stressors unique to those identities.

As the minority stress model states, being part of a minority or stigmatized group can be stressful even when people do not experience any explicit bias. Simply expecting to experience such behaviors can cause physical and mental health stress.

Microaggressions can also lead to stress. Microaggressions are when people act in discriminatory ways that are subtle or indirect, often without realizing it. An example of this is when two friends are shopping and people insist on talking to the one who is not using a wheelchair, even when she is not the one asking the question or having the interaction. Another example is when people unconsciously cross the street because they see a young man of color approaching, where they wouldn't do so if he were white.

Minority Stress and Health Disparities

Health disparities are defined as between-group health differences that are related to social or economic disadvantages. Gay, lesbian, bisexual, and transgender youth have been shown to experience a number of health disparities linked to minority stress. Many other minority groups also experience one or more health disparities.

Only very rarely can health disparities between groups be linked back to actual biological differences between groups. They are far more often linked to social and medical inequities, both current and historical. They are also often linked to behaviors that may be exacerbated by minority stress.

Each aspect of minority stress has the potential to affect health risks and outcomes—both directly and indirectly.

Internalized Stigma (Homophobia/Racism) and Health Disparities

Internalized racism, homophobia, and other forms of stigma have the potential to affect health in a number of different ways. The most obvious way is that when people dislike (or even hate) a fundamental aspect of themselves, it can lead to anxiety, depression, and other forms of mental health dysfunction. It can also lead to engaging in risky behaviors, such as unprotected sex or illicit drug use. These behaviors may be used to either numb or distract from a sense of self-hatred.

Internalized racism has also been shown to be linked to abdominal obesity, possibly mediated by some form of stress response. Abdominal obesity has been linked to an increased risk for a number of health conditions, including insulin resistance, diabetes and cardiovascular disease.

Expectations of Discrimination and Health Disparities

Expectations of discrimination can lead to both hypervigilance and avoidance. Hypervigilance can lead to feelings of stress and depression. It can also lead to exhaustion, changes in appetite, and other health concerns. It may even affect the experience of pain.

Avoidance can have even more direct effects on health and health disparities. If, for example, an individual is afraid to go to the doctor because she's concerned they may be hostile towards her, that can directly impact her health. She may not get tested as often as she needs to or engage in preventative health checks to maintain her health. She may even avoid care when she's sick or injured, increasing the risk of developing longer-term health problems and or disabilities.

Fear of experiencing discrimination in a healthcare setting has been shown to lead to avoidance of care. Avoidance of care can result in delays in testing and treatment that have negative effects on overall health.

Experiences of Discrimination and Health Disparities

Experiences of discrimination have the potential to affect health both indirectly and indirectly. For example, in terms of indirect effects of discrimination on health, a person from a minority group may not be able to get housing that is close to accessible health care. She may not be able to afford to take the time off work. Both things could make her less likely to access health care regularly.

She could live in a food desert or someplace where it isn't safe to walk or bike for exercise. Lack of access to healthy food and inexpensive, safe exercise can both have profound effects on overall health.

Discrimination also affects a number of other life areas that have indirect effects on health, such as the risk of incarceration. These issues of systemic racism have also been implicated in the high HIV rates seen in Black men who have sex with men.

There's also the direct effects of discrimination on health. Discrimination causes even stronger stress effects than just expecting to be mistreated. In addition, healthcare providers have been shown to provide lower quality of care to individuals from a variety of minority groups. This is sometimes, although not always, the result of conscious racism, sexism, or other forms of bias. It is, perhaps more often, the result of implicit bias—bias that is outside of conscious awareness.

Implicit bias against racial minorities has been shown to affect a number of aspects of interactions between doctors and patients. These include everything from treatment decisions to what diagnoses are suspected and which tests are ordered.

One particularly pervasive issue that has been reported is that Black Americans are systematically undertreated for pain. This has been attributed to beliefs about Black people having "thicker" skin that is less sensitive to pain, which leads to a tendency to underestimate the pain they experience. Research has shown that doctors who don't carry implicit biases against Black people do not make these assumptions or undertreat their patient's pain.

There is also the problem of explicit bias. The groundbreaking National Transgender Discrimination Survey released in 2016 showed that almost one out of every five transgender individuals had been refused care in healthcare settings. That includes not just being refused gender-affirming care but being refused treatment for emergencies, such as broken bones and other traumas. More than a quarter reported being harassed in a medical setting.

A Word From Verywell

How can we, as a society, work to address the effects of minority stress on health disparities? The most important thing is to be aware that racism, heterosexism, and other forms of discrimination aren't just about saying hurtful things and looking down on people. They are systematic and affect so many areas of our world and our lives—including physical and mental health. In many ways, overtly racist people are a much smaller problem than invisible systems of inequity that distort the shapes of peoples lives.

One big part of that is raising awareness of the ways that kind, intelligent, and well-meaning people can carry subconscious beliefs that have the potential to have enormous impacts on population health. Schools and universities need to do a better job of educating medical and other professionals about implicit bias, and the ways that unexamined beliefs and assumptions affect healthcare decision making and patient outcomes. Most people are pretty well meaning. They just don't know what they don't know—and they can't see the things that they don't realize they should be looking at.