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(/content/journals/publhealth) / Volume 41, 2020 (/content/journals/publhealth/41/1) / Article
ANNUAL REVIEW OF PUBLIC HEALTH (/content/journals/publhealth) Volume 41, 2020

(/content/journals/publhealth/41/1)
Review Article Open Access
Measures of Racism, Sexism, Heterosexism, and

Gender Binarism for Health Equity Research: From
Structural Injustice to Embodied Harm—An
Ecosocial Analysis
Nancy Krieger (/search?value1=Nancy+Krieger&option1=author&noRedirect=true)1
 View A!iliations
Vol. 41:37-62 (Volume publication date April 2020)

https://doi.org/10.1146/annurev-publhealth-040119-094017 (https://doi.org/10.1146/annurev-
publhealth-040119-094017)
First published as a Review in Advance on November 25, 2019

Copyright © 2020 Annual Reviews.
This work is licensed under a Creative Commons Attribution 4.0 International License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source
are credited. See credit lines of images or other third party material in this article for license information.
ABSTRACT
Racism. Sexism. Heterosexism. Gender binarism. Together, they comprise intimately harmful,
distinct, and entangled societal systems of self-serving domination and privilege that
structure the embodiment of health inequities. Guided by the ecosocial theory of disease
distribution, I synthesize key features of the specified “isms” and provide a measurement
schema, informed by research from both the Global North and the Global South. Metrics
discussed include (a) structural, including explicit rules and laws, nonexplicit rules and laws,
and area-based or institutional nonrule measures; and (b) individual-level (exposures and
internalized) measures, including explicit self-report, implicit, and experimental.
Recommendations include (a) expanding 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 measures 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.
Keywords
gender identity (/search?option1=pub_keyword&value1="gender identity"), health equity (/search?
option1=pub_keyword&value1="health equity"), heterosexism (/search?
option1=pub_keyword&value1="heterosexism"), racism (/search?
option1=pub_keyword&value1="racism"), sexism (/search?
option1=pub_keyword&value1="sexism"), structural injustice (/search?
option1=pub_keyword&value1="structural injustice")
INTRODUCTION
Racism. Sexism. Heterosexism. Gender binarism. Each of these seemingly abstract terms
encompasses 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 di!erences in health status
between social groups (26, 194). Accounting for the avoidable and inequitable su!ering these
“isms” cause requires measures of exposure 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
(http://www.annualreviews.org/doi/suppl/10.1146/annurev-publhealth-040119-
094017)). 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
094017)).
Accordingly, in this review I focus first on first principles for thinking through what measuring
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 di!erent types of injustice and in di!erent
societal contexts, but also over time, depending on advances and setbacks in collective e!orts
to build equitable societies. Drawing on the ecosocial theory of disease distribution (91, 93, 97
), I synthesize 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
094017)). As shown in the examples below, the availability of apt measures—and, more o"en,
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.
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
Toggle display: Table 1  
Open Table 1 fullscreen  (/content/table/10.1146/annurev-publhealth-040119-

094017.t1?fmt=ahah&fullscreen=true&lang=en)
Feature
Fallacious
unjust
premise(s)
Privileged
group
Targeted
group
Supporting
beliefs and
institutional
ideologies
Reliance on
biological
essentialism
Erroneous
beliefs
regarding
group's
health
status
Supporting
structures
and
practices
(for each
type of
unjust isms)
Links to
political
economy,
political
sociology,
and political
ecology
Contrasting
views of
anti-isms
Table 2
Schema of types of measures of unjust isms, and anti-isms, for health equity research and
implications for study design

Exposure
to ism:
level
Structural
Individual
Internalized
Table 3
Health equity research: illustrations of measures of isms, and anti-isms, for racism, sexism,
heterosexism, and gender binarism, by level a

Level
Structural
Individual:
exposure to
ism
Individual:
internalization
Abbreviations: IAT, implicit association tests; LGBT, lesbian, gay, bisexual, transgender.
a
For clarity, this table lists types of measures by level and type of ism, but specific studies can, and do, employ measures at multiple levels (for any given
type of adverse ism) and can, and do, employ measures for multiple types of unjust isms.
b
Detailed technical descriptions (including direct quotation, tables explaining construction of metrics, etc.) for the specific measures used in the cited
studies are provided in Supplemental Table 3 (http://www.annualreviews.org/doi/suppl/10.1146/annurev-publhealth-040119-094017).
c
In this table, the categories of “heterosexism” and “gender binarism” are considered together because studies on sexual and gender minorities (including
lesbian, gay, bisexual, queer, transgender, and gender fluid persons) often include persons across this range of social categories, even as some studies
may focus exclusively on transgender persons (regardless of sexual orientation) or solely on persons who identify as belonging to a sexual minority
(regardless of gender identity).
ON ISMS AND HEALTH EQUITY: CONCEPTS 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 su!ix that forms nouns of action
(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 conceived 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). Familiar 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…Taoism…Whiggism ” (153, italics in original); illustrating the latter
is a fascinating list encompassing “agnosticism, altruism, animism, atheism, bimetallism,
deism, egoism, egotism, empiricism, evangelism, fanaticism, feminism, heathenism,
hedonism, idealism, imperialism, jingoism, libertinism, monarchism, naturalism,
opportunism, pædobaptism, paganism, polytheism, realism, romanticism, sansculottism,
scepticism, stoicism, theism, universalism” (153, italics in original).
Nothing about isms requires that they involve injustice. However, directly relevant to this
review, in 2004 the OED included two new dra" additions to their definition of isms (153):
a. a. Forming nouns with the sense ‘belief in the superiority of one—over another’; as racism,
sexism, speciesism, etc.
b. b. Forming nouns with the sense ‘discrimination or prejudice against on the basis of—’; as
ageism, bodyism, heightism, faceism, lookism, sizeism, weightism, etc.
These sets of isms likewise provide guidance for action, in this case, unjust practices variously
implemented by states, nonstate institutions, and individuals within their societal contexts.
Table 1 accordingly presents features of the isms addressed in this article in relation to health
inequities. At issue is how the specified forms of unjust treatment structure exposure to which
types of harmful biophysical and social phenomena, at what point in the life course, with
which kinds of etiologic periods, and with what potential for intergenerational harm.
Tenets Relevant to Analyzing Isms and Health Inequities: Ecosocial Theory of

Disease Distribution
The second point is that much as isms involving injustice are about beliefs, they are
fundamentally rooted in real-world material conflicts over power and property (13, 67, 74)—
as tied to the workings of diverse political economy isms, e.g., capitalism (including
neoliberalism), socialism, communism, feudalism, communitarism, etc. At issue are societal
structures linking political governance, economic rules, and rules governing who is allowed
which rights to live, produce, and reproduce (or not) where, in which community and family
structures, and with which rights to use, own, and extract resources from which land, water,
forests, and other species (13, 21, 57, 66, 67, 117, 162).
The ecosocial theory of disease distribution—which I first proposed in 1994 and have
elaborated since—accordingly conceptualizes health inequities in relation to power, levels, life
course, historical generation, biology, and ecosystems (91, 93, 95–97) ( Figure 1 ). Its four core
conjoined constructs pertain to (a) embodiment; (b) pathways of embodiment; (c) cumulative
interplay of exposure, susceptibility, and resistance across the life course and across levels;
and (d) accountability and agency. As the ecosocial construct of embodiment has clarified
from the start (91, 95, 97), we jointly live our myriad legally and socially ascribed categories
and identities, which notably can vary, among individuals, over time and by context (25, 86,
122, 151, 190). We are not a member of a particular racial/ethnic group one day, have a
particular gender identity on another, and on still another day have a particular sexual
orientation (whether identity, behavior, or desire)—and the same holds for our social class,
immigration status, and where we live and work (91, 92, 95, 97, 109). Instead, we live
embodied—and our bodies each and every day biologically integrate each and every type of
unjust, and also beneficial, exposure encountered, at each and every level (96, 97). The
construct of intersectionality, a term originating in the legal and social sciences (67, 74),
similarly conveys the socially structured entanglement of multiple types of injustice, albeit
without a focus on the pathways and processes of literal biological embodiment (91–99).
Figure 1
This figure schematically presents how the ecosocial theory of disease distribution conceptualizes the relationship
between population distributions of health, levels, pathways, and power to clarify how health inequities constitute
biological expressions of injustice. The ecosocial theory of disease distribution posits four conjoined core constructs
(white oval with blue outline) (91–98): (i) embodiment; (ii) pathways of embodiment; (iii) cumulative interplay of
exposure, susceptibility, and resistance; and (iv) accountability and agency. These constructs are fundamental to causal
explication of population distributions of health. All of these constructs operate (v) across the life course, contextualized
in relation to historical generation (i.e., birth cohort) (yellow rectangle) and (vi) across levels (turquoise rectangle), as
mediated by (vii) the society's political economy and political ecology (light blue oval). For further explication of these
concepts, please see the sidebar titled Core Constructs of Ecosocial Theory as well as the sidebar titled Pathways of
Embodiment.
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Analyzing Isms Requires Engaging with Biology and Challenging Biological

Essentialism
The third point is that, in accord with ecosocial theory (91, 97), a structural systems-oriented
understanding of isms necessarily challenges two faulty premises of biological essentialism:
(a) the spurious construct of biological race, which wrongly presumes humanity can be
cleaved into distinct biological “races” that intrinsically di!er in health status and other traits
(169, 203), including their human needs for rights and resources to thrive (49); and (b) the
erroneous beliefs that gender and sexual orientation are fixed, binary, and biologically
determined by sex-linked biology (54, 61, 86, 94, 161, 190). Also to contest are (a)
conventional legal definitions that restrict “discrimination” to mean unfair treatment based
on allegedly innate immutable and discrete characteristics, e.g., “race,” “sex,” or “sexual
orientation” (3, 174) and (b) the conventional—and contradictory—causal inference
suppositions that “race,” “sex,” and “sexual orientation” are either “unmodifiable”
characteristics (and thus cannot be “causes”) or else, unto themselves, are intrinsically the
“causes” of health disparities (105). Rather, the very idea that these are fixed attributes that
determine who people are—and at the same time are themselves causally su!icient to explain
group di!erences in health (without reference to the causal perpetrators, both systemic and
individual)—is part of the belief system of the very isms at issue. Notably, other forms of
discrimination recognized and prohibited by law include discrimination on the basis of
religious beliefs and political views (3), which, while potentially influenced by familial context,
are surely neither innate nor immutable.
Producing Knowledge for Action and Accountability, Not to Prove Injustice

The final point is that, to reiterate what I stated 20 years ago, the reason to study how injustice
harms health is not to prove that injustice is wrong, since it is, by definition (92). Instead, the
reasons are to deepen understanding of how injustice shapes population health, for whose
benefit at whose expense; to contest narratives that naturalize inequities; and to generate
evidence for accountability. A"er all, if people have created unjust societal systems and
structures, so too can people challenge these systems and structures and advocate instead for
human rights, health equity, and ecological sustainability (13, 21, 67, 74, 97, 155, 162, 181).
CORE CONSTRUCTS OF ECOSOCIAL THEORY Embodiment refers to how we literally

incorporate, biologically, the material (biophysical) and social world in which we live. The
concept of pathways of embodiment refers to how processes of embodiment are shaped
simultaneously by histories of societal arrangements of power and property and by
constraints and possibilities of our evolved biology in ecological context, involving gene
expression and not just gene frequency. Cumulative interplay of exposure, susceptibility, and
resistance across the life course and across levels refers to the importance of timing and
accumulation of, and responses to, embodied exposures, taking into account both
individuals’ life course social and biological development and the historical generation into
which they have been born, as well as the levels at which both the exposures—and
susceptibility and resistance to these exposures—are occurring (i.e., global, national,
regional, area or group, household, individual). The concept of accountability and agency
refers to both (a) the institutions and persons responsible for generating or perpetuating
health inequities and (b) the public health researchers for the theories used to explain or
ignore these injustices. Together, these conjoined constructs underscore why measures of
isms must take into account (a) structural, legal, and policy contexts, as tied to changes in
political and economic power (at di!erent levels) to uphold or challenge the isms, and (b)
timeframes of both exposures and their impacts, in relation to both the biophysical and
social worlds and the relevant etiologic periods within and across generations.
PATHWAYS OF EMBODIMENT Pathways of embodiment especially relevant to exposure

to unjust isms involve adverse exposures to (95–99) social and economic deprivation;
exogenous hazards (e.g., toxic substances, pathogens, and hazardous conditions); social
trauma (e.g., discrimination and other forms of mental, physical, and sexual trauma);
targeted marketing of harmful commodities (e.g., tobacco, alcohol, other licit and illicit
drugs); inadequate or degrading medical care; and degradation of ecosystems, including
degradation linked to the alienation of Indigenous populations from their lands. These
pathways, and multiple isms, occur—and are embodied—concurrently and interactively.
OPERATIONALIZING ISMS FOR HEALTH EQUITY RESEARCH: A SCHEMA AND

CONCRETE EXAMPLES
Table 2 provides a schema for delineating di!erent types of measures of the specified isms—
and anti-isms—relevant for health equity research, with attention to issues of study design.
Including anti-isms matters because, from the causal standpoint of inference to the best
explanation (105, 124), if adverse isms are posited to drive health inequities, then anti-isms
should aid health equity. Table 3 in turns provides selected examples of health equity studies
that have used such measures, at di!erent levels, from both the Global South and the Global
North; Supplemental Table 3
(http://www.annualreviews.org/doi/suppl/10.1146/annurev-publhealth-040119-094017)
provides the technical details of the metrics these studies employed.
Structural Measures: Isms and Anti-Isms

The term structural—as applied to isms—has, in the past decade, begun to surface in a small
but growing number of health equity studies (8, 14, 58, 77, 99, 196) ( Table 3 ; Supplemental
Table 1 (http://www.annualreviews.org/doi/suppl/10.1146/annurev-publhealth-040119-
094017)). “Structural” is meant to convey the “totality of ways” in which societies foster
unjust isms through “mutually reinforcing systems” that can variously involve “housing,
education, employment, earnings, benefits, credit, media, health care, and criminal justice” (8
, p. 1453) and also marriage law, family law, identity documents, and property ownership (13,
21, 67). These laws, rules, and practices in turn “reinforce discriminatory beliefs, values, and
distribution of resources” (8, p. 1453). Structural injustice thus exists above and beyond—
while also shaping—unjust interpersonal interactions and individual beliefs aligning with the
isms at issue ( Table 1 ).
When it comes to the measurement of structural isms, however, more precision is required.
Clarifying the di!erent types and meanings of “structure” is crucial for accurate identification
of etiology, accountability, and agency, and thus avenues for action.
Explicit laws and rules.

One class of structural measures pertain to explicitly stated “rules of the game” (13, p. 11) (
Tables 2 , 3 ; Supplemental Table 3
094017)). These rules can be articulated in explicit laws, policies, or algorithms, for which
either government or nongovernmental institutions bear responsibility, thereby pointing to
potential legal liability, claims for remedies or reparations, and alternative legislation (13, 181,
187). Well-known example include, in the United States, legally sanctioned white supremacy,
black enslavement, and subsequent legal racial discrimination (i.e., Jim Crow laws) (1, 4, 56,
151); legal and genocidal “racial hygiene” in Nazi Germany (informed by U.S. Jim Crow laws)
(56, 151); legal apartheid in South Africa (which also drew on U.S. Jim Crow laws) (56); the
long-standing legal disenfranchisement of women in most countries around the world
[women were first legally granted the right to vote, nationally, in New Zealand in 1893, and,
most recently, in 2015, in Saudi Arabia, albeit only at the local level (184)]; national laws in 72
countries (as of 2017) that prohibit same-sex relationships (34); and a new US federal policy,
under legal challenge, that prohibits transgender persons from enlisting in the military (123).
Two potential limitations involving these types of structural measures concern inadequate
measure of exposure and also correlated exposures. First, health equity studies using these
types of metrics typically focus on the presence of such rules; less attention, if any, is given to
assessing whether or how these rules are (selectively) enforced, such that important
variations in actual exposures may be overlooked (13, 66, 181). Second, health equity studies
typically focus on rules for solely one type of ism, and while this approach may sometimes be
warranted, o"en the ideological orientation of state policies means that rules for related
adverse isms travel together (13, 35); a potential corrective could be inclusion, as covariates,
of indices that capture multiple related policies (13, 35).
Nonexplicit laws and rules.

Other times, the laws or rules deliberately do not name the targeted groups, e.g., because it is
illegal to do so, but nevertheless discriminate adversely, by design or e!ect ( Tables 2 , 3 ;
Supplemental Table 3 (http://www.annualreviews.org/doi/suppl/10.1146/annurev-
publhealth-040119-094017)). Two classic examples from the United States, designed to
target African Americans without the relevant laws naming this group explicitly, include (a) the
War on Drugs (1, 75) and its links to mass incarceration, both of which have been a focus of
health equity research (140, 195), and (b) voter suppression, whether by (now outlawed) poll
taxes and literacy tests or by (still legal) partisan gerrymandering, restrictive voter ID laws, and
limits on times and places to vote (4, 151), which by contrast has received scant attention in
health equity research (88). A newer form of nonexplicit rule-based discrimination is
discrimination-by-algorithm, whereby algorithms applied to biased data yield biased
predictions, as has occurred with machine learning, big data, and institutional decisions
regarding employment, criminal sentencing, mortgage approval, and medical care (63, 148,
168). In both cases, the anti-ism measures needed to counter these types of injustice require
explicit use of ism-conscious rules to protect the targeted groups (1, 4, 70, 148, 168, 187).
Area-based or institutional nonrule measures.

Other measures appearing in the health equity research literature that are also referred to as
structural do not directly assess actual rules (whether explicit or implicit), but instead
comprise area-based or institutional measures regarding legacies and indicators of inferred
rule-based structural injustice ( Tables 2 , 3 ; Supplemental Table 3
094017)). Most commonly, such measures employ population-based data and quantify the
di!erence (relative or absolute) between the targeted group and the privileged group in
relation to one or more specified social outcomes, e.g., group di!erences in income,
education, employment, home ownership, residential segregation, political representation,
policing, mass incarceration, access to transportation, access to reproductive health services,
proximity to toxic waste sites or polluting industries or facilities, etc. ( Tables 2 , 3 ;
publhealth-040119-094017)). The measures used, to date, in health equity research have
been highly heterogeneous, rendering comparison of results across studies di!icult. They also
have thus far been limited by reliance on data that are publicly available and which can be
stratified by the relevant social groups. Also potentially of interest, but not yet used in
quantitative population-based health equity research, are area-based metrics for exposure to
public monuments that support unjust isms (e.g., in the United States, monuments
supporting the Confederacy) and also, as anti-isms, the removal of these monuments as well
as their replacement by public art that exposes the unjust isms (23, 82, 136, 172).
Additional area-based measures newly being used in health equity research seek to measure
social norms regarding isms by employing survey or Internet data ( Tables 2 , 3 ;
publhealth-040119-094017)). Caution is required, however, given (a) well-known biases
(especially underreporting) in self-report survey data on adverse discriminatory attitudes (10,
92, 99, 145, 154, 157) and (b) fast-rising fraudulent postings online, especially on hot-button
isms, to foment political divisions (30, 148). An alternative approach, not subject to these
biases but apparently not yet used in population-based health equity research, involves audit
studies, i.e., investigations that send identical resumes—or identically dressed people of
similar body build—to potential employers or landlords; in such studies, the applicants di!er
solely in their racial/ethnic or gendered appearance or couple status (e.g., single, same-sex
couple, heterosexual couple) (118, 145, 154, 167). Another newly employed approach in
health equity research is to use area-based implicit bias data (137, 152); however, an
important caveat concerns how selection bias can a!ect who voluntarily seeks out and takes
such Web-based tests (e.g., mainly highly educated and a!luent persons) (18, 22, 201).
Together, these types of area-based measures provide evidence solely about what is termed
statistical discrimination (i.e., statistical evidence of group di!erences inferred to arise due to
unjust processes but absent explicit evidence of motivation), and while such evidence may
not meet legal standards that require proof of intent (3, 174), it can still usefully inform and
galvanize action for equity.
Historical contingency and choice of structural measures and comparison groups.

Which types of structural measures can be used depend on societal and historical context. A
key consideration is whether the type of injustice at issue is legally under contest.
Consider, first, the case of adverse racial residential segregation in the United States. Its
contours were shaped by US federal and state laws and policies, translated into o!icial maps,
that mandated neighborhood residential racial segregation and disinvestment both in and
outside Jim Crow states from the 1930s to the mid-1960s, a"er which such legal racial
discrimination was nationally outlawed (55, 135, 170). Given the post-1965 lack of variation
by place or time in laws permitting racial discrimination in housing, health equity studies have
relied primarily on area-based indicators that are inferred to reflect the impact of historical
legal adverse racial residential segregation and also current illegal racial discrimination. Such
indicators have variously pertained to neighborhood composition (e.g., racial/ethnic, income)
and conditions (e.g., physical environment, housing stock), intergenerational transfers of
wealth and impoverishment as tied to home equity, and political power as tied to voting
districts and voting facilities (4, 8, 58, 99, 135, 157, 192, 196). Only with the recent unearthing
and digitization of the original 1930s maps (55, 170) has it become possible for health equity
researchers to start to investigate the long-term impacts of the original legal discrimination on
both neighborhood trajectories and health inequities (79, 130, 135; N. Krieger, E. Wright, J.T.
Chen, P.D. Waterman, E.R. Huntley, M. Arcaya, unpublished data; N. Krieger, G. Van Wye, M.
Huynh, P.D. Waterman, G. Maduro, W. Li, R.C. Gwynn, O. Barbot, M.T. Bassett, unpublished
data).
By contrast, present-day legal and policy conflicts over, say, same-sex marriage and civil
unions (19, 34), and over the rights of transgender and third-gender persons (e.g., travesties in
South America, hijras in India, and muxes in Mexico) (19, 34, 47, 190, 193), render it feasible to
analyze the contemporaneous health impacts of the explicit rules at issue. The same holds, in
relation to sexism, for current conflicts over laws and policies regarding sexual harassment (81
, 86, 149, 204), gender-based violence (24, 86, 133, 188), and sexual and reproductive rights
and health, e.g., regarding access to contraception, abortion, or inclusive health care for
sexual or gender minorities, or policies regarding pregnancy and parental leave (13, 24, 53, 59
, 62, 67, 68, 86, 144, 181).
Regardless of the type of structural measure employed, careful thought needs to be given to
both the comparison groups (101, 173) and the etiologic period (14, 97). Also at issue is the
extent to which people are legally able to move in order to benefit from or avoid policy
changes (13, 135). Contrasts can include (a) comparisons of the health of the targeted groups
before and a"er the law or policy goes into e!ect in their polity; (b) within-polity changes in
the magnitude of health inequities comparing the targeted and privileged group, before or
a"er the policy change; and (c) cross-sectional comparisons of either the health status of the
targeted group or the magnitude of the health inequities between the targeted group and the
privileged group across polities that di!er in the relevant law or policy. Short-term (or even
cross-sectional) temporal comparisons may be apt for outcomes with a short etiologic period
(e.g., psychological distress); if longer etiologic periods are involved, time lags must be
considered (13, 97).
An especially important consideration concerns the long-term life course and

intergenerational realities of embodied harm. What may seem “long ago,” from a legal or
policy standpoint, can be but an instant in terms of biological generations (97, 104, 107). Jim
Crow laws, for example, were decreed illegal in the United States in 1964 (1, 4, 151). However,
anyone born in the United States who, in 2019, is age 55 or older was born when Jim Crow was
the law of the land, and any child of theirs is the child of a person who potentially experienced
this all-encompassing form of structural racism (2, 83, 101). The handful of health equity
studies on Jim Crow and its abolition demonstrate its relevance to rates of infant mortality,
premature mortality, and current risk of more lethal types of breast cancer (2, 70, 83, 101, 102
, 106, 107). It is this understanding of embodied history that health equity researchers can
bring to their choice of measures of isms.
Individual: Exposure to Isms and Anti-Isms

Despite the importance of structural conditions shaping people's exposures, the most
commonly used measures in health equity research on isms and health nevertheless are
individual-level explicit self-reports of exposure to discrimination (whether as a target or a
witness) ( Tables 2 , 3 ; Supplemental Tables 1–3
094017)). Other individual-level metrics, used less frequently, include implicit measures of
exposure to discrimination and measures of internalized oppression.
Explicit self-report.
As discussed at length in other recent reviews (12, 89, 98, 99, 121, 141, 142, 157, 158, 196), in
the case of racism, heterosexism, and gender binarism, most studies rely on self-report
explicit measures. These measures typically assess if the exposure has occurred; in which
context (e.g., at work, in a public setting, at school, from the police or in the courts, online,
getting medical care, etc.); with what intensity, chronicity, and duration of exposure (including
age at onset); and also how the exposed person responds (e.g., from resistance to
internalization) ( Tables 2 , 3 ; Supplemental Tables 1–3
094017)). By contrast, for sexism, measures more typically pertain to phenomena that can be
conceptualized as actualizing beliefs and practices emblematic of sexism, e.g., sexual
harassment (especially at work, but also in public settings) (31, 103, 150, 204), gender-based
violence, and control over sexual and reproductive rights and health (24, 77, 86, 99, 133, 139,
161, 188) ( Tables 2 , 3 ; Supplemental Tables 1–3
094017)).
As with any self-report measures, caveats abound ( Table 2 ). First, self-reported measures can
express only what people are willing and able to say (92, 99), as shaped by fear, social
desirability, trauma, internalized oppression, and lack of knowledge (10, 33, 98, 145, 154, 157
). Moreover, members of the privileged group may claim reverse discrimination when
confronted by potential diminishment of prior privilege (99, 144, 165, 191, 200); health equity
studies that include members of the privileged groups could—but rarely do—employ relevant
measures of resentment [e.g., racial resentment (191) or hostile sexism (164)] to aid
interpretation of results. Self-reported experiences of discrimination, moreover, are typically
analyzed solely as a psychosocial stressor (12, 89, 92, 98, 99, 121, 141, 142, 157, 158, 196),
even as some exposures (e.g., unfair policing) pose physical, not just psychosocial, risks (1, 52,
75, 98).
Pointing further to limitations of a solely psychosocial focus, consider the case of wage
discrimination, which can harm people's health by causing material (economic) harm (92, 99,
155, 174). Notably, in the United States, the workplace is among the most commonly self-
reported sites for racial, gender, and anti-LGBT (lesbian, gay, bisexual, transgender)
discrimination (99, 147). It is di!icult, however, for employees to know if wage discrimination
is occurring. Why? The answer is not simply social norms. Rather, it is currently legal in only 15
of the 50 US states, plus the District of Columbia, for employees to share information about
their wages (198). Not surprisingly, several recent high-profile wage discrimination suits in the
United States have been started by plainti!s who accidentally discovered the pay stubs of
fellow workers who were paid higher wages for the same job (120, 199). Also not surprisingly,
research has found that states with legally protected transparency about wages have the
lowest within-job-title gender wage inequities (85). Thus, where rules govern what individuals
cannot know, it is likely that structural measures will outperform self-report data as a measure
of exposure.
Additional concerns about self-report measures, discussed at length in other literature (11, 27,
99, 121, 157, 196), pertain to whether questions should refer explicitly to discrimination [as
per the Experiences of Discrimination measure (110, 111)] or to unfair treatment [as per the
Everyday Discrimination Scale (196, 197)], or should solely name the behaviors at issue. Even
in research on sexual harassment and gender-based violence, for which the consensus is to
focus on behaviors (with no explicit mention of abuse or sexism), controversies abound over
which behaviors, enacted by whom, against whom, should count, and how best to counter
fears and internalized blame that contribute to underreporting (133, 188, 204). Another
problematic issue is that the discrimination and health literature contains numerous studies
that employ solely one- or two-item instruments, despite well-known psychometric flaws
a!ecting reliability and validity of instruments with so few items (12, 44, 99, 141, 142).
Despite these challenges, studies from around the world have found that self-reported
experiences of diverse types of discrimination and hate crimes rooted in unjust isms are
robustly associated with psychological distress and are more complexly associated with
adverse health behaviors, biomarkers, and disease outcomes (99, 128, 157, 158, 193, 196).
They are, accordingly, an important complement to structural measures, providing insights
into personal experiences that lie on the pathways of embodiment connecting structural
drivers to embodied harm and population health inequities.
Implicit measurement.
Another option is a!orded by the implicit association test (IAT), a robustly validated and
widely accepted cognitive time-reaction test well-described in the psychological literature,
which was designed to address the well-known problems a!ecting the use of self-report data
to measure socially sensitive topics (10, 44, 64, 146). Our preliminary studies (33, 100, 113,
114) of the new IATs we developed to assess someone's sense of being a target of
discrimination found that these IATs were not associated with social desirability (as commonly
is the case for self-report data), they did not display the well-known person-group
discrimination discrepancy that a!ects self-report measures (which previously had been
hypothesized to be an artifact of social desirability), and they were also associated with
smoking and with elevated blood pressure (33, 114). Work on these measures remains in its
infancy.
Experimental.
Less commonly, psychosocial research on health impacts of isms has also used experimental
techniques, exposing participants either to vignettes or to controlled situations designed to
correspond to experiences shaped by these isms, to assess their impact on psychological
state, physiological arousal, or diverse biomarkers (44, 99, 128, 145, 158). Despite well-known
questions regarding the generalizability of such results to impacts of real-world psychosocial
stressors (44, 145, 154), such studies can potentially yield insights into sets of psychological
and biological mechanisms that may be involved in behaviorally and biologically translating
unjust isms into embodied harm (44, 99, 116, 128).
Individual: Internalized Isms and Anti-Isms

Finally, health equity studies addressing racism, heterosexism, and gender binarism, but
rarely sexism, have employed measures of what may be termed internalized isms, e.g.,
internalized oppression or stigma ( Tables 2 , 3 ; Supplemental Table 3
094017)). At issue is the extent to which persons in the targeted group consciously or
unconsciously accept the privileged group's view of them as inferior, deviant, or shameful,
thus potentially increasing the targeted group's risk of harm to health via psychosocial
pathways, both behavioral and biological (99, 128, 157, 193, 196). Measures of anti-isms (
Table 1 ) conversely can assess, at the individual level, the extent of pride (and perhaps
defiance) that persons in the targeted group feel about their group and their analysis of who
discriminates against them and why (99, 157); also germane, at the population level, are
public demonstrations about, and the appearance of, public slogans regarding, say, LGBT
pride or “black is beautiful” (74, 127, 176, 187, 190). As in the case of the self-report measures
of exposure to discrimination, measures of internalized oppression and pride typically rely on
explicit self-report instruments (with all the same caveats about self-report data) (44, 99, 157)
or, less commonly, implicit measures (10, 38).
CHALLENGES AHEAD: KNOWLEDGE FOR ACTION TO END HEALTH INEQUITIES DUE

TO UNJUST ISMS
As should be evident, the field of health equity research is ripe to improve measures of unjust
isms, and anti-isms, to generate more powerful knowledge for understanding and for action to
advance health equity. As part of moving the field beyond the preponderance of work using
individual-level psychosocial measures, I would recommend the following actions:
Expand the scope of validated structural measures by type and timeframe to encompass
historical injustices whose embodied health harms manifest within and across generations (97, 101,
102, 104) and to integrate exposure (as our bodies do every day) across diverse types of isms (67, 74,
92, 95, 99, 162), in addition to clarifying whether the structural measures are rule based or indicators
of inferred rules.
Expand complementary use of anti-ism measures, spanning from structural to internalized,

drawing on new work for health justice (21, 69, 155, 162).
Expand the scope of comparative health equity research (13, 15), taking advantage of cross-
national (or subnational) and cross-temporal variations in exposures to unjust isms and corrective
anti-isms.
Develop terrestrially grounded measures that can reveal links between the structural drivers of
unjust isms and their toll on environmental degradation, the climate crisis, and health inequities (16,
21, 57, 87, 117, 162, 182).
I encourage you, the reader, to join in the collective e!orts to take on these challenges, as one
small part of the multifaceted, multisectoral work needed to advance health equity on a
threatened planet.
DISCLOSURE STATEMENT
The author is not aware of any a!iliations, memberships, funding, or financial holdings that
might be perceived as a!ecting the objectivity of this review.
ACKNOWLEDGMENTS
This work was supported in part by the American Cancer Society, Clinical Research Professor
Award (to N.K.) and sabbatical funds from the Harvard T.H. Chan School of Public Health
(Boston, Massachusetts).
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ANNUAL REVIEW OF PUBLIC HEALTH (/content/journals/publhealth) Volume 41, 2020

Measures of Racism, Sexism, Heterosexism, and

Vol. 41:37-62 (Volume publication date April 2020)

First published as a Review in Advance on November 25, 2019

option1=pub_keyword&value1="health equity"), heterosexism (/search?

option1=pub_keyword&value1="heterosexism"), racism (/search?

option1=pub_keyword&value1="racism"), sexism (/search?

option1=pub_keyword&value1="sexism"), structural injustice (/search?

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heterosexism, and gender binarism, by level a

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ON ISMS AND HEALTH EQUITY: CONCEPTS AND KEY CONSIDERATIONS

Tenets Relevant to Analyzing Isms and Health Inequities: Ecosocial Theory of

Analyzing Isms Requires Engaging with Biology and Challenging Biological

Producing Knowledge for Action and Accountability, Not to Prove Injustice

CORE CONSTRUCTS OF ECOSOCIAL THEORY Embodiment refers to how we literally

PATHWAYS OF EMBODIMENT Pathways of embodiment especially relevant to exposure

OPERATIONALIZING ISMS FOR HEALTH EQUITY RESEARCH: A SCHEMA AND

Structural Measures: Isms and Anti-Isms

Explicit laws and rules.

Nonexplicit laws and rules.

Area-based or institutional nonrule measures.

Historical contingency and choice of structural measures and comparison groups.

An especially important consideration concerns the long-term life course and

Individual: Exposure to Isms and Anti-Isms

Individual: Internalized Isms and Anti-Isms

CHALLENGES AHEAD: KNOWLEDGE FOR ACTION TO END HEALTH INEQUITIES DUE

Expand complementary use of anti-ism measures, spanning from structural to internalized,

New York: Bloomsbury

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