Abstract and Keywords
Invisible Visits tells the story of middle class Black women whose experiences of race and gender discrimination in healthcare settings are all but overlooked in social science research. The book uses interviews and focus groups to analyze how the perception of bias and stereotyping affect healthcare for Black women who are not poor but remain socially and economically vulnerable nonetheless. The introduction argues that these women anticipate being stereotyped and often feel they have to emphasize hard won skills, like their education or careers, to push back against their physician’s biased or discriminatory views. This chapter also presents data on healthcare and health outcome disparities among Black middle class women. In so doing, it lays the groundwork for the remainder of the book.
On several occasions I have felt as if my doctor is dismissive or makes assumptions about me because I’m a single Black woman. Ob-gyns weren’t interested in hearing my concerns about the pill or willing to answer questions about an IUD. Right now, I can’t remember all the circumstances when I felt like a poor pregnant teenager in Washington. All I remember was how often I left the office feeling angry and confused. I would go into doctor’s appointments with my guard up, ready to give a run down of my pedigree so that they would know that they were dealing with someone who was informed, not ignorant. And the crazy thing is, that I definitely remember this happening with both Black female docs and White men. So you just don’t know who you’ll connect with or what kind of stereotypes they have of you when you walk through the door. Eventually, I just stopped going to the doctor because I got so tired of feeling frustrated when I walked out.
—Cherie, a Washington, DC-based journalist, recounts her experiences with healthcare providers
Invisible Visits tells the story of middle-class Black women whose experiences of race and gender discrimination in healthcare settings are all but overlooked in social science research. Through interviews and focus groups with these women, I analyze how the perception of bias and stereotyping affect healthcare for Black women who are not poor but who remain socially and economically vulnerable nonetheless. I argue that these women anticipate being stereotyped and often feel they have to emphasize hard-won skills, like their education or careers, to push back against their physicians’ biased or discriminatory views.
If Cherie’s experience is any indication, going to the doctor often requires forethought, strategy, and great effort. Cherie and I were childhood friends who went to a private prep school on Chicago’s South Side. Although we were two Black girls in a private high school, Cherie and I nevertheless had very different upbringings. Cherie’s father had been the first Black person to attend a prominent southern law school and later went on to hold leadership positions in the city government of Gary, Indiana. In the late 1980s, reeling from the waning steel industry, Gary’s middle-class population, both Black and White, was rapidly declining. But Cherie’s family was safely ensconced in one of the remaining Black middle-class enclaves.
(p.2) I remember one of the first times I made the 40-minute drive from Chicago to Gary to visit her. The neighborhood seemed similar to my own, with its neat lawns and single-family homes. The interior of the house was like a perfectly coifed woman. There was not a throw pillow or framed photo out of place. The powder room was adorned with monogrammed guest towels and delicate, untouched soap in a beautiful dish. Although I was also ostensibly middle class, I did not grow up with such orderly attention to detail. The soap in my house was encrusted with dried bubbles, evidence of the previous hands that had used it. By contrast, Cherie’s house was a symbol of the people who lived in it: fancy, fashionable, and established.
Ironically, even to me, Cherie was somewhat of a unicorn. She was both undeniably culturally Black and upper middle class. Although I was also Black and middle class, my family and my life were markedly different. Cherie’s family was the kind that took excursions to the Caribbean with other similarly situated family friends and made weekend trips to football games at historically Black colleges. She was somehow both Black and able to take ski trips to Colorado with the White kids with whom we went to school. She didn’t even need to code switch,1 she simply moved seamlessly between the worlds she inhabited. Perhaps this had something to do with her mother, who was young and glamorous and deeply connected to all the right people. In fact, Cherie debuted at a cotillion sponsored by a local chapter of Jack and Jill, a national organization started in 1938 to help middle- and upper-class Black children remain connected to Black culture and identity.
The notion that there were enough upper middle-class Black people to form 230 US chapters of their own club was not something that occurred to me before I met Cherie. I grew up middle class in an interracial, interfaith family with a Black mother and a White, Jewish father. As an interracial family in the 1970s and ’80s, we were still something of a taboo and certainly outside the norm. My mother, a Black woman who grew up very poor in the Jim Crow South, knew nothing of the insular upper-crusty Black community that gathered in Jack and Jill meetings. My father grew up with parents who emigrated from Eastern Europe and spoke Yiddish as their primary language. Like children of many immigrant families, my father did well in school and became a lawyer, although my grandparents never learned to read or write in English. Given this backdrop, it’s probably not surprising that no one in my family could have envisioned that there were many young women like Cherie in major cities around the country.
(p.3) And, yet, Cherie and I ended up in the same high school and were close friends for years. She went on to attend a tony private university on the East Coast and ultimately earned a master’s degree at the London School of Economics. We would both likely be characterized as middle class in spite of what seemed like substantial differences in our upbringing and adult socioeconomic status (SES). But, if we were to rely on popular renderings of Black women, one would think that people like Cherie and I didn’t exist. Or that, if we did, our experiences in the world would be exactly the same. In many ways, Cherie’s experience planted the seed for this book long before I even knew anything about healthcare disparities. This book uses qualitative methods in original research with Black middle-class women like Cherie to understand their experiences overall and to illuminate their experiences at the doctor’s office, in particular.
For example, in spite of Cherie’s pedigree, her comments suggest she often had to deal with doctors’ unnamed set of stereotypes about Black women: angry, loud, promiscuous like the “sista” girl from around the way or the fraudulent users of government benefits (i.e., “welfare queens”). The list of negative characterizations of Black women is easy to find in American culture and society. In fact, the former First Lady Michelle Obama’s depiction in the media represents one of the most striking examples of stereotyping of Black women regardless of class status. Mrs. Obama was often characterized as an “angry Black woman,” a trope that followed her to the White House in spite of her Ivy League education, career, and social position.2 If former First Lady Michelle Obama’s experience is any guide, Black women of any class remain vulnerable to the specific racist and sexist antipathy/stereotypes some scholars call misogynoir.3
I argue that these stereotypes follow them into the doctor’s office as well. What Cherie and others like her experience at the doctor’s office is an extension of the general sense of illegitimacy that taints Black Americans regardless of class status. One of the more durable stereotypes is the notion that most Black people live in ghettos or are poor and uneducated. This is a prevailing and purposeful myth designed to erase the contours, context, and humanity of Black Americans as a whole. Against this backdrop, Cherie’s experience suggests that she and the other Black middle-class women I interviewed feel the need to go to the doctor with their guard up. From the moment they approach the receptionist to the (p.4) weigh-in with the triage nurse, women feel they must emphasize their education, upbringing, or career, in an effort to counterbalance the pervasive, demeaning, stereotyping they face.
Cherie, for example, catalogued the adjustments she made during visits with the doctor. They ranged from highlighting her education to her efforts to make her own reproductive healthcare decisions. Yet all of these adjustments were not enough to overcome the deeply ingrained stereotypes held by male, female, Black, and White healthcare providers. She also noted that doctors viewed her in the same highly stigmatized way that they viewed a “poor, pregnant teenager.” Of course, having children early and outside of marriage is another persistent stereotype of Black women, one that plays on underlying assumptions of Black lasciviousness and irresponsibility (Benkert & Peters, 2005). As a result of her frustration, Cherie eventually stopped going to the doctor all together.
Curtailing medical care, in and of itself, should be cause for concern. And may in part explain why Black women have worse health outcomes than their White counterparts (Jackson & Cummings, 2011; Jacobs, Rolle, Ferrans, Whitaker, & Warnecke, 2006; LaVeist, Nuru-Jeter, & Jones, 2003). It is also unclear how women make decisions about avoiding the doctor. Would they eschew going to the doctor even if they had a serious or life-threatening condition? In Cherie’s case, she needed a specific form of contraception that seemed unpopular with physicians during that time period.4 Cherie’s experience suggests that we just do not know how women make decisions about not seeing their doctor or when it may negatively affect their health. But it implicates bias and stereotyping as a main driver of healthcare disparities, especially among Black middle-class women who are not poor and who have health insurance (Earnshaw et al., 2016; Harris et al., 2006; Pascoe & Smart Richman, 2009).
Furthermore, Cherie’s statement highlights another way stereotyping may affect Black people’s health. She notes that even in her encounters with Black female physicians she felt as though she was being stereotyped as a poor pregnant teenager. Although the research about interventions to end differences in treatment emphasizes having Black patients seek treatment from Black doctors, Cherie’s experience hints at the inherent problem with using that strategy alone. One of the most pernicious effects of stereotypes is that they also affect the self-concept of the target group. For example, some women have stereotypical views of women’s intellectual capacities (Steele, 1997), and some Black people have internalized the stereotype that other Black people are lazy or don’t want to work (Frost, 2011). In fact, Claude Steele, the psychologist who developed the (p.5) concept of stereotype threat, found that Black people, women, and other groups who are often the targets of negative stereotyping eventually internalize them. His studies noted that when women were primed with a stereotypical depiction of women’s poor math ability, they actually performed worse on math tests (Steele, 1997). The same was true of Black people (Steele & Aronson, 1995). Steele’s research indicates that the targets of the stereotype may come to view themselves through that same lens.
In a similar vein, many scholars have written about internalized racism in which minorities come to view themselves from the perspective of the dominant society (Fanon, 1952). The legendary sociologist, W. E. B. DuBois (1903) characterized the experience of Black people in America as one of “double consciousness,” in which Black people come to view themselves from the perspective of the White society that dominated them. DuBois (1903) notes, “It is a peculiar sensation, this double-consciousness, this sense of always looking at one’s self through the eyes of others, of measuring one’s soul by the tape of a world that looks on in amused contempt and pity” (p. 3).
Finally, as I argue throughout the book, stereotypes and bias must be understood in the broader context of structural discrimination. In other words, in trying to understand healthcare disparities, it is important to go beyond the individual-level interaction between provider and patient. As psychiatrist Jonathan M. Metzl (2010) argues in his book The Protest Psychosis: How Schizophrenia Became a Black Disease, “racial tensions are structured into clinical interactions long before doctors or patients enter examining rooms” (p. xi). He also notes that our interventions to reduce disparities fail when they “focus exclusively on the race of the patient and of the doctor, and define the problem as arising in the intersection of these two races” (Metzl, 2010, p. xiii).
Metzl’s framing of the clinical interaction illuminates Cherie’s experience with both Black and White physicians. Given that Black and female providers certainly may hold stereotypical views of their patients, interventions to end healthcare disparities must address the broader context. Furthermore, while increasing the proportion of Black and female healthcare providers is much needed, addressing Black and female experiences of discrimination in healthcare should not stop there.5 Rather, we need to go further in attending to the multiple structural causes of differences in treatment.
• How does race and gender, particularly race and gender stereotypes, bias, and discrimination, affect Black middle-class women’s healthcare treatment?
• Why do Black middle-class women continue to receive less than standard treatment and often have poorer health outcomes than their white counterparts?
• How do historical experiences of racial and gender discrimination affect Black women’s contemporary engagement with healthcare providers?
The Problem: Health and Healthcare Disparities Among the Black Middle Class
Health Outcome Disparities
Despite Black Americans economic mobility gains, members of the Black middle class are still disproportionately more sick and die earlier than their White counterparts. In fact, Black–White disparities in health outcomes in the United States have been present and extensively studied for years (Krieger, 2001a; 2002; 2005; Krieger & Sidney, 1996; LaVeist et al., 2003). Black Americans are at higher risk for many chronic, debilitating conditions including diabetes, hypertension, cardiovascular disease, and certain cancers (Abell et al., 2008; Hershman et al., 2005; Jackson et al., 2014; Reeder-Hayes & Anderson, 2017; Saydah, Imperatore, Cheng, Geiss, & Albright, 2017). However, many public health studies documenting these inequities fail to account for the many structural factors that affect individual health and instead rely on biological determinants, which may further the myth of racial essentialism (Hatch, 2016). Health indices such as overall mortality rates and infant mortality rates point to systematic inequalities in health between Blacks and Whites (Braveman & Barclay, 2009; Geronimus, 1996).
One of the most important systematic inequalities is unequal access to material resources like income and wealth, which may lead to poor health behaviors, chronic health conditions, and diseases (Phelan, Link, & Tehranifar, 2010). Scholars have known for decades that health and well-being are closely related to SES (Deaton, 2002; Marmot, Kogevinas, & Elston, 1987; Waitzkin, 2000). However, in studies that adjust statistically for socioeconomic resources, Black–White health disparities do not disappear (Pollack et al., 2007; Williams, 1999). This represents somewhat of a paradox that Black people, regardless of their material resources, cannot “buy” the same health as their White counterparts. For many Black middle-class folk, simply being as healthy as the majority middle class remains stubbornly out of reach.
(p.7) We also know that Blacks of middle-class status share a disproportionate burden of illness and premature death, also termed “morbidity and mortality,” compared to Whites. For instance, college-educated Black women still have infant mortality rates that are twice that of their college-educated White counterparts (Mullings & Wali, 2001). To really appreciate the magnitude of that fact, we must consider several contextual factors.
First, the United States is the most advanced industrialized economy in the world, yet the nation’s infant mortality rate remains higher than most other developed countries (Mathews, MacDorman, & Thoma, 2015). In fact, the United States ranks 26th out of 29 member countries of the Organization for Economic Cooperation and Development (OECD), behind most European countries and Japan, Korea, Israel, New Zealand, and Australia (Osterman & Martin, 2014). Black infant mortality is a big reason the United States lags behind its economic counterparts in this important health indicator (Giscombé & Lobel, 2005). Although Black infant mortality recently declined (Osterman & Martin, 2014), Black babies are still more than twice as likely to die before their first birthday than White babies.
Importantly, Black women with a college degree are more likely to lose an infant before it reaches its first year than White women with much less education. In a society in which health status is so closely related to educational attainment (Braveman, Cubbin, Marchi, Egerter, & Chavez, 2001), the fact that Black women with much more education fare worse than White women with less is striking. The question, of course, is why. Some scholars suggest that underlying genetic differences between Blacks and Whites explains the disparity, while many critical scholars reject biologically determined explanations outright (Bediako, BeLue, & Hillemeier, 2015; David & Collins, 2007; Duster, 2005; Hatch, 2016; Obasogie, Harris-Wai, Darling, Keagy, & Levesque, 2014). Still other scholars note that the social environment, and particularly the race and gender discrimination Black women face, is the most likely cause (Anachebe, 2006; Wallace, Green, Richardson, Theall, & Crear-Perry, 2017). To date, the research points to chronic stress as a result of long-term exposure to race and gender discrimination (Kramer, Hogue, Dunlop, & Menon, 2011). In other words, Black women are affected by systemic discrimination regardless of their class status, which may ultimately harm their developing fetus.
Another striking difference between Blacks and Whites are wealth disparities. At every level of income, the differences in wealth between African Americans and Whites are large, pervasive, and widely documented (Oliver & Shapiro, 2006; Shapiro, 2004). For example, the median wealth (assets minus debts) of White households is 20 times that of Black households (Kochhar, Fry, Taylor, Velasco, & Motel, 2011). In 2009, the median wealth of Black families was $5,677 while White families had a median wealth of $113,149 (p.8) (Kochhar, Fry, Taylor, Velasco, & Motel, 2011). This is more than a matter of not being able to save money to pass on to future generations, although that is certainly problematic. The economic foundation of middle-class Blacks is substantially more precarious than Whites. On average, Black people do not have the savings to weather economic downturns, to take vacations to reduce their stress, or to carry them through an unexpected job loss.
Given this backdrop, Black Americans often expend significant effort to acquire additional financial security. This ultimately may lead African Americans to pay the mental health costs of upward social mobility (Cole & Omari, 2003). Furthermore, stressors such as racial discrimination may diminish their returns on their education, training, and other human capital investments, which limits their financial capabilities (Hudson et al., 2012).
Here, again, we see middle-class Black Americans face additional challenges and stressors as they try to solidify the economic foundation of their families.
Unequal Treatment: How Provider Biases Contribute to Healthcare Disparities
In addition to differences in health outcomes (i.e., differences in life expectancy, infant mortality, etc.), inequities persist even after people arrive at the doctor’s office. In the early 2000s, against a backdrop of growing concern about healthcare disparities, the Institute of Medicine (IOM) conducted a groundbreaking study to understand the causes and consequences of the problem (Nelson, Stith, & Smedley, 2002). The study documented widespread and pervasive differences in the way ethno-racial minorities were treated in medical settings.
They found that people of color did not receive the standard of care for many health conditions regardless of their health insurance status or ability to pay for treatment (Nelson et al., 2002). The study became one of the seminal works in the field of healthcare disparities and launched a cascade of follow-up studies to better understand how the interaction between the patient and provider contributes to differences in treatment. The IOM study, and the voluminous body of evidence that emerged in its wake, suggested that physician bias, whether conscious or unconscious, is a main driver of differences in treatment (Hall et al., 2015; Nelson et al., 2002). Ethnic and racial minorities, women, and others from vulnerable social positions are particularly vulnerable to bias and stereotyping (Williams, 2012). Numerous studies have documented that healthcare providers are unconsciously or unintentionally biased against members of marginalized groups, which ultimately leads to differences in treatment across multiple domains (i.e., specialty care, pain management, mental health services, etc.; Aronson, Burgess, Phelan, & Juarez, 2013; Burgess, Fu, & Van (p.9) Ryn, 2004; Van Ryn & Fu, 2003). Even though physicians often report an aversion to racial or gender biases, empirical tests of physician attitudes and behavior find that healthcare providers certainly have negative feelings or evaluations of their patients based on their race, gender, and other factors (FitzGerald & Hurst, 2017). Analyses of unconscious (implicit) biases find that these forms of bias are relatively common (FitzGerald & Hurst, 2017; Penner et al., 2010).
For example, a large body of evidence indicates that Black people are systematically undertreated for pain compared to Whites (Hoffman, Trawalter, Axt, & Oliver, 2016). Healthcare providers often underestimate and undertreat Black people’s pain (Hoffman et al., 2016). These differences even extend to Black children who present in emergency departments for acute appendicitis (Goyal, Kuppermann, Cleary, Teach, & Chamberlain, 2015). In a study that reviewed almost 1 million cases of appendicitis in the United States, Black children were less likely to receive any type of pain management for moderate pain and less likely to receive opiates for severe pain (Goyal et al., 2015).
Incredibly, a 2015 study of more than 400 medical students and residents found that differences in pain management may be explained by the fact that providers believe Blacks are fundamentally biologically different from Whites.6 The study found half of medical students and residents endorsed the erroneous idea that Blacks’ nerve endings are less sensitive than Whites and that Whites have larger brains than Blacks. Importantly, this study also found that students and residents who endorsed false beliefs also inaccurately evaluated the pain of Black patients in simulations of pain evaluation and treatment. The misevaluation of pain ultimately led to less accurate treatment recommendations for the Black patients as compared to Whites (Goyal et al., 2015).
Given that we know physicians’ negative evaluations of members of a group may lead to healthcare disparities regardless of the patient’s class status, scholars are beginning to focus on differences in treatment that affect the Black middle class. For example, one of the world’s most prominent health disparities researchers, sociologist David Williams, and his colleagues strongly emphasize that race matters even after class status is taken into account (Williams, Priest, & Anderson, 2016). Williams has also called for more attention to how the factors that can negatively or positively affect or improve health are systematically (p.10) patterned by race, ethnicity, and SES. This means that exposure to the toxic stress of financial insecurity or inadequate access to healthy food is not equally distributed in American society. It depends on one’s race, gender, and class status. The same is true of resources that promote health, like clean air and adequate household income (Jackson & Williams, 2006).
For example, we know that Black people may still be treated differently at the doctor and have worse mental health outcomes than their White counterparts regardless of their class status (Hudson, Neighbors, Geronimus, & Jackson, 2016; Jackson & Cummings, 2011; Williams, Mohammed, Leavell, & Collins, 2010). In addition to physical health outcomes, Hudson and colleagues have found that middle-class Blacks are at even greater risk than their poorer counterparts for mental health problems associated with exposure to racial discrimination (Hudson et al., 2016). Although Americans typically think of acquiring education as the way to a better life, researchers have found that greater levels of education were associated with increased levels of racial discrimination and depression (Hudson et al., 2016). This research supports Williams et al.’s (Williams, 1999; Williams & Collins, 1995) work documenting the fact that, although Black middle-class health improves with additional SES resources, Black people do not receive the same health protections as their White counterparts. This has also been called the “diminishing returns” hypothesis, in which Farmer and Ferraro (2005) found that Black people actually receive declining health returns as SES (i.e., education) increases. In other words, it seems that, for Black Americans, acquiring more education leads to more opportunities to be discriminated against, which ultimately is bad for one’s health.
Perhaps due to his own experience in acquiring education, sociologist and health disparities researcher Sherman James recognized the potentially deleterious effect of striving for upward mobility while Black. James observed that Black people who worked tirelessly to gain economic or education resources actually had worse health outcomes, particularly with regard to hypertension, than their White counterparts (James, Strogatz, Wing, & Ramsey, 1987). James called this relentless striving in the face of structural barriers “John Henryism,” harkening back to American folklore in which a Southern Black man of remarkable strength and endurance suddenly collapsed and died after years of overwork. James, himself a Black man who endured overt racial discrimination in the American South, noted that John Henryism was caused by the indecency of daily racial discrimination and Black people’s effort to cope with it (James, 1994).
In addition to high-effort coping and exposure to racial discrimination, the pernicious effects of stereotyping may help to explain mental and physical health disparities that persist for the Black middle class. Scholars have long noted that stereotyping is a critical component of a system that creates racist subordination (Omi & Winant, 1994). Stereotyping may also negatively affect health through both interpersonal pathways, such as increasing hypervigilance and allostatic load, and structural pathways, such as perpetuating unhealthy social and physical environments (e.g., public transportation systems) that degrade and devalue Black health (Kwate & Meyer, 2011). Black women experience the healthcare system in the context of pervasive negative stereotypes about their race and gender, including the angry Black woman, mammy, welfare queen, and prostitute (Harris-Perry, 2011). In describing the particular stereotypes Black women face in the United States, noted Black feminist scholar Patricia Hill Collins (2000) also theorizes the connection between stereotyping and oppression:
From the mammies, jezebels, and breeder women of slavery to the smiling Aunt Jemimas on pancake mix boxes, ubiquitous Black prostitutes, and ever-present welfare mothers of contemporary popular culture, negative stereotypes applied to African-American women have been fundamental to Black women’s oppression. (p. 7)
In addition to Collins, psychologists Charise Jones and Kumea Shorter-Gooden analyzed the specific challenges Black women face in their seminal book on how Black women experience American society. Jones and Shorter-Gooden found that Black women are routinely confined to caricatures that are grotesque, narrow, and unfair (Jones & Shorter-Gooden, 2003). Furthermore, intersectional scholars who study how race and gender join to create unique conditions informed by multiple, overlapping identities have long noted that Black women face the double bind of Blackness and womanhood (Collins, 2000; Crenshaw, 1991; Samuels & Ross-Sheriff, 2008). Their experiences cannot be understood through either the lens of race or gender in isolation, but at the intersection of these identities.
In spite of the pervasiveness of negative stereotypes of Black women, relatively few works of social science consider how stereotyping contributes to a far less than ideal healthcare environment. The work of medical sociologist Janet Shim, who conceptualizes the healthcare encounter as a transaction between patient and provider, may help us understand how Black women approach the particular challenges of the healthcare encounter (Shim, 2010).
(p.12) Rooted in noted sociologist Pierre Bourdieu’s concept of habitus, cultural health capital theorizes that one’s ability to reproduce certain cultural actions is central to the patient–provider interaction (Shim, 2010). Shim defines this form of capital as a specialized collection of cultural skills, attitudes, behaviors, and interactional styles that are valued, leveraged, and exchanged by both patients and providers during clinical interactions. These skills and resources may include styles of dress, verbal skills, scientific knowledge, educational credentials, and healthcare literacy. Cultural health capital is also rooted in the historical and cultural moment, which emphasizes patient consumerism, initiative, and self-surveillance.
For Black middle-class women, elements of cultural health capital are particularly relevant. For example, Shim notes that cultural health capital rests on one’s ability to communicate social privilege and resources that can act as cues of favorable social and economic status and consumer savvy. To establish these resources, patients must demonstrate knowledge of medical topics and vocabulary and also have the ability to convey healthcare information to the provider in an efficient and rational manner. All of these skills are critical to a successful healthcare encounter. Cultural health capital presupposes a belief in the value of, and resources to, practice self-discipline and the ability to take an instrumental attitude toward the body. Given that Black people are often reduced to caricatures about laziness, lack of intelligence, and the like, demonstrating one’s cultural health capital may be characterized of as a form of resistance to stereotyping (Sacks, 2017).
Importantly, although cultural health capital suggests that patients may indeed possess the resources to manage the healthcare encounter, these transactions may come at a cost. Shim posits that cultural health capital may contribute to the accumulation of power and the persistence of inequality (Shim, 2010). For example, in a study of how healthcare providers think about their patients, researchers found that they have particular expectations of what makes a capable and proficient patient (Dubbin, Chang, & Shim, 2013). Patients who do not meet the provider’s expectation of astute self-management are considered less appealing all together, causing a rupture in the patient–provider relationship (Dubbin et al., 2013).
Although the dominant paradigm in American medicine emphasizes the importance of physician objectivity and scientific rationality, this research highlights the obvious: physicians are human beings replete with foibles and subject to the same socialization that reinforces stereotypes as anyone else. We know that physicians are not immune to bias and stereotyping, but few scholarly works have explored how Black women perceive and respond to it or how it affects the healthcare encounter overall. Given the pervasive stereotypes of Black women, they may feel even more pressure to emphasize certain elements (p.13) of such capital in the hopes of connecting with their physicians and mitigating prevailing notions of Black female illegitimacy (Sacks, 2017).
The analysis of Black women’s experience in healthcare settings rests on an understanding of the impact of stereotyping, including the concept of stereotype threat, as well as with the socially distributed set of resources Black women may use to mitigate these threats. This book delineates the conditions under which women feel they need to counter such stereotypes, the burden they experience in enacting these behaviors, and the potentially negative effects on their health. Finally, the work provides an in-depth exploration of how Black women actually perceive the healthcare encounter and healthcare providers and considers the situational adjustments women make to advocate on their own behalf. In so doing, the book is among the first to analyze how implicit and explicit bias affects women and leads to differences in treatment and health disparities. Moreover, the book avoids the dominant paradigm in public health research, one that uses a neo-liberal frame to blame individuals for their worse health outcomes (Chowkwanyun, 2011; Krieger, 2001a). By placing the contemporary experience of the Black middle class in a historical context, this book also describes how pervasive stereotyping coupled with scientific racism has led to poor treatment in (and as a result of) cases such as the Tuskegee Syphilis Experiment and the Mississippi Appendectomy (a term used to denote the eugenic practice of overuse of hysterectomy among African American women). These forms of medical maltreatment are often reinstantiated in contemporary forms of discrimination in healthcare settings, as reflected in disparities in hysterectomy rates, pain management, and mental health treatment.
To analyze this topic, I conducted interviews and focus groups in 2010 and 2011 with a total of 30 African American middle-class women in Chicago. At the onset, I set out to better understand subtle intraracial class differences in the healthcare experiences of lower middle-class Black women relative to upper middle-class Black women.7 Given that the research literature focuses almost exclusively on the Black poor and, to a lesser extent, on the lower middle classi, I wanted to explore how differences in class/SES affect Black women’s engagement with healthcare providers. I knew that because SES categories are notoriously messy (p.14) and hard to define (Braveman et al., 2001; Conley, 2010), a Black woman who is an administrative assistant with an associate’s degree and a Black woman with an MBA making six figures would likely both be considered “middle class” based on their income, education, and occupation (Pattillo, 2013). However, it is unclear whether the relative difference in socioeconomic position leads to different experiences in the world and in healthcare settings. As such, this research was designed to break out an underresearched subset of Black women and, in turn, understand how they experience healthcare settings from these markedly different positions.
Taking the argument a step further, an explicit purpose of this book is to explore intragroup variation among African Americans. Although healthcare disparities studies are explicitly concerned with Black–White comparisons, this work focuses solely on African Americans. Moreover, it contributes to research that makes sense of similarities and differences between Black people who may share a similar racial phenotype or purported Black identity but are likely to differ ideologically, politically, socially, and economically. This body of research, including scholarship by Cathy Cohen, Melissa Harris-Perry, Mary Patillo, Karyn Lacy, and others, analyzes within-group variation in Black political thought, social behavior, and life outcomes. The work of these scholars provides the precedent for the in-depth study of African Americans as a group unto themselves.
A secondary purpose of this work, in which I move away from studying African Americans in comparison to Whites, is to carve out more space to explore how race, class, and gender affect Black women in healthcare settings. Limiting the study to African Americans facilitates understanding (1) the lived experience of class and racial status among non-poor Black people, (2) variation within the Black middle class, and (3) how Black people relate to each other on matters of class, racial identity, and racial authenticity. Moreover, understanding the factors that affect healthcare interactions among the Black middle class contributes to our overall understanding of healthcare disparities, as well as suggesting new possibilities for intervention.
Based on findings from these data, I make the following core claims, which will be explicated in the remainder of the book. First, stereotyping and race and gender discrimination persists across SES. Contrary to the dominant post-racial paradigm, race and gender discrimination continues to affect people even when they are not poor. Second, trying to resist stereotyping, bias, and discrimination can be exhausting, stressful, and may contribute to health problems (in a similar vein to the high-effort coping termed “John Henryism”; James, 1994). Third, although enacting specific strategies, including emphasizing one’s career, intelligence, or health literacy, is sometimes stressful, women purposely use these tactics as forms of resistance despite their oft deleterious effects. As evidenced (p.15) by the empirical data presented in the book, trying to advocate for oneself necessitates walking a fine line. Black women may emphasize their social status to disrupt implicit and explicit provider stereotyping, yet displaying too much knowledge and self-advocacy may backfire if providers think their patients are too pushy or noncompliant.
Given the power difference between patients and providers, this form of resistance does not always produce its intended effect and may ultimately hinder the patient’s ability to attend to important information. Moreover, the intent of this work is not to suggest that women should bear the responsibility of strategizing to receive high-quality, unbiased, equitable healthcare. On the contrary: the work reorients us to the structural constraints that give rise to healthcare disparities in the first place. Fourth, minorities who are not poor, particularly Black middle-class women, are often overlooked in research. Yet by studying this group, we can isolate and better understand the persistence of race and gender discrimination and its relationship to class status. Fifth, historical instances of medical maltreatment and discrimination cast a long shadow on the contemporary healthcare experience of Black middle-class women and should be more thoroughly integrated into social science research on disparities. Finally, I argue that, given the overwhelming persistence of disparities, it is long past time to do something about them. Taken together, the evidence suggests that the healthcare experiences of Black women do not vary across SES in the same way that we see for White women. That is, the experience of White middle-class and poor women is likely very different, but Black women’s experience does not seem to vary by class status to the same degree.
Rather than questioning why Black women’s health outcomes are not the same as other populations, this book renders visible the intricacies and intimacies of the lives of Black women as they interact with the American healthcare system.
Plan of the Book
What follows is an investigation of the ways in which Black women who are not poor adapt, resist, and are shaped by race and gender discrimination, particularly in healthcare settings. Chapter 1 lays the groundwork for our understanding of the particular strengths and vulnerabilities of the Black middle class, especially Black middle-class women. In so doing, I describe why this group warrants consideration unto itself, review previous work on the Black middle class, and explore similarities and differences between the Black middle class, the Black poor, and the middle class in general. The chapter also provides an overview of stereotypes Black women face (e.g., the Mammy, Jezebel, and Sapphire), as well (p.16) as stereotype threat, the situational predicament in which people are or feel themselves to be at risk of confirming negative stereotypes about their social group (Steele & Aronson, 1995). Finally, the chapter describes how Black women employ cultural health capital and other skills, such conducting research to prepare for a provider encounter, to resist negative stereotyping.
Chapter 2 outlines women’s efforts to make connections with providers and ultimately secure quality treatment. I review how women use their cultural health capital, class resources, and self-presentation skills to advocate for themselves. The chapter also explores the impact of advocacy on the relationship between the provider and patient and develops the idea that self-advocacy may also be experienced as burdensome by the patient or pushy by the provider. This is particularly salient in an era of “patient-centered” medicine in which people are expected to advocate for themselves, thereby shifting the burden from the provider back to the patient.
Chapter 3 explores race and gender concordance as a strategy to mitigate stereotype threat and differences in treatment. I first introduce a case study, which describes the experiences of Tammy, a 42-year-old woman whose great-grandfather was killed as a result of his involuntary participation in the Tuskegee Syphilis Study. This case illustrates how past incidents of discrimination and trauma affect Black women’s contemporary experience dealing with doctors. Then, the chapter reports on women’s evaluation of the healthcare system overall as a rushed, impersonal, profit-driven enterprise that emphasizes money over clinical expertise, patient outcomes, and patient–provider trust. Finally, I analyze how Black women evaluate whether seeking a Black female provider leads to better care.
Chapter 4 examines contemporary reproductive healthcare in the context of pervasive stereotypes of Black women’s purported physical hardiness. The chapter also provides a brief history of the overuse of hysterectomy, particularly in the American South, and details women’s contemporary experience with hysterectomy as a treatment for uterine fibroids, a medical condition that disproportionately affects Black women of reproductive age.
The book concludes with Chapter 5, in which I argue that (1) racial and gender stereotypes negatively affect the healthcare experiences of Black middle-class women, (2) stereotyping is threatening regardless of whether healthcare providers hold conscious or unconscious biases about their patients, and (3) the threat of stereotyping certainly contributes to the US healthcare system’s persistent problem with inequities in treatment. Invisible Visits concludes with recommendations for how healthcare providers and the healthcare system can explicitly acknowledge and mitigate these challenges by reorienting their focus to the structural causes of healthcare inequities (Metzl & Hansen, 2014).
(1) Code-switching is the practice of alternating between two languages or styles of language in conversation. The term often connotes the process through which ethno- racial minorities use different language or colloquialisms depending on the racial or cultural background of the person with whom they are speaking or the context (Anderson, 2000).
(2) See New Yorker cover https://www.theguardian.com/world/2008/jul/15/barackobama.usa) http://www.thedailybeast.com/articles/2012/01/13/michelle-obama-confronts-racial-stereotypes-in-white-house-tell-all.html).
(3) “Misogynoir” is a term first coined by Professor Moya Bailey to describe the specific way racism and sexism combine to oppress Black women: “Misogynoir describes the co- constitutive, anti-Black, and misogynistic racism directed at Black women, particularly in visual and digital culture” (Bailey, 2016, p. 1).
(4) More recently, reproductive justice scholars have argued that healthcare providers disproportionately prescribe long-acting reversible contraception (LARCs) like IUDs or Norplant to Black and Latina women (Downey, Arteaga, Villaseñor, & Gomez, 2017).
(5) Striving to ensure patients and providers are matched on race, ethnicity, gender, and/or language preference, also termed “race and gender concordance” in the research literature (LaVeist, Nuru-Jeter, & Jones, 2003), has long been one of the preferred strategies to reduce differences in treatment.
(6) Much of biomedical science, research, and training implicitly rests on the notion of racial dimorphism, or the fundamental biological differences between Blacks, Whites, and other groups (Hatch, 2016; Krieger, 1987; Obasogie et al., 2014). In fact, I would argue, that much of the health disparities literature approaches differences in health outcomes from this biologically determined, essentialist point of view, even when many of these same researchers purport to subscribe to a social constructionist explanation of race (Ford, 2016). The implications of this perspective will be explored further in Chapter 4.
(7) Although the study was initially designed to better understand intraracial class variation in the healthcare experiences of Black women, the findings suggested that lower middle- and upper middle-class Black women had very similar healthcare experiences related to pervasive stereotyping based on race and gender. As such, this book focuses on Black middle-class women as a whole.