Book Review

Assessing Race, Ethnicity, and Gender in Health

N Engl J Med 2007; 356:1279-1280March 22, 2007

Article

Assessing Race, Ethnicity, and Gender in Health
By Sana Loue. 158 pp. New York, Springer, 2006. $69.95. ISBN: 978-0-387-32461-6

A fair society promises equality in the pursuit of happiness. Yet society — often unwittingly — withholds that promise. Assessing Race, Ethnicity, and Gender in Health is a study of how different nations have categorized their populations by race, ethnicity, and gender. Sana Loue, a professor of bioethics, epidemiology, and law, makes the case that the categories nations use in their censuses, birth certificates, and many other records are not naturally occurring categories but are socially constructed, often shifting over time and reflecting current prejudices. In many countries, the census has focused on skin color, with constructs intended to distinguish those who are white from those who are not white. Until 1960 in the United States, it was the census taker — not the head of household, as is the case today — who determined a person's race, using constructs such as “mulatto,” “quadroon,” or “octoroon,” or even “a single drop of black blood.” Inevitably, the ways in which societies label people influence the ways in which social policies are shaped.

With regard to human behavior, Loue develops the thesis that gender, like race and ethnicity, is a complex subject, one that cannot be understood only through the simple dichotomy of “It's a boy” or “It's a girl.” How little we understand gender diversity was the subject of a front-page article in the New York Times (December 2, 2006) about children who do not conform to gender norms. Accompanying the article was an idyllic image of two young girls skipping away, their long hair swinging in the wind. But the caption read that one of the children was a 5-year-old boy who had begun identifying as a girl after turning 3 years old. Parents who were interviewed for the article struggled to understand why their children insisted on cross-dressing and on other behaviors not typical for their sex and how these children could be protected from what they perceived as a hostile world. Pediatric experts have noted that such children are at risk for depression, suicidal feelings, and self-mutilation.

Loue summarizes a large body of literature on human sexuality and gender identity, including hermaphroditism, sexual orientation, and transsexual and transgender behaviors. A few decades ago, surgical correction was recommended for babies born with genitalia that appeared ambiguous. This recommendation was based on the theory that nurture shapes a child's identification with the male or female sex and that children will take on the identity of the gender in which they are raised. The flaws in this theory become evident as the complexities of human biology, including the interplay of morphology, chromosomes, and hormones, are reviewed. Implicit throughout the book is the idea that sexual diversity and gender diversity are naturally occurring phenomena. There is no consensus on whether certain behaviors are deviant. In the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), transsexuality is included, whereas homosexuality is no longer included. Pediatricians, educators, mental health professionals, and parents who are concerned about these issues will find this book informative.

The author is to be especially commended for bringing together a number of resources for improving health and health care research. One chapter draws on published studies on topics such as diabetes and breast cancer to assess whether the variables of race, ethnicity, and sex used were sufficient to warrant the conclusions. Another chapter identifies several instruments designed by experts to capture the racial, ethnic, and gender diversity in a population under study. Throughout, hundreds of relevant references are provided.

Because this slim volume (only 158 pages) has so much to offer, I hesitate to find fault with the fact that it does not include a chapter on assessing socioeconomic status and health. Given that only a few biologic factors have been found to explain disparities in health, a question arises: Will improved race and ethnicity data be sufficient for studying health outcomes and health care, or is it necessary to take variables such as income and education into account? Perhaps this question calls for an expanded edition of this fine book.

Marian E. Gornick
Centers for Medicare and Medicaid Services (Retired), Baltimore, MD 21244
mgornick@aol.com

Citing Articles (1)

Citing Articles

1. 1

   Tarynn M. Witten. (2009) Graceful Exits: Intersection of Aging, Transgender Identities, and the Family/Community. Journal of GLBT Family Studies 5:1-2, 35-61
   CrossRef