Marginalized identities, healthcare discrimination, and parental stress about COVID-19

Abstract

Objective: This paper assesses stress disparities among marginalized parents in 2020-21 during the COVID-19 pandemic through the mechanism of healthcare discrimination. Background: The pandemic upended the lives of American families and had particularly stark mental health consequences for women, racial and ethnic minority (REM), and sexual and gender minority (SGM) parents. Scholars have been called to understand these unequal experiences via marginalizing mechanisms rather than using race, gender, and sexual identities as proxies for racism, sexism, and cis-heterosexism. Methods: Structural equation modeling was used to test associations between marginalized identities and parental stress about COVID among partnered parents using healthcare discrimination, a marginalizing mechanism, as a mediator. The data come from The National Couples' Health and Time Study, a population-representative study of couples in the United States. Results: Findings indicate that compared to nonmarginalized parents, Black parents, women, transgender and nonbinary parents, and gay, lesbian, and bisexual parents experienced higher levels of parental stress about COVID through heightened healthcare discrimination. When accounting for healthcare discrimination, only one marginalized identity-that of womcn-was directly associated with parental stress about COVID along with the indirect relationship through healthcare discrimination. Conclusion: These findings highlight healthcare discrimination as a process that puts marginalized parents at risk for heightened stress. Parental stress has the potential to accumulate across the life course and crossover to children and communities.

Headnote

Objective: This paper assesses stress disparities among marginalized parents in 2020-21 during the COVID-19 pandemic through the mechanism of healthcare discrimination. Background: The pandemic upended the lives of American families and had particularly stark mental health consequences for women, racial and ethnic minority (REM), and sexual and gender minority (SGM) parents. Scholars have been called to understand these unequal experiences via marginalizing mechanisms rather than using race, gender, and sexual identities as proxies for racism, sexism, and cis-heterosexism. Methods: Structural equation modeling was used to test associations between marginalized identities and parental stress about COVID among partnered parents using healthcare discrimination, a marginalizing mechanism, as a mediator. The data come from The National Couples' Health and Time Study, a population-representative study of couples in the United States. Results: Findings indicate that compared to nonmarginalized parents, Black parents, women, transgender and nonbinary parents, and gay, lesbian, and bisexual parents experienced higher levels of parental stress about COVID through heightened healthcare discrimination. When accounting for healthcare discrimination, only one marginalized identity-that of womcn-was directly associated with parental stress about COVID along with the indirect relationship through healthcare discrimination. Conclusion: These findings highlight healthcare discrimination as a process that puts marginalized parents at risk for heightened stress. Parental stress has the potential to accumulate across the life course and crossover to children and communities.

KEYWORDS

discrimination, health care, marginalized, parents, quantitative methodology, stress

INTRODUCTION

The COVID-19 pandemic upended family environments. One in five children had a parent lose their job (Bokun et al., 2020), 38% of Americans were food insecure (Wolfson & Leung, 2020), and children and parents experienced mental health declines (Gassman-Pines et al., 2020). Individuals marginalized due to their race and ethnicity, sexual identity, and/or gender experienced more severe detriments during the pandemic. Understanding how parents fared as they sought to protect their children during this crisis is crucial to identifying mechanisms linking race, gender, and sexual identity marginalization to disparities in parental well-being.

Scholars have documented the toll of the pandemic on racial and ethnic minoritized persons (REMs) and sexual and gender minoritized persons (SGMs). Women, especially mothers, were more likely to quit paid work due to "home or family concerns" (Tedeschi, 2020) which included managing physical and mental health risk for themselves and their families and parenting children who were learning from home (Reading Turchioe et al., 2021). Among REMs, disproportionate virus vulnerability and a lower vaccination rate (Ndugga et al., 2022), along with the stress of elevated economic precarity (Bokun et al., 2020) may have especially compromised mental health. Pre-existing conditions put SGMs at risk for CO VID (i.e., higher prevalence of chronic respiratory diseases; Operario et al., 2015) and social isolation was especially risky due to SGMs' unique mental health challenges (Flentje et al., 2020). For both SGMs and REMs, stigma and discrimination heightened health vulnerabilities during the pandemic (Hatzenbuehler et al., 2013; Quinn et al., 2020). Although many studies collected data during the pandemic, representative studies with sufficient samples of REMs and SGMs are essential for examining disparities related to CO VID and the mechanisms underlying them.

Leveraging novel, population-based survey data collected in 2020-2021, we examine healthcare discrimination as a mechanism underlying REM and SGM disparities in parental stress about CO VID. We draw on partnered parents of children under age 18 in the National Couples' Health and Time Study (NCHAT; N = 1113), a representative sample of individuals living in same and different-gender couples in the United States with oversamples of Black, Hispanic/Latina/o/e/x (referred to as Latine here forward), and Asian families. This study will advance our understanding of disparities in parental stress during the pandemic by motivating and testing a marginalizing mechanism linking parents' marginalized identities and stress outcomes.

BACKGROUND

Given the massive upheaval the pandemic provoked, we need more research on how families navigated it and how it shaped their well-being. In the United States, marginalized individuals arc at unique risk for health problems due to structural and interpersonal experiences of racism, sexism, and heterosexism (Hardeman et al., 2018; Lukachko et al., 2014; Meyer, 1995). Evidence suggests that not only did those who hold marginalized identities disproportionately experience the negative health effects of CO VID (Andrasfay & Goldman, 2021; Reading Turchioe et al., 2021), but they also disproportionately bore the social and mental health costs of the pandemic (e.g., Goldberg et al., 2021; Manning & Kamp Dush, 2022). The mechanisms driving the long-term effects of CO VID for families in America will remain elusive, however, unless their acute impacts are identified.

Many parents struggled during the pandemic. In a community sample of parents, 40% met the criteria for major or severe depression during the pandemic, and these parents also reported elevated stress (Lee et al., 2021). Greater pandemic stressors (e.g., COVID-induced relationship problems), parental or child health problems (Brown et al., 2020), and psychological distress (Brown et al., 2020; Lee et al., 2021) were associated with parental stress. Over 70% of parents said they worried about the impact of the pandemic on their children (American Psychological Association, 2020). This paper assesses variation in parental stress among partnered parents during the pandemic by experiences with racism, sexism, and heterosexism.

Many studies of CO VID and health disparities examine race as a risk factor. Race is not a risk factor. Rather, racism is the risk factor (Hardeman et al., 2018). Family researchers have been called to capture the collective practices and structures that serve to benefit White families and disadvantage non-White families (Bonilla-Silva, 2023). The same is true for gender and sexual identity. Sexism (Homan, 2019) and heterosexism (Everett et al., 2022) underlie gender and sexual minority disparities in well-being. Using a measure of one marginalizing processhealthcare discrimination-wc move beyond identities as risks to attempt to identify a key underlying process that may generate disparities in well-being.

Stress process theory

Stress process theory offers a theoretical framework to understand the social and structural patterning of stress (Pcarlin et al., 1981). This model highlights the complex and dynamic nature of stress and how structures of inequality burden marginalized populations with stress that ultimately produces health disparities (Pearlin et al., 2005). These stressors can come in the form of acute life events (e.g., CO VID diagnosis) and chronic hardships (e.g., experiencing discrimination). This theory posits that one's likelihood of experiencing many of these stressors is largely determined by processes-like racism and sexism-built into structures and institutions in society (Pearlin, 1989). For example, Black individuals are less likely than their white counterparts to receive pain management treatment in healthcare settings (Hoffman et al., 2016). These stressors have impacts that reverberate across the life course. Stress proliferation refers to the process by which certain stressors lead to the generation or layering of additional stressors (Pearlin et al., 2005). Stress process theory has also been used to conceptualize family-level stressors and the distinct ways in which parents experience stress (Milkie, 2010). In this paper, we use the stress process framework to make sense of how reports of parental stress about COVID are related to healthcare discrimination for parents with a range of marginalized identities.

Race/Racism

COVID-19 will reduce the life expectancy of Black and Latine populations by two and 3 years, respectively, which is three to four times the reduction for White populations (Andrasfay & Goldman, 2021). Americans who arc Black and Latine have more risk factors for COVID (e. g., living in densely populated neighborhoods, inability to work from home, elevated hypertension, e.g., Webb Hooper et al., 2020). Most research examining the pandemic and race has focused on racial disparities in infections and deaths; it has not assessed stress outcomes.

Following the death of George Floyd in the summer of 2020 and concurrent with the pandemic, the percent of Black Americans saying that discrimination was a source of stress grew from 42% to 67%, and 78% agreed that it was difficult being Black in America (American Psychological Association, 2020). Healthcare may have been a common setting of discrimination during this time as people sought medical advice, vaccination, and treatment more frequently. Furthermore, those with marginalized identities had increased risk of COVID morbidity and mortality (Webb Hooper et al., 2020), putting them in more frequent contact with the healthcare system.

A nascent literature has emerged on how best to measure marginalization, especially for racialized and stigmatized groups (Hardeman et al., 2018; Lukachko et al., 2014). Traditional quantitative analyses have used respondents' race as a proxy for the disadvantages racialized people face (Brondolo et al., 2009). Prominent scholars warn that this may reify biological notions of race, placing the source of disadvantage in the individual rather than the structures and processes that create it (Zuberi, 2000). Race scholars suggest attempting to assess disadvantaging structures or processes to accurately reflect reality and, importantly, do less harm to racialized persons (Sewell, 2016). In other words, we should measure racism, not race. A similar case can be made for measuring sexism, not gender, and heterosexz^m, not sexual minority identity.

Gender/Sexism

While most studies indicate that COVID was more fatal for men than women, recent evidence indicates the higher overall CO VID case rate among women in the pre-vaccination period (Danielsen et al., 2022), the primary period covered in our data. Women's higher case rate was likely due to a higher testing rate of pregnant people and those in healthcare professions, disproportionately women. In this early pandemic period, when the short and long-term effects of CO VID were less well known, infections were particularly stressful. As the pandemic progressed out of this phase, gender differences shifted toward more CO VID mortality among men than women (Danielsen et al., 2022). Women's mental health, however, seems to have been disproportionately affected. Using longitudinal data comparing mental health levels before and during COVID, several studies reveal a larger increase in depression (Vloo et al., 2021) and more detriments for general mental health (Dal Santo et al., 2022) among women than men.

That women's mental health was particularly compromised by the pandemic is no surprise given that many mothers balanced their participation in the paid labor force with more time and effort in unpaid family and household labor, especially tending to children who were, at once, doing school from home (Landivar et al., 2020). Moreover, as the primary managers of family healthcare decisions (Kaiser Family Foundation, 2018), mothers' mental load was taxed during the pandemic with a high concentration of health-related decisions with high stakes like masking, going out in public, and vaccinating.

A growing literature documents the mental health detriments-depression, anxiety, selfinjury, and suicide attempts-that accrue to transgender and nonbinary individuals due to experiences of stigma (i.e., Valentine & Shipherd, 2018). Evidence suggests that the mental health of transgender and nonbinary persons worsened during the pandemic due to reduced access to care and decreased social connectedness (Jarrett et al., 2021).

Sexual identity/Heterosexism

Families headed by sexual minorities are a growing segment of the population; the number of married or cohabiting same-gender couples in the United States doubled between 2008 and 2021, reaching 1.2 million in 2022 (Scherer, 2022), and 15% of same-sex couples in the United States have a child under the age of 18 (Taylor, 2020). However, sexual minorities have poorer self-rated health (Fredrikscn-Goldsen et al., 2012), more acute physical symptoms, and chronic conditions (Operario et al., 2015), risky health behaviors (Reczek et al., 2014), and higher rates of depression (Lewis, 2009). During the pandemic, sexual minorities experienced more stress and greater disruption to their lives than heterosexual individuals (Manning & Kamp Dush, 2022). Minority stress theory posits that these health disparities at least partially result when individuals with sexual minority identities suffer greater stress because of social stigma and prejudice (Brooks, 1981; Meyer, 1995), processes that manifest in interactions and institutions.

Before the pandemic, same-sex parents reported higher stress (Bos et al., 2016) and stigma and discrimination (Prendergast & Macphee, 2018). Evidence suggests that the pandemic increased discriminating attitudes toward sexual minorities (Mattei et al., 2021), which has exacerbated mental health problems for sexual and gender minorities (Goldberg et al., 2021). In this paper, we assess discrimination in the healthcare setting as a potential mechanism in the association between marginalized identities and COVID-related parental stress.

Healthcare discrimination

A key source of stress for parents during the pandemic, when demand for healthcare was high but access was uncertain, was the perception of healthcare discrimination. U.S. healthcare is an institution developed over time through people who pursue roles in the system, the training and socialization of healthcare professionals, and its structural features. Historically, medical professions were disproportionately occupied white, male, and middle- to upper-class individuals, yet the population they serve is much more diverse (Sullivan Commission on Diversity in the Healthcare Workforce, 2004). One particular healthcare context relevant to early pandemic healthcare provision, the hospital emergency department, still exhibits stark under representation of minoritized providers (Landry et al., 2013). The lack of representation of minoritized individuals in healthcare may result in negative interactions.

Regarding socialization in healthcare, the positivist turn in the 1900s favored the "clinical gaze" (Foucault, 1994 [1963]), which shifted physicians' perspectives from the patient as a whole person (What is wrong with you?) to their anatomically localized condition (Where does it hurt?). A focus on isolated parts rather than whole people enables dehumanization of individuals as simply vessels of parts (Leila & Pawluch, 1988). Furthermore, the "clinical gaze's" myopic vision obscures the contexts in which the part is nested (the body, the community, the society), which facilitates misattribution of the cause of a patient's trouble to their own behavior rather than other culpable contextual factors (Holmes, 2013). Finding fault with a patient's behavior lessens provider empathy and enables discrimination (Sim et al., 2021).

Finally, structural features like the "clock" of healthcare provision results in patient-provider interactions lasting less than 20 min with significantly shorter average time for Black and Hispanic patients (Neprash et al., 2023). Shorter visits are associated with compromised care, such as inappropriate pharmaceutical prescriptions (Neprash et al., 2023). Research suggests that implicit bias, or cognitive short-cuts that unintentionally advantage or disadvantage people based on identity (Shah & Bohlen, 2023), are more likely in highly stressed contexts like in hospital emergency departments that are overcrowded or with a high patient load (Johnson et al., 2016), which were common conditions during the early pandemic months.

Thus, given these inputs, the healthcare system may have contributed to inequalities to the detriment of minoritized persons during the pandemic. Some of these inequalities were levied when individuals were navigating the system and in their interactions with providers. Below we focus on the discrimination that generally occurs in interactions in healthcare for those with marginalized identities, and then specifically how these interactions may play out in the case of COVID-related healthcare. This was particularly relevant for parents who confronted an overwhelmed healthcare system that lacked established treatment plans for CO VID.

Racism

Racism in the healthcare system is often established at the institutional level and meted out by providers. As early as medical school, students learn from textbooks that lack skin tone representation (Oozageer Gunowa et al., 2020). This lack of representation enables racism among medical professionals. In a study of medical students and residents, 50% reported at least one false belief regarding biological differences between White and Black people being "possibly," "probably," or "definitely" true (e.g., Black people feel less pain than White people; Hoffman et al., 2016). Healthcare discrimination is often levied interpersonally via providers labeling REM patients as less compliant, assuming REM patient's health issues are a result of poor behaviors, and offering less empathetic care to REM patients especially when there is racial discordance between the patient and provider (Sim et al., 2021). One promising avenue for ameliorating experiences of healthcare discrimination among REMs is enabling or facilitating racial concordance between patients and their physician. Patient-physician racial concordance is associated with better patient outcomes, however there is a disproportionately low number of REM providers vis-a-vis the number of REM patients (Jetty et al., 2022).

Evaluating the role of healthcare discrimination in the context of the pandemic is particularly important as health was the central concern at the time, and REMs faced disproportionately high mortality rates (Wrigley-Field et al., 2020). Experiencing healthcare discrimination is associated with vaccine hesitancy and low vaccination rates (Elam Evans, 2023; Ndugga et al., 2022), particularly for Black and Native Americans (Madorsky et al., 2021). In addition to first-hand experiences of discrimination in healthcare, distrust in medical institutions due to historical abuses (e.g., The Tuskegee Syphilis Study) also contributes to COVID-related REM disparities in well-being (Madorsky et al., 2021).

Heterosexism

Homophobia and stigma are leading reasons why gay, lesbian, and bisexual people experience less satisfaction with and are less likely to seek healthcare services (Whitehead et al., 2016). Cisheterosexism is perpetrated in healthcare settings by providers assuming heterosexuality (Neville & Henrickson, 2006), lacking education on sexual minority health, and holding negative perceptions of gay, lesbian, and bisexual people (Sharma et al., 2019).

The pandemic laid bare stress and health disparities among the sexual minority population. Sexual minority individuals reported higher levels of stress and were more likely to report an increase of stress during the pandemic compared than heterosexual individuals (Manning & Kamp Dush, 2022). Furthermore, sexual minority persons had higher prevalence of several underlying health conditions like chronic respiratory disease and chronic pain that increase risk for more severe COVID-related illnesses (Heslin & Hall, 2021).

Sexism

The prevalence of gender discrimination among medical institutions and medical professionals is well documented. Women are less likely than men to receive the most effective diagnostic procedures for diseases like Chronic Obstructive Pulmonary Disease (COPD) for which researchers revealed a decrease of gender disparities in diagnosis when objective information was provided (e.g., spirometry results) (Chapman et al., 2001); these results suggest that healthcare discrimination may be particularly salient when providers rely on subjective assessments of health and symptoms. Women also experience being disbelieved by medical professionals when describing chronic pain (Bullo, 2020), and women do gendered "work" to be considered credible patients (Werner & Malterud, 2003). These studies are of cis-gender women compared to cis-gender men.

Cis-sexism pervades healthcare experiences for transgender people. Many healthcare providers lack education and knowledge about transgender health and/or hold negative attitudes about transgender individuals (Sharma et al., 2019). Others are unable to provide transgender specific services or gender affirming care (Bradford et al., 2013). As a result, transgender individuals report avoiding healthcare settings due to expected discrimination (Kcomt et al., 2020). During the CO VID, accessibility of healthcare services to transgender persons became even more critical as this population was more likely to have underlying conditions that elevate the risk for severe CO VID like asthma (Herman & O'Neill, 2020). Moreover, healthcare settings concentrated resources on CO VID care, and in many cases gender affirming health care was deferred, leaving this population especially vulnerable to stress (van der Miesen et al., 2020).

In sum, discrimination in healthcare shapes healthcare utilization among marginalized populations. Stigma and discrimination have been linked to less and delayed healthcare seeking among SGMs (Whitehead et al., 2016) and Black Americans (Casagrande et al., 2007). Discriminatory practices and norms built into healthcare systems and revealed in patient-provider interactions can explain why marginalized persons may have elevated stress around healthcare. Discriminatory experiences of parents of color are relevant to what worries they hold for children. Thus, parents with marginalized identities may experience high levels of stress as they anticipate or experience greater demands for healthcare during the pandemic.

Correlates of marginalization and parental stress

We account for a number of other factors that vary by marginalized status and may also be associated with parental stress. Adverse childhood experiences (ACEs) are experiences such as victimization or witnessing violence, parental divorce or death, food insecurity, or living with someone with a mental health or substance use condition. Trauma in early childhood impacts brain development, which contributes to heightened responsiveness to threatening cues (e.g., Bick & Nelson, 2016). Thus, survivors of ACEs worry more given the cognitive awareness that the world is inherently unsafe (Jones et al., 2018). This worry may be exacerbated for parents who are responsible for the safety of their children. There are clear demographic patterns in the experience of ACEs. Women had significantly higher levels of ACEs than men, White people had significantly lower ACE scores than Black or Hispanic people, and multiracial people had the highest overall level of ACEs. Sexual minorities had higher ACE scores than heterosexual individuals, and bisexual individuals had the highest scores of all (Giano et al., 2020).

Marriage has long been considered protective of one's health and well-being. Compared to cohabitation, married individuals report more emotional assurance, financial stability, and a higher sense of security for themselves and their children (Perelli-Harris et al., 2014). The legal and cultural commitment of marriage may serve to reduce uncertainty and increase general well-being (Liu & Umberson, 2008). Marriage rates vary widely across identities, with lower rates among Black (Raley et al., 2015) and transgender and nonbinary individuals (Dawson et al., 2023), for example, compared to those who arc White and cis-gender. The lack of access to legal marriage for those with same-sex partners until 2015 has resulted in lower shares of sexual minority and same-sex couples who arc married (Julian et al., 2024).

The number and ages of one's children can shape parental stress as well. Parents with more children may experience increased economic burden given the cost of care for children (Raikes & Thompson, 2005). Despite the joys of raising children, parents must also develop and manage parent-child relationships with each child, which may increase the mental and emotional toll of parenting, even if each child brings additional joy (Qian et al., 2021). Regarding the ages of children, prior research suggests that parenting adolescents is associated with lower well-being than parenting children at younger ages (Meier et al., 2018). However, the pandemic may have heightened stress for parents of younger children, who may have been supervising on-line learning or compensating for a lack of childcare for preschool children and infants.

Finally, there is scant evidence on how stress levels varied across the span of the pandemic which some consider having ended in May 2023 with the lifting of the federal COVID-19 Public Health Emergency Declaration. What little literature exists suggests that there was especially heightened mental health distress early in the pandemic when less was known about the virus, and vaccines were not yet available. However, it seems that the course of stress as the pandemic unfolded varied substantially across groups, with healthcare workers, those with psychiatric disorders, and children, adolescents and students retaining stress detriments further into the pandemic (Manchia et al., 2022). Therefore, accounting for time may be important to understanding stress outcomes in a sample collected across the pandemic.

PRESENT STUDY

The present study leverages nationally representative data to assess parental stress for partnered parents during COVID among a broad array of parents with particular attention to a marginalizing mechanism-healthcare discrimination-that may shape the COVID-related stress experiences of REM and SGM parents. This extends scholarship from documenting disparities by identity categories to identifying potential sources for those disparities. Appropriately, these sources are outside of the individual and in the interactions and institutions of our society. Given the literature reviewed above, we anticipate heightened parental stress among minoritized parents can be partially explained by their more frequent experiences of healthcare discrimination.

METHODS

Sample

The National Couples' Health and Time Study (NCHAT) is the first fully-powered, population-based study of couples in America with representative samples of REMs and SGMs as well as White and heterosexual couples. The NCHAT is an on-line survey that began in September 2020 and ended in April 2021. Participants were recruited through the Gallup Panel (Gallup, 2021a), sourced from the Gallup Daily Tracking Survey (Gallup, 2021b), that used techniques to achieve a nationally representative sample and included demographic questions relevant for sample construction including the age, marital status, race/ethnicity, and LGBT identity. Gallup generated sample weights based on national estimates, and person-level weights were applied to all analyses (Marlar et al., 2022). The sample includes 3642 main respondents ages 20-60 years, who were married or cohabiting, and who could read English or Spanish.

Parent sample characteristics

One-third, 34% (n = 1225), of NCHAT main respondents were parents with children under the age of 18. Our analytic sample (/? = 1113) was restricted to parents who reported information for each independent variable and the mediator noted below. As a sample of couples, all NCHAT parents are partnered (cohabiting or married). Of parents in our sample, 11% identified as NH/NL Black (и = 120), 53% identified as NH/NL White (и = 586), and 37% identified with another non-White identity (n = 407). 52% were cis-gendered women (n = 581) and less than 3% identified as transgender or gender nonbinary (n = 35). In terms of sexual identity, 6% are exclusively gay or lesbian (n = 70), 15% are bisexual, and 8% reported another or multiple identities. The average number of children under the age of 18 was 1.9, and the average age for the youngest child was 7.5 years. The percentages noted above are unweighted.

Measures

Below we detail our measures of minoritized identities, a mediator of healthcare discrimination, the parental stress outcome, and controls. Weighted descriptive statistics are shown in Table 1.

Independent variables

Racial!Ethnic identity

There are multiple ways to measure racial/ethnic identity in the NCHAT data. We leverage the exclusive race approach by first categorizing NH/NL Black as any respondent who endorsed Black race, and no other race or ethnicity. Then, we categorize as "another REM" those who endorsed another racial or ethnic minority (REM) identity, including multiple identities. We originally separated Hispanic/Latino/a/e/x ethnicity, and Asian and Pacific Islander, multiracial, and other racial identities. Ultimately, except for NH/NL Black identity, we grouped races/ethnicity because our outcome was similar between the groups, and we favored a parsimonious model with proper power. Finally, we categorize as "White" those who endorsed white and no other race or ethnicity. Each variable was dichotomous; 1 indicated that the respondent is coded to that race or ethnicity, and 0 indicated that the respondent was not coded to that race or ethnicity. The set of three race/ethnicity indicators are mutually exclusive.

Gender identity

Respondents reported their gender identity from five options, including woman, man, trans woman, trans man, and some other gender (e.g., nonbinary, gender-fluid). We coded gender into three categories: cisgender men (47.7%), cisgender women (52.2%), and transgender and nonbinary (TGNB; <1%). We decided to group transgender men and women with nonbinary respondents to capture discrimination related to gender diversity rather than grouping transgender men with cisgender men and transgender women with cisgender women, which would potentially mute these experiences given a small sample of transgender persons.

Sexual identity

In terms of sexual identity, NCHAT includes the following question: "What do you consider yourself to be? Select all that apply" with 11 response options: heterosexual or straight, gay or lesbian, bisexual, same-gcnder-loving, queer, pansexual, omniscxual, asexual, don't know, questioning, and "something else," with an option to specify. We coded respondents into four mutually exclusive categories: exclusively gay or lesbian (<1%), bisexual (<1%), exclusively heterosexual or straight (98.2%), and another or multiple sexual identities (referred to as "another sexual identity"; <1%). "Another sexual identity" includes same-gender loving, queer, pansexual, omnisexual, asexual, don't know, questioning, and something else. We collapsed individuals into these categories to ensure sufficient sample size.

Mediator

As noted, we posit that it is not one's race or ethnicity, gender, or sexual identity itself that leads to adverse outcomes, but rather it is racism, sexism, or hctcroscxism that marginalizes particular identities. We aim to do better than simply using these identities as proxies for racism, sexism, and hctcroscxism. Therefore, we assessed respondents' expectation of discrimination in healthcare settings, a highly relevant institutional setting during the pandemic.

The scale capturing healthcare discrimination (a = 0.81) derives from a prompt asking respondents how much they agree or disagree with each of the following: When seeking healthcare, I: (1) worry about being negatively judged, (2) worry that my diagnoses will be negatively affected by who I am, (3) worry that I might confirm negative stereotypes about people like me, (4) can trust I'll get high quality care (reverse coded), and (5) healthcare providers don't take my concerns seriously. Response options ranged from 1 {strongly disagree) to 5 {strongly agree). We averaged scores on the items for a composite measure of healthcare discrimination ranging from 1 to 5 (M = 2.23). Healthcare discrimination was used as an observed variable in the structural models because a latent variable adds too many parameters given our sample size.

Dependent variables

We use an indicator of parental stress relevant to the healthcare context. Respondents were asked: "How stressed are you about the following?" We use the item: "My child getting coronavirus" (M = 2.74). Response options for parental stress-COVID ranged from 1 (not at all stressed) to 5 (very stressed). This parental stress indicator is different from validated measures of parenting stress used in the literature (i.e., parenting stress index, Abidin, 1995; parental stress scale, Berry & Jones, 1995) as our measure is specific to CO VID risk in the pandemic context. However, its mean suggests that it was a salient parental stressor.

We tested a composite measure that also included parents' stress about themselves getting CO VID and stress about their partner getting CO VID. Parents' stress was highest about their child getting COVID (M = 2.74, vs. M = 2.38 for self and M = 2.58 for partner). Moreover, we are interested in parental stress and therefore opt for the referent that most signals the parent role-one's child. Still, it is worth noting that results from models that incorporate the broader measure are consistent with what we present below with the single-item indicator.

Control variables

We control for parents' ACEs using a 10-question version of the Behavior Risk Factors Surveillance Survey ACEs module. The questions cover experiences of victimization or witnessing of violence, parental divorce or death, food insecurity, as well as living with someone with a mental health condition, drug abuse, alcoholism, or someone who had been in prison. All measures index experiences before the age of 18 years. We sum affirmative answers to the 10 questions for a summary measure ranging from zero to 10 (M = 2.21). We also control for marital status, youngest child's age, number of children in the household, and month of survey. All respondents are in residential partnerships, so our marital status variable differentiates between married and cohabiting (but not married). Number of children and youngest child's age were identified using the household roster (Kamp Dush et al., 2023). Number of children counts all children living in the respondent's household who are under age 18. Youngest childs age is identified among all household children under age 18. Our variable for the month of survey indexes the first month of the survey-September 2020-as the baseline with each unit increase being 1 month further into the pandemic.

Plan of analysis

Figure 1 depicts the sets of variables and the expected relationships between in our hypothesized model. We posit that those variables typically used as proxies for marginalization-race/ethnicity, gender, and sexual identity-will be related to parental stress. However, their relationships with parental stress will be mediated by healthcare discrimination. While mediation analysis often employs longitudinal data, we note that we are working with cross-sectional data and, therefore, we cannot determine temporal ordering or estimate causal relationships.

Weighted regressions were estimated to assess whether parental stress-COVID differed between minoritized and nonminoritized identities. Our hypothesized model was tested using path analysis in MPlus. Root mean square error of approximation (RMSEA), comparative fit index (CEI), Tucker-Lewis index (TEI), and standardized root mean square residual (SRMR) were used to evaluate model fit. Models were considered to have a close fit when: RMSEA was less than .05, CFI and TEI were above .95, and SRMR was less than .05. Models were considered to have acceptable fit when RMSEA was over .05 but less than .08, CFI and TEI were less than .95 but above .90, and SRMR was above .05 but less than .08. Direct paths were added to improve model fit when identified by modification indices (M.I. over 10).

RESULTS

Descriptive analyses

Figure 2 displays the mean levels of parental stress-COVID on the left and healthcare discrimination on the right by race/ethnicity, gender, and sexual identity. Weighted regressions (not shown) assessed statistical significance of differences in these three variables across groups. Levels of the parental stress-COVID and healthcare discrimination measures were higher for nearly all minoritized groups than for the privileged group in each category-White, men, and heterosexual/straight parents.

In terms of parental stress-COVID, Black parents had the highest levels of stress (M = 3.22, p < .001), followed by parents with another REM identity = 2.83, p < .05), which were significantly higher than White parents (M = 2.61). By sexual identity, gay and lesbian parents reported the highest parental stress-COVID (M = 3.56, p < .001), closely followed by parents with another or multiple sexual identities (M = 3.45, p < .05), and bisexual parents (M = 3.35, p < .01), which were significantly higher than the levels of parental stress-COVID reported by heterosexual/straight parents (7И = 2.73). By gender, women had the highest levels of parental stress-COVID (M = 3.02, p < .001) which were significantly higher than reports among men (M = 2.43) and transgender and nonbinary parents (M = 2.24).

In terms of healthcare discrimination, Black parents reported the highest levels (M = 3.17, p < .001), which were significantly higher than levels reported by both parents of another REM identity (M = 2.25) and White parents (M = 2.15). Regarding sexual identity, bisexual parents reported the highest levels (M = 2.74, p < .001), followed by parents of another or multiple sexual identities (M = 2.65, p < .05), both of which were significantly higher than levels of healthcare discrimination among heterosexual/straight parents. Gay and lesbian parents reported similar levels of healthcare discrimination (M = 2.45) as heterosexual/straight parents (M = 2.23). By gender, transgender and nonbinary parents reported the highest levels of healthcare discrimination (M=2.36, p < .001), closely followed by women (M=2.33, p < .001), both of which were significantly higher than men (M = 2.12).

Path analysis: Parental stress-COVID

Our hypothesized model assessing parental stress-COVID, had poor fit (RMSEA = 0.055, CEI = 0.86, TEI = 0.68, SRMR = 0.019). Modification indices showed that a direct path between woman identity and the outcome would improve model fit (M.I. = 32.5). Including the path improved fit from poor to acceptable (RMSEA = 0.024; CFI = 0.98; TLI = 0.94; SRMR = 0.009).

Most of the minoritized identities were associated with healthcare discrimination. Black race (p <.001), gay or lesbian identity (p = .04), bisexual identity (p = .043), woman identity (p = .003), and TGNB identities (p = .04) were directly associated with healthcare discrimination. Healthcare discrimination (p <.001) and woman identity (p <.001) were directly associated with parental stress-COVID (Figure 3).

The indirect effects between Black race (p <.001), woman gender identity (p = .005) and bisexual identity (p = .002), and parental stress-COVID through healthcare discrimination were significant. TGNB identities and gay or lesbian sexual identities were not indirectly associated with parental stress-COVID through healthcare discrimination by conventional standards, but for the relatively small sample and identity group sizes, the model provides evidence suggestive of an indirect relationship for these groups as well (p = .053, p = .050, respectively). This model accounted for 16% of the variance in the outcome variable (R2 = 0.161).

DISCUSSION

COVID-19 was an unprecedented stressor in the United States, and as is often the case with traumatic societal events, it has been most stressful for those who arc marginalized. This paper set out to assess parental stress during the pandemic among marginalized parents. Although a large body of research has examined disparities in stress, mental health, or other well-being outcomes by marginalized identities, such an approach can carry an assumption that the disparities are rooted in the individual's identity (race, gender, sexual identity) rather than discriminatory societal institutions and practices (Zuberi, 2000). By measuring discrimination in a relevant institution-the US healthcare system-we aimed to establish the root of disparities outside the marginalized individual by examining a setting where disparities arc generated.

In descriptive analyses (Figure 2), we found that parents of almost every marginalized identity reported higher parental stress about their child getting CO VID and more healthcare discrimination than parents with identities that are not marginalized (White, men, heterosexual). In the structural model, we found Black parents reported significantly more healthcare discrimination and, in turn, more parental stress about their child getting CO VID. That Black parents had more parental stress about CO VID was no surprise given higher rates of CO VID infection and COVID-related death for Black individuals (Wrigley-Field et al., 2020).

Women reported significantly higher levels of healthcare discrimination and, in turn, higher levels of parental stress about their child getting CO VID. Our finding that women experienced more discrimination in healthcare is consistent with past findings regarding women's compromised healthcare for a range of conditions including COPD that has symptoms in common with COVID (e.g., Chapman et al., 2001). Our findings also offer suggestive evidence that TGNB parents had marginally higher levels of parental stress levels during CO VID operating through healthcare discrimination. Coefficients are small and not significant at conventional levels, however, suggesting caution in interpretation. Future research with more respondents in these groups would allow us to verify this suggestive evidence.

Bisexual parents reported significantly higher levels of healthcare discrimination, and in turn, higher levels of parental stress during the pandemic. That bisexual parents experienced more discrimination in healthcare is consistent with earlier findings of increased stigma and prejudice toward those with marginalized sexual identities during the pandemic (Mattei et al., 2021). Again, we sec suggestive evidence that gay and lesbian parents had marginally higher levels of parental stress operating through healthcare discrimination. Coefficients are small and not significant at conventional levels, suggesting caution in interpretation.

Among all marginalized identity groups that we assessed, we found a direct link from gender identity and parental stress (in addition to its indirect link through healthcare discrimination) for women only. The direct link from woman identity to parental stress is consistent with mothers' disproportionate responsibility for children's health-related decisions (Kaiser Family Foundation, 2018). The health domain was especially affected by the pandemic, putting mothers in the eye of the stress storm. These stresses may accrue independent of healthcare discrimination (as well as through it), simply because of the sheer salience of this domain during the pandemic.

Aside from this one direct link, the overwhelming pattern of indirect links through healthcare discrimination supported our inclusion of a measure of discrimination rather than relying on individual identity indicators which leave open to interpretation the source of disadvantage (Bonilla-Silva, 2023; Zuberi, 2000). As posited at the outset of the paper, it is not race (or gender or sexual identity) that leads to elevated stress, it is raczszrz (and sexism and heterosexism) that is linked to more stress. These findings arc consistent with stress process theory which posits that social structures of inequality burden marginalized populations with stress that produces health disparities (Pearlin et al., 2005). The experience of healthcare discrimination, meted out in interpersonal interactions by actors in an institutional setting, is tied to parental stress about their children in the event that they contract the novel and frightening coronavirus and-potentially-interact with the institution of healthcare themselves.

Several other features of this study are worthy of discussion. First, while items representing healthcare discrimination focused on worry about discrimination the respondent, themselves, expected, the stress we assessed is focused on the respondent in their role as a parent. That is, we are assuming that a Black parent who expects healthcare discrimination for themselves will have more stress about their children's health. Wc do not have direct measures of children's own worries about discrimination. If discrimination is meted out according to skin color as much literature suggests (e.g., Goldsmith et al., 2006), a child of color will be more likely to experience discrimination than a White child. While not all children of color have parents of color, an overwhelming majority of parents of color have a child of color. Therefore, discriminatory experiences of parents of color are relevant to what worries they hold for children. Regarding parents marginalized for their gender or sexual identities, their own worries about discrimination may contribute to general concern about health and healthcare for their children, regardless of whether their children's identities match their own.

Second, we examined discrimination in one institution-healthcare. The institution of healthcare was particularly relevant to the stresses around the mass health event of CO VID. Our findings regarding the central role of healthcare discrimination as a source of parental stress during CO VID does not mean that the healthcare system, alone, is responsible for marginalizing experiences. Healthcare discrimination may proxy for other institutional discriminations; it may also exacerbate them as negative experiences in one institution can erode trust in other institutions (Alang et al., 2020). We did not set out to establish which institution is especially responsible for the stress measured here, but rather to measure one institution that is plausibly implicated. We find evidence to support it as a source of parental stress during CO VID.

Finally, increased parental stress from discrimination experiences of marginalized parents may operate through increased vigilance. Himmelstein et al. (2015) argue that those who have experienced negative interactions with other people and systems arc more likely to be on alert for repeat experiences of discrimination, and this constant vigilance can wear on their psyches, increasing stress levels. We controlled for ACEs, a set of prior negative experiences that arc known to induce hypcrvigilance for other negative interactions like discrimination. Thus, any associations we find that implicate healthcare discrimination in parental stress about CO VID arc net of the hypcrvigilance induced by ACEs.

Limitations

We have captured and documented stressors among a wide diversity of parents in a nationally representative sample during a period of crisis, however the timing of this study introduces several limitations. First, we do not have measures of stress before the pandemic, so we are unable to assess changes and differences in changes among marginalized parents or by marginalizing processes. Second, because our study was based on cross-sectional data collected during this unprecedented historical period, our evidence cannot be generalized to other periods before or after the pandemic. Furthermore, our findings are based on associations, and causal conclusions cannot be drawn. Fortunately, the NCHAT study is in the process of collecting additional waves so that we will be able to see whether parental stress levels and discrimination experiences and disparities abated as the pandemic receded.

We set out to study disparities in parental stress about CO VID and the processes that generated them. The NCHAT data, with its relatively large and diverse national sample of parents and measures of COVID-related stress and healthcare discrimination, was well suited to our question. However, the NCHAT sample is designed to capture couples, so our analysis of disparities, discrimination, and parental stress applies only to partnered parents. Single parents arc excluded. Thus, our estimates of links between marginalized identities, healthcare discrimination, and parental stress are likely lower-bounds estimates of the disparities in parental stress due to discrimination. This is likely to be especially true due to the exclusion of custodial single parents who shouldered primary or exclusive responsibility for children as they navigated the CO VID context. Finally, selecting on couples also resulted in a somewhat more advantaged sample. However, NCHAT includes both married and cohabiting couples, and cohabiting couples arc, on average, less advantaged than married couples (Sassler & Miller, 2017). The inclusion of cohabiting couples may balance the relative advantage of a sample of couples.

While we were able to assess parental stress among a broader array of marginalized parents than many past studies, due to data constraints, we were forced to make choices that ultimately obscure the full range of marginalized identities. For example, we would have liked to separately assess parental stress for transgender parents, especially due to the current cascade of challenges to gender-affirming care which may influence their experiences with healthcare discrimination. However, due to the small number of transgender-identifying respondents, we were forced to combine them with nonbinary identifying persons who may not suffer from the same set of challenges in healthcare. This may obscure discrimination that is specific to each group. Thus, even research based on particularly inclusive, nationally representative data is constrained by small sample sizes due to limited budgets and also likely societal stigma that prevents some respondents from claiming their identities on national surveys.

Finally, as is common in surveys, our measure of healthcare discrimination is a subjective assessment. This has several possible limitations. First, many forms of structural discrimination are hidden from those being discriminated against (e.g., discriminatory employment practices). Hidden forms of discrimination are unlikely to be captured in measures like the one we use. Second, many factors shape if and how people perceive discriminatory events which leads to issues of confounding (Meyer, 2003). For example, minoritized groups may overlook discrimination in order to avoid disruption to social relations (Contrada et al., 2000). Although limitations exist, capturing individuals' expectations of discrimination is a credible route to assessing racism, sexism and heterosexism as mechanisms that create health disparities.

CONCLUSION

Discrimination is associated with parental stress about children during the COVID-19 pandemic. Identifying discrimination as the underlying cause of disparities remains critical as we move toward antiracist/antidiscriminatory family studies (Hardeman et al., 2018). This research answers the challenge from race scholars to family scholars, asking us to adopt a structural perspective on racism (Bonilla-Silva, 2023). We further extend the challenge to also consider institutional discrimination among parents marginalized by their gender or sexual identities. Without acknowledging, measuring, and reporting on patterns of institutional discrimination and their consequences, we risk continuing to produce research, policies, and practices focused on fixing individuals rather than fixing the systems at the root of disparities. Our research shows that if not for institutional discrimination in the healthcare system, marginalized parents would likely have experienced less parental stress about CO VID. Instead, in addition to their elevated rates of COVID morbidity and mortality, marginalized parents report higher levels of healthcare discrimination and associated elevated parental stress.

Our use of the rich NCHAT data allowed us to assess stress and healthcare discrimination experiences among marginalized parents in three different identity categories (race, gender, and sexual identity). We know that many people are multiply-marginalized (Jones, 2022). For example, a portion of our Black and other REM parents are also women, transgender or nonbinary, and/or lesbian/gay, bisexual, or another sexual identity. Our finding that differences by marginalized identities in parental stress about CO VID operates through healthcare discrimination invites future research to investigate the healthcare discrimination and parental stress experiences of multiply marginalized groups by conducting intersectional analysis. This would yield insights that match a fuller set of identities embodied by respondents.

Finally, our study suggests important implications for those working with marginalized parents in institutional settings. Our finding of higher levels of healthcare discrimination and parental stress for gay, lesbian, bisexual, and TGNB parents highlights the dangers of discriminatory state and local policies and laws as applied in healthcare (e.g., bans on gender-affirming care) for already marginalized groups. These policies take what should be inherently pro-social and safe spaces like clinics and make them dangerous for the mental health of our most vulnerable people and families. Healthcare policymakers and advocates should underscore the prosocial ethos of the institutions they represent to buoy policies and practices that are consistent with this and to defeat those that run counter to it.

Our findings suggest that marginalized parents reported heightened expectations of discrimination in healthcare settings. Given the heavy health burden in the United States relative to the number of providers, healthcare professionals spend less than 20 minutes per visit, on average, with patients (Neprash et al., 2023). Furthermore, few providers hold marginalized identities that match their patients' identities (e.g., Jetty et al., 2022), potentially limiting their empathy for their lived experiences. Together, the short amount of time and unfamiliar life experiences create a healthcare context ripe for implicit bias on the part of healthcare providers (Sabin, 2022). It is no surprise, then, that marginalized individuals report worry that they will be judged negatively and that their concerns will not be taken seriously. This suggests that more training for healthcare professionals on the risks of implicit bias in their work could improve marginalized patients' experiences and, eventually, their expectations for discrimination in these settings (Sabin, 2022).

In summary, we found that marginalized individuals' higher levels of parental stress about CO VID were linked to the discrimination they have faced in the healthcare system. The central role of discrimination should reinforce the call for family scholars to stop relying solely on marginalized identities to assess differential health outcomes and to start analyzing the structures and processes that do the work of racism, sexism, and hctcroscxism to unequally burden people of color and sexual and gender minorities with well-being detriments. These detriments have the potential to accumulate over the life course and crossover to children and communities.

Sidebar

FUNDING INFORMATION

This research was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD; 1R01HD094081-01A1 and 1U01HD108779). 1U01HD108779 is also supported by NIH's Office of The Director and National Institute on Minority Health and Health Disparities. This project also benefited from support provided by the University of Minnesota's Minnesota Population Center (P2CHD041023) also supported by NICHD. This paper and its contents are solely our responsibility and do not necessarily represent the official views of NICHD, OD, or NIMHD.

How to cite this article: Meier, A., Kamp Dush, C., VanBergen, A. M., Clark, S., & Manning, W. (2025). Marginalized identities, healthcare discrimination, and parental stress about COVID-19. Journal of Marriage and Family, 57(1), 258-279. https://doi.org/ 10.1111/jomf.l 3023

References

REFERENCES

Abidin, R. R. (1995). Parenting stress index (3rd Edition (PSI) ed.). Psychological Assessment.

Alang, S., McAlpine, D. D., & Hardeman, R. (2020). Police brutality and mistrust in medical institutions. Journal of Racial and Ethnic Health Disparities, 7(4), 760-768. doi:10.1007/s40615-020-00706-w

American Psychological Association. (2020). Stress in the time of COVID-19 (Stress in America™ 2020) Issue, https:// www.apa.org/news/press/releases/stress/2020/stress-in-america-covid-june.pdf

Andrasfay, T., & Goldman, N. (2021). Reductions in 2020 US life expectancy due to COVID-19 and the disproportionate impact on the black and Latino populations. Proceedings of the National Academy of Sciences-PNAS, 118(5), 1. https://doi.org/10.1073/pnas.2014746118

Berry, J. O., & Jones, W. H. (1995). The parental stress scale: Initial psychometric evidence. Journal of Social and Personal Relationships, 12(3), 463-472. doi:10.1177/0265407595123009

Bick, J., & Nelson, C. A. (2016). Early adverse experiences and the developing brain. Neuropsychopharmacology, 41(f), 177-196. doi:10.1038/npp.2015.252

Bokun, A., Himmelstern, J., Jeong, W., Meier, A., Musick, K., & Warren, J. R. (2020). The unequal impact of CO VID19 on Children's economic vulnerability. EconoFact Blog.

Bonilla-Silva, E. (2023). It's not the rotten apples! Why family scholars should adopt a structural perspective on racism. Journal of Family Theory & Review, 15(2), 192-205. doi:10.1111/jftr. 12503

Bos, H. M. W., Knox, J. R., van Rijn-van Gelderen, L., & Gartrell, N. K. (2016). Same-sex and different-sex parent households and child health outcomes: Findings from the National Survey of Children's health. Journal of Developmental & Behavioral Pediatrics, 37(3), 179-187. https://doi.org/10.1097/dbp.0000000000000288

Bradford, J., Reisner, S. L., Honnold, J. A., & Xavier, J. (2013). Experiences of transgender-related discrimination and implications for health: Results from the Virginia transgender health initiative study. American Journal of Public Health (1971), 103(10), 1820-1829. https://doi.org/10.2105/AJPH.2012.300796

Brondolo, E., Gallo, L. C., & Myers, H. F. (2009). Race, racism and health: Disparities, mechanisms, and interventions. Journal of Behavioral Medicine, 32(1), 1-8. doi:10.1007/sl0865-008-9190-3

Brooks, V. R. (1981). Minority stress and lesbian women. Lexington Books.

Brown, S. M., Doom, J. R., Lechuga-Peña, S., Watamura, S. E., & Koppels, T. (2020). Stress and parenting during the global COVID-19 pandemic. Child Abuse & Neglect, 110, 104699.

Bullo, S. (2020). "I feel like I'm being stabbed by a thousand tiny men": The challenges of communicating endometriosis pain. Health (London, England: 1997), 24(5), 416-492. https://doi.org/10.1177/1363459318817943

Casagrande, S. S., Gary, T. L., Laveist, T. A., Gaskin, D. J., & Cooper, L. A. (2007). Perceived discrimination and adherence to medical care in a racially integrated community. Journal of General Internal Medicine: JGIM, 22(3), 389-395. doi:10.1007/sll606-006-0057-4

Chapman, K. R., Tashkin, D. P., & Pye, D. J. (2001). Gender bias in the diagnosis of COPD. Chest, 119(6), 1691-1695. doi:10.1378/chest.H9.6.1691

Contrada, R. J., Ashmore, R. D., Gary, M. L., Coups, E., Egeth, J. D., Sewell, A., Ewell, K., Goyal, T. M., & Chasse, V. (2000). Ethnicity-related sources of stress and their effects on well-being. Current Directions in Psychological Science: A Journal of the American Psychological Society, 9(4), 136-139. https://doi.org/10.llll/1467-8721. 00078

Dal Santo, T., Sun, Y., Wu, Y., He, C., Wang, Y., Jiang, X., Li, K., Bonardi, O., Krishnan, A., Boruff, J. T., Rice, D. B., Markham, S., Levis, B., Azar, M., Neupane, D., Tasleem, A., Yao, A., Thombs-Vite, L, Agic, B., ... Thombs, B. D. (2022). Systematic review of mental health symptom changes by sex or gender in early-COVID-19 compared to pre-pandemic. Scientific Reports, 12(1), 11417. https://doi.org/10.1038/s41598-022-14746-l

Danielsen, A. C., Lee, K. M., Boulicault, M., Rushovich, T., Gompers, A., Tarrant, A., Reiches, M., ShattuckHeidorn, H., Miratrix, L. W., & Richardson, S. S. (2022). Sex disparities in COVID-19 outcomes in the United States: Quantifying and contextualizing variation. Social Science á Medicine, 1982(294), 114716. https:// doi. org/10.1016/j. socscimed.2022.114716

Dawson, L., Kates, J., Sparks, G., & Kirzinger, A. (2023). Trans people in the US: Identities, demographics, & wellbeing. Kaiser Family Foundation, https://www.kff.org/other/issue-brief/trans-people-in-the-u-s-identitiesdemographics-and-wellbeing/#

Elam Evans, L. D. (2023). The association of reported experiences of racial and ethnic discrimination in health care with COVID-19 vaccination status and intent-United States, April 22, 2021-November 26, 2022. MMWR. Morbidity and Mortality Weekly Report, 72.

Everett, B. G., Limburg, A., Homan, P., & Philbin, M. M. (2022). Structural heteropatriarchy and birth outcomes in the United States. Demography, 59(1), 89-110. doi: 10.1215/00703370-9606030

Flentje, A., Obedin-Maliver, J., Lubensky, M. E., Dastur, Z., Neilands, T., & Lunn, M. R. (2020). Depression and anxiety changes among sexual and gender minority people coinciding with onset of COVID-19 pandemic. Journal of General Internal Medicine: JGIM, 35(9), 2788-2790. doi: 10.1007/sl 1606-020-05970-4

Foucault, M. (1994 [1963]). The birth of the clinic. Vintage Press.

Fredriksen-Goldsen, K. L, Kim, H. J., & Barkan, S. E. (2012). Disability among lesbian, gay, and bisexual adults: Disparities in prevalence and risk. American Journal of Public Health (1971), 102(1), el6-e21. https://doi.org/10.2105/ AJPH.2011.300379

Gallup. (2021a). How does the Gallup panel work? https://www.gallup.com/174155/gallup-daily-tracking-methodology. aspx

Gallup. (2021b). How does Gallup daily tracking work? https://www.gallup.com/174158/gallup-panel-methodology. aspx

Gassman-Pines, A., Ananat, E. O., & Fitz-Henley, J. (2020). COVID-19 and parent-child psychological well-being. Pediatrics (Evanston), 146(4). doi: 10.1542/peds.2020-007294

Giano, Z., Wheeler, D. L., & Hubach, R. D. (2020). The frequencies and disparities of adverse childhood experiences in the US. BMC Public Health, 20(1), 1-12.

Goldberg, A. E., McCormick, N., & Virginia, H. (2021). Parenting in a pandemic: Work-family arrangements, wellbeing, and intimate relationships among adoptive parents. Family Relations, 70(1), 7-25. https://doi.org/10.llll/ fare. 12528

Goldsmith, A. H., Hamilton, D., & Darity, W. (2006). Shades of discrimination: Skin tone and wages. The American Economic Review, 96(2), 242-245. doi:10.1257/000282806777212152

Hardeman, R. R., Murphy, K. A., Karbeah, J. M., & Kozhimannil, K. B. (2018). Naming institutionalized racism in the public health literature: A systematic literature review. Public Health Reports, 133(3), 240-249. https://doi.org/ 10.1177/0033354918760574

Hatzenbuehler, M. L., Phelan, J. C., & Link, B. G. (2013). Stigma as a fundamental cause of population health inequalities. American Journal of Public Health (1971), 103(5), 813-821. https://doi.org/10.2105/AJPH.2012.301069

Herman, J. L., & O'Neill, K. (2020). Vulnerabilities to COVID-19 among transgender adults in the U.S. the Williams Institute, https://williamsinstitute.law.ucla.edu/publications/transgender-covid-19-risk/

Heslin, K. C., & Hall, J. (2021). Sexual orientation disparities in risk factors for adverse COVID-19-related outcomes, by race/ethnicity-Behavioral risk factor surveillance system, United States, 2017-2019. MMWR. Morbidity and Mortality Weekly Report, 70.

Himmelstein, M. S., Young, D. M., Sanchez, D. T., & Jackson, J. S. (2015). Vigilance in the discrimination-stress model for black Americans. Psychology & Health, 30(3), 253-267. doi: 10.1080/08870446.2014.966104

Hoffman, K. M., Trawalter, S., Axt, J. R., & Oliver, M. N. (2016). Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proceedings of the National Academy of Sciences-PNAS, 113(\6), 4296^4301. doi: 10.1073/pnas. 1516047113

Holmes, S. M. (2013). Fresh fruit, broken bodies: Migrant farmworkers in the United States. University of California Press.

Homan, P. (2019). Structural sexism and health in the United States: A new perspective on health inequality and the gender system. American Sociological Review, 84(3), 486-516. doi: 10.1177/0003122419848723

Jarrett, B. A., Peitzmeier, S. M., Restar, A., Adamson, T., Howell, S., Barai, S., & Beckham, S. W. (2021). Genderaffirming care, mental health, and economic stability in the time of COVID-19: A multi-national, cross-sectional study of transgender and nonbinary people. PLoS ONE, 16(7), e0254215. https://doi.org/10.1371/journal.pone. 0254215

Jetty, A., Jabbarpour, Y., Pollack, J., Huerto, R., Woo, S., & Petterson, S. (2022). Patient-physician racial concordance associated with improved healthcare use and lower healthcare expenditures in minority populations. Journal of Racial and Ethnic Health Disparities, 9(Y), 68-81. doi: 10.1007/s40615-020-00930-4

Johnson, T. J., Hickey, R. W., Switzer, G. E., Miller, E., Winger, D. G., Nguyen, M., Saladino, R. A., Hausmann, L. R. M., & Gerson, L. (2016). The impact of cognitive stressors in the emergency department on physician implicit racial bias. Academic Emergency Medicine, 23(3), 297-305. doi: 10.1111/acem. 12901

Jones, J. (2022). Growing LGBT ID growing across U.S. Ethnic Groups, https://news.gallup.com/poll/393464/growingIgbt-seen-across-major-racial-ethnic-groups.aspx

Jones, T. M., Nurius, P., Song, C., & Fleming, C. M. (2018). Modeling life course pathways from adverse childhood experiences to adult mental health. Child Abuse & Neglect, 80, 32^-0. doi: 10.1016/j.chiabu.2018.03.005

Julian, C. A., Manning, W. D., & Kamp Dush, C. M. (2024). Measurement opportunities for studying sexual and gender diverse partnerships in population-based surveys. Journal of Marriage and Family, 86(5), 1410-1431.

Kaiser Family Foundation. (2018). Women, work, and family health: Key findings from the 2017 Kaiser Women's health survey. the-2017-Kaiser-Womens-Health-Survey Kamp

Dush, C. M., Manning, W. D., Berrigan, M., Marlar, J., VanBergen, A., Theodorou, A., & M. (2023). National couples' health and time study: Sample, design, and weighting. Population Research and Policy Review, 42(4), 62. Kcomt,

L., Gorey, K. M., Barrett, B. J., & McCabe, S. E. (2020). Healthcare avoidance due to anticipated discrimination among transgender people: A call to create trans-affirmative environments. SSM-Population Health, 11, 100608. doi: 10.1016/j.ssmph.2020.100608 Landivar,

L. C., Ruppanner, L., Scarborough, W. J., & Collins, C. (2020). Early signs indicate that COVID-19 is exacerbating gender inequality in the labor force. Socius: Sociological Research for a Dynamic World, 6, 2378023120947997. doi:10.1177/2378023120947997 Landry,

A. M., Stevens, J., Kelly, S. P., Sanchez, L. D., & Fisher, J. (2013). Under-represented minorities in emergency medicine. The Journal of Emergency Medicine, 45(\), 100-104. doi: 10.1016/j. jemermed.2012.11.064 Lee,

S. J., Ward, K. P., Chang, O. D., & Downing, K. M. (2021). Parenting activities and the transition to home-based education during the CO VID-19 pandemic. Children and Youth Services Review, 105585. doi: 10.1016/j.childyouth. 2020.105585 Lella,

J. W., & Pawluch, D. (1988). Medical students and the cadaver in social and cultural context. In Biomedicine examined (pp. 125-153). Springer. doi:10.1007/978-94-009-2725-4_6 Lewis,

N. M. (2009). Mental health in sexual minorities: Recent indicators, trends, and their relationships to place in North America and Europe. Health & Place, 15(4), 1029-1045. https://doi.Org/10.1016/j.healthplace.2009.05.003 library/stories/2022/11/same-sex-couple-households-exceeded-one-million.html. Liu,

H., & Umberson, D. J. (2008). The times they are a Changin': Marital status and health differentials from 1972 to 2003. Journal of Health and Social Behavior, 49(3), 239-253. doi:10.1177/002214650804900301 doi:10.1177/002214650804900301

Lukachko, A., Hatzenbuehler, M. L., & Keyes, K. M. (2014). Structural racism and myocardial infarction in the United States: Structural stigma and population health. Social Science & Medicine, 1982(1W5), 42-50.

Madorsky, T. Z., Adebayo, N. A., Post, S. L., O'Brian, C. A., & Simon, M. A. (2021). Vaccine distrust: A predictable response to structural racism and an inadequate public health infrastructure. American Journal of Public Health (1971), 777(S3), S185-S188. https://doi.org/10.2105/AJPH.2021.306411

Manchia, M., Gathier, A. W., Yapici-Eser, H., Schmidt, M. V., de Quervain, D., van Amelsvoort, T., Bisson, J. L, Cryan, J. F., Howes, O. D., Pinto, L., van der Wee, N. J., Domschke, К., Branchi, L, & Vinkers, C. H. (2022). The impact of the prolonged COVID-19 pandemic on stress resilience and mental health: A critical review across waves. European Neuropsychopharmacology, 55, 22-83. doi:10.1016/j.euroneuro.2021.10.864

Manning, W. D., & Kamp Dush, C. M. (2022). COVID-19 stress and sexual identities. Socius: Sociological Research for a Dynamic World, 8, 237802312211053. https://doi.org/10.1177/23780231221105376

Marlar, J., Kamp Dush, C., Manning, W., Berrigan, M., VanBergen, A., Tsabutashvili, D., Chattopadhyay, M., & Theodorou, A. (2022). National Couples' Health and Time Study (NCHAT): Methodology report. Gallup. Minnesota population center working paper Series #2022-03. https://doi.org/10.18128/MPC2022-03

Mattei, G., Russo, T., Addabbo, T., & Galeazzi, G. M. (2021). The COVID-19 recession might increase discriminating attitudes toward LGBT people and mental health problems due to minority stress. International Journal of Social Psychiatry, 0, 0020764020960770. doi:l0.1177/0020764020960770

Meier, A., Musick, K., Fischer, J., & Flood, S. (2018). Mothers' and Fathers' well-being in parenting across the arch of child development. Journal of Marriage and Family, 80(4), 992-1004. doi: 10.1111/jomf. 12491

Meyer, I. H. (1995). Minority stress and mental health in gay men. Journal of Health and Social Behavior, 36(1), 38-56. doi:10.2307/2137286

Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674-697. doi: 10.1037/0033-2909.129.5.674

Milkie, M. A. (2010). The stress process model: Some family-level considerations. In Advances in the conceptualization of the stress process (pp. 93-108). Springer, doi: 10.1007/978-1-4419-1021-9_6

Ndugga, N., Hill, L., Artiga, S., & Haidar, S. (2022). Latest data on COVID-19 vaccinations by race!ethnicity. KFF. https://www.kff.org/coronavirus-covid-19/issue-brief/latest-data-on-covid-19-vaccinations-by-race-ethnicity/

Neprash, H. T., Mulcahy, J. F., Cross, D. A., Gaugler, J. E., Golberstein, E., & Ganguli, I. (2023). Association of Primary Care Visit Length with Potentially Inappropriate Prescribing. JAMA Health Forum., 4(3), e230052. https:// doi.org/10.100 l/jamahealthforum.2023.0052

Neville, S., & Henrickson, M. (2006). Perceptions of lesbian, gay and bisexual people of primary healthcare services. Journal of Advanced Nursing, 55(4), 407-415. doi:10.1111/j.1365-2648.2006.03944.x

Oozageer Gunowa, N., Brooke, J., Hutchinson, M., & Jackson, D. (2020). Embedding skin tone diversity into undergraduate nurse education: Through the lens of pressure injury. Journal of Clinical Nursing, 29(21-22), 4358^4367. doi: 10. Ill 1/jocn. 15474

Operario, D., Gamarel, K. E., Grin, B. M., Lee, J. H., Kahler, C. W., Marshall, B. D. L., Van Den Berg, J. J., & Zaller, N. D. (2015). Sexual minority health disparities in adult men and women in the United States: National health and nutrition examination survey, 2001? 2010. American Journal of Public Health ( 1971 ), 795(10), e27-e34. https://doi.org/10.2105/AJPH.2015.302762

Pearlin, L. L, Menaghan, E. G., Lieberman, M. A., & Mullan, J. T. (1981). The stress process. Journal of Health and Social Behavior, 22(4), 337-356. doi:10.2307/2136676

Pearlin, L. L, Schieman, S., Fazio, E. M., & Meersman, S. C. (2005). Stress, health, and the life course: Some conceptual perspectives. Journal of Health and Social Behavior, 46(2), 205-219. doi: 10.1177/002214650504600206

Perelli-Harris, B., Mynarska, M., Berrington, A., Berghammer, C., Evans, A., Isupova, O., Keizer, R., Klärner, A., Lappegård, T., & Vignoli, D. (2014). Towards a new understanding of cohabitation: Insights from focus group research across Europe and Australia. Demographic Research, 77(34), 1043-1078.

Prendergast, S., & Macphee, D. (2018). Family resilience amid stigma and discrimination: A conceptual model for families headed by same-sex parents. Family Relations, 67(1), 26-40. doi: 10.1111/fare. 12296

Qian, G., Mei, J., Tian, L., & Dou, G. (2021). Assessing mothers' parenting stress: Differences between one- and twochild families in China. Frontiers in Psychology, 11, 609715. doi:10.3389/fpsyg.2020.609715

Quinn, D. M., Camacho, G., Pan-Weisz, B., & Williams, M. K. (2020). Visible and concealable stigmatized identities and mental health: Experiences of racial discrimination and anticipated stigma. Stigma and Health ( Washington, D.C), 5(4), 488^491. doi:10.1037/sah0000210

Raikes, H. A., & Thompson, R. A. (2005). Efficacy and social support as predictors of parenting stress among families in poverty. Infant Mental Health Journal, 26(3), 177-190. doi: 10.1002/imhj.20044

Raley, R. K., Sweeney, M. M., & Wondra, D. (2015). The growing racial and ethnic divide in U.S. marriage patterns. The Future of Children, 25(2), 89-109. doi: 10.1353/foc.2015.0014

Reading Turchioe, M., Grossman, L. V., Myers, A. C., Pathak, J., & Creber, R. M. (2021). Correlates of mental health symptoms among US adults during COVID-19. Public Health Reports, 136(1), 97-106. doi:10.1177/ 0033354920970179

Reczek, C., Liu, H., & Brown, D. (2014). Cigarette smoking in same-sex and different-sex unions: The role of socioeconomic and psychological factors. Population Research and Policy Review, 33(4), 527-551. doi: 10.1007/sl 1113-0139297-2

Sabin, J. A. (2022). Tackling implicit bias in health care. The New England Journal of Medicine, 387(2), 105-107. doi: 10.1056/NEJMp2201180

Sassler, S., & Miller, A. J. (2017). Cohabitation nation: Gender, class, and the remaking of relationships. University of California Press.

Scherer, Z. (2022). Key demographic and economic characteristics of same-sex and opposite-sex couples differed. U. S. Census Bureau: https://www.census.gov/

Sewell, A. A. (2016). The racism-race reification process: A Mesolevel political economic framework for understanding racial health disparities. Sociology of Race and Ethnicity (Thousand Oaks, Calif), 2(4), 402^432. doi: 10.1177/ 2332649215626936

Shah, H. S., & Bohlen, J. (2023). Implicit bias.

Sharma, A., Shaver, J. C., & Stephenson, R. B. (2019). Rural primary care providers' attitudes towards sexual and gender minorities in a midwestern state in the USA. Rural and Remote Health, 19(4), 1-10. https://doi.org/10.22605/ RRH5476

Sim, W., Lim, W. H., Ng, C. H., Chin, Y. H., Yaow, C. Y. L., Cheong, C. W. Z., Khoo, C. M., Samarasekera, D. D., Devi, M. K., & Chong, C. S. (2021). The perspectives of health professionals and patients on racism in healthcare: A qualitative systematic review. PLoS ONE, 16(f), e0255936. doi: 10.1371/journal.pone.025593

Sullivan Commission on Diversity in the Healthcare Workforce. (2004). Missing persons: minorities in the health professions. https://campaignforaction.org/wp-content/

Taylor, D. (2020). Fifteen percent of same-sex couples have children in their household, https://www.census.gov/library/ stories/2020/09/fifteen-percent-of-same-sex-couples-have-children-in-their-household.html

Tedeschi, E. (2020). The mystery of how many mothers have left work because of school closings. New York Times, 29. uploads/2016/04/SullivanReport-Diversity-in-Healthcare-Workforcel.pdf.

Valentine, S. E., & Shipherd, J. C. (2018). A systematic review of social stress and mental health among transgender and gender non-conforming people in the United States. Clinical Psychological Review, 2018(66), 24-38.

van der Miesen, A. I. R., Raaijmakers, D., & van de Grift, T. C. (2020). "You have to wait a little longer": Transgender (mental) health at risk as a consequence of deferring gender-affirming treatments during COVID-19. Archives of Sexual Behavior, 49(5), 1395-1399. doi:10.1007/sl0508-020-01754-3

Vloo, A., Alessie, R. J. M., Mierau, J. O., Boezen, M. H., Mierau, J. O., Franke, L., Dekens, J., Deelen, P., Lanting, P., Vonk, J. M., Nolte, L, Ori, A. P. S., Claringbould, A., Boulogne, F., Dijkema, M. X. L., Wiersma, H. H., Warmerdam, R., & Jankipersadsing, S. A. (2021). Gender differences in the mental health impact of the COVID-19 lockdown: Longitudinal evidence from The Netherlands. SSM-Population Health, 15, 100878. https ://doi. org/10.1016/j. ssmph.2021.100878

Webb Hooper, M., Ñapóles, A. M., & Pérez-Stable, E. J. (2020). COVID-19 and racial/ethnic disparities. JAMA, 323 (24), 2466-2467. https://doi.org/10.1001/jama.2020.8598

Werner, A., & Malterud, K. (2003). It is hard work behaving as a credible patient: Encounters between women with chronic pain and their doctors. Social Science & Medicine (1982), 57(8), 1409-1419. https://doi.org/10.1016/ S0277-9536(02)00520-8

Whitehead, J., Shaver, J., & Stephenson, R. (2016). Outness, stigma, and primary health care utilization among rural LGBT populations. PLoS ONE, 77(1), e0146139. doi:10.1371/journal.pone.0146139

Wolfson, J. A., & Leung, C. W. (2020). Food insecurity during COVID-19: An acute crisis with long-term health implications. American Journal of Public Health, 110(12), 1763-1765. doi: 10.2105/ajph.2020.305953

Wrigley-Field, E., Garcia, S., Leider, J. P., Robertson, C., & Wurtz, R. (2020). Racial disparities in COVID-19 and excess mortality in Minnesota. Socius: Sociological Research for a Dynamic World, 6, 2378023120980918. doi: 10. 1177/2378023120980918

Zuberi, T. (2000). Deracializing social statistics: Problems in the quantification of race. The Annals of the American Academy of Political and Social Science, 568(1), 172-185. https://doi.org/10.1177/000271620056800113