Abstract
Background The ‘skin-deep resilience’ hypothesis suggests that Black Americans from disadvantaged backgrounds who persevere and attain academic or professional success despite various social obstacles may nevertheless suffer from poorer underlying physical health. This study examined the ‘skin-deep resilience’ phenomenon among Black American women with systemic lupus erythematosus (SLE).
Methods Data were from the Black Women’s Experiences Living with Lupus (BeWELL) Study, which recruited largely from a population-based sample of Black women living with SLE in metropolitan Atlanta, GA, USA (n=438). Multivariable linear regression models were specified examining SLE disease activity measured using the patient-reported Systemic Lupus Activity Questionnaire (SLAQ), in relation to educational attainment, adverse childhood experiences (ACEs), and experiences of racial discrimination in adulthood. We examined whether associations between racial discrimination and disease activity differed by educational attainment and ACEs, particularly for those who achieved high levels of education despite greater childhood adversity—an indicator of resilience.
Results We found a significant three-way interaction between educational attainment, ACEs, and racial discrimination, consistent with the skin-deep resilience hypothesis (F(26,399)=2.92, p=.02). As expected, racial discrimination was positively associated with disease activity (b=1.89, 95% Confidence Interval [CI] [1.19, 2.59], p<.001). However, this relationship was strongest among those who experienced greater childhood adversity and attained a graduate degree, in other words, those who were highly resilient. There was no interaction between education attainment and racial discrimination among those who experienced low childhood adversity.
Conclusions Findings suggest that ‘highly resilient’ Black women living with SLE (those who achieved a graduate degree despite high childhood adversity), were the most physically impacted by experiences of high racial discrimination. This study challenges traditional conceptualizations of resilience by demonstrating the unintended physical health tolls of ‘building resilience’ without addressing other social and structural inequities stemming from racism.
