In the present study, self-reported experiences of racism were associated with an increased risk of uterine myomas. Associations did not vary according to case definition (ie, confirmation by ultrasound vs. surgery), age, education, income, or levels of gynecologic screening, but the associations were notably weaker among foreign-born women and among women with higher coping skills (“everyday” racism only).
The negative impact of racism on health-related behaviors20
could increase myoma risk via heavy alcohol consumption, poor diet, and overweight or obesity.70-72
However, we found that the association between racism and myomas persisted after adjustment for various health-seeking and health-related behaviors (eg, Papanicolaou test screening, alcohol consumption, and BMI), suggesting that other mechanisms are at play. Other potential markers of “stress” (lifetime violence victimization, working on a second job, childcare or caregiving responsibilities, night shift work, and physician diagnosed depression) were positively associated with perceived racism but not with myoma risk. Moreover, control for these measures had little impact on the strength of the association between racism and myoma. These findings suggest that stressors other than racism do not explain the observed association and that the type of stress induced by racism may be different from other types of stress.
The association between “everyday” racism and myomas was weaker among women with high coping skills as measured by the Carver coping scale,61
but the association with “lifetime” racism was similar in both coping groups. A similar interaction was observed for vigorous exercise. The observation that coping skills and exercise modified the effect of racism supports a stress mechanism. These findings agree with studies showing that allostatic load can be mediated or “buffered” by social support73-75
Our findings also suggest that stress mediators have a larger impact on chronic than acute exposure to racism, as the buffering effects were most pronounced for the “everyday” racism associations. However, because coping was measured after the occurrence of myoma, a cautious interpretation of these findings is warranted.
Foreign-born women reported lower levels of perceived racism than native-born women, consistent with findings from several studies of US immigrants.77-80
According to Waters, voluntary immigrants to the United States tend to “see prejudice and discrimination as more isolated occurrences, and as temporary barriers to be overcome, rather than as permanent, pervasive symptoms of a society that has overarching enmity toward them.”77(p. 147)
Immigrants may downplay race in their perceptions of interpersonal relations,thereby making them less likely to define discriminatory events as racism. If foreign-born women who experience unfair treatment are less likely to perceive it as race-based, this might explain the lack of association between racism and myoma risk in this subgroup.
Another explanation for the absence of an effect among foreign-born blacks is that they are more likely to challenge unjust or unequal treatment77
and have more resources for buffering the effects of discrimination.51-53,55,81
In a study of more than 4000 women and men, those who were conscious of instances of discrimination and who challenged discrimination (ie, tried to do something about unfair treatment and talked to others about it) had a lower risk of elevated blood pressure relative to those who were less aware of discriminatory acts and less likely to challenge them.82
If, as suggested by Waters,77
foreign-born women are more likely to challenge racism, and the act of challenging these events protects against myoma risk, we might also observe smaller effects in this subgroup. In agreement with prior data, foreign-born women had higher coping scores on average than native-born women in our study. Nonetheless, given the relatively small number of such women in this subgroup, we cannot rule out chance as a possible explanation.
Measures of self-reported racism in the present study have been widely used17,50,83
and demonstrate high reproducibility both within our cohort50
and in other studies.17,24,83
Exploratory factor analysis confirmed the preconceptualized domains of “everyday” and “lifetime” experiences of racism, suggesting that these questions are capturing the underlying constructs they were intended to measure. The prevalence of reported perceived discrimination is consistent with other studies that have measured perceived racism.17,82
Because the racism data were collected before the diagnosis of myoma, any error in the reporting of racism is unlikely to depend on the outcome and will generally result in bias towards the null.
A limitation of the present study is that myoma diagnoses were self-reported. However, in our validation study,67
the diagnosis was confirmed in more than 96% of the cases from whom we obtained medical records. There was little difference between the cases who did and did not release their medical records with respect to reported symptoms, method of diagnosis, or important risk factors for myomas. Not all study participants were screened for myomas and true cases may have missed, particularly those with asymptomatic disease. However, our data should more accurately represent women with symptomatic tumors because, a low percentage of cases (13%) were detected incidentally and because rates of myoma diagnoses in our study are similar to rates reported in other US studies based on prospective cohort and hospital discharge data.67
Symptomatic myomas reflect the burden of disease in reproductive-aged women.6
The association between perceived racism and myomas was evident after adjustment for several lifestyle and behavioral risk factors, as well as important measures of socioeconomic status (education, occupation, income, and marital status), although it is still possible that confounding by unmeasured or unknown risk factors contributed to the observed associations.
The Black Women’s Health Study is a convenience sample of women with higher levels of education than the general population. Nonetheless, prevalence estimates of established risk factors for myomas— eg, age at menarche84
—are similar to those found in nationally representative studies. Because the association between perceived racism and myomas in US-born participants did not vary appreciably by other factors such as education, income, and age, we expect the positive findings to be generalizable to a broader population of US black women.
In summary, we found that self-reported experiences of racism were positively associated with risk of uterine myomas in US-born black women and that greater coping skills might buffer this association. Racial discrimination is a prevalent and pervasive problem in the United States, and self-reported racism has been linked to several mental and physical health outcomes.20
Although the associations seen here are modest, the prevalence of perceived racism is high enough that a causal association could explain a non-negligible fraction of the excess disease burden of uterine myomas in black women.