To understand identity, look at it through the view of the iceberg exercise. Icebergs typically have a small portion of their mass visible above the water. The majority of the iceberg, in whatever form it takes, is below the surface of the water, out of sight. If you’re trying to navigate around it, you have to make some guesses and hope you aren’t wrong.
Assumptions vs Reality Based on Visible Identity
Assume that we have just met and that I am an iceberg. You’ve only met me in one professional context. You have some visual information, but what’s below the surface? Take a chance and start making some guesses. What are they? Using this exercise with my students, they start off safe. I’m male. Check. I’m tall—6’5”. I’m Caucasian. Not entirely true, but mostly true.
Then they start to make some more inferences. I’m not married; there’s no wedding ring, but that doesn’t mean I’m single. They can’t quite place my accent. Some think I come from the Midwest, some from California, some even say New England. All wrong. I was born and raised in Madison, Tennessee, just outside of Nashville. Now they’re starting to get warmed up. They assume I come from a wealthy family. They assume my parents were doctors. They imagine I went to prep school and never had to work during high school. They guess that my first job was in a research lab and my Dad pulled a few strings so that I could get it.
My first job? Bus boy at the Grand Ole Opry, where I had dreams of meeting Dolly Parton.
How accurate were they? Terrible. My Dad was an appliance delivery and repairman for Sears, and my Mom worked all sorts of jobs, including babysitting and cashiering at Walmart. Neither was able to go to college. We probably would have been considered middle or even lower middle class. I went to a public high school where almost no one went out of state to college. When I told my guidance counselor I wanted to go to MIT he replied, “Well, you’ll like Memphis. It’s right nice.” My first job? Busboy at the Grand Ole Opry, where I had dreams of meeting Dolly Parton. Of course, the point being, appearances can be deceiving. People are immensely complicated and interesting. Your job is to learn how to elicit each person’s story and savor it. What’s your story? What’s your identity?
Personal Identity as a Function of Narrative
What are the elements of identity? How do we perceive, change and build identity? How does identity affect our health? What are the pathways? Identity is composed of many elements, including social support, socioeconomic status, work stress, and public health. But It is certainly partly science, both quantitative and qualitative. We need numeric data, but we also need stories and narratives.
Elements or characteristics of identity would include race, ethnicity, gender, age, sexual orientation, physical attributes, personality, political affiliations, religious beliefs, professional identities, and so on.
Consider some of the basics about individual identity. Identity is simply defined as the characteristics determining who or what a person or thing is. Elements or characteristics of identity would include race, ethnicity, gender, age, sexual orientation, physical attributes, personality, political affiliations, religious beliefs, professional identities, and so on.
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Individually, we belong to multiple groups at the same time. We may hold some traits more central to our identity than others, but not everyone holds that same value system. What we value the most might change as we grow older. This overlapping, interconnected aspect of identity is called intersectionality, the intersection of those different elements of our identity. It’s important to keep that in mind as we dig deeper into how identity affects health.
Changing Identities and Identity Development
We know that our identities are somewhat fluid. Although some characteristics are stable, our height, our skin color, maybe even some personality traits, our identity develops over time. There are many different identity development stage theories, mostly concerned with race, that range from starting out expressing denial: I’m color blind, color just doesn’t matter; to immersion, I only want to be around people from the same race; to autonomy, and eventually to integration. In short, we try to find our tribe while being able to connect with and to understand others.
Our tribe, of course, shares the same cultures. Culture is the collage of language, beliefs, traditions, codes of conduct, rules, membership, and health beliefs that guide our daily lives. Our culture influences our tastes, our food choices, sensations of pain and pleasure, and even how we love. Like identity, we can belong to many cultures at the same time, however, we can’t necessarily be competent in all of them. Belonging to a culture doesn’t mean you’re competent or fully understand that particular culture either.
Lest you think that culture and the study of culture is unscientific or pseudoscience, remember that science itself is a shared system of beliefs, practices, norms, expectations, and maybe even a special language, just like any other culture. It’s slippery to grasp because we are so immersed in it. As a student once told me, a fish doesn’t even know it’s wet.
Research on Culture and Identity
Research done on culture suggests how it can substantially, but often implicitly, influence our behaviors. They were cross-cultural studies done with U.S. western individuals, compared to Japanese and Korean individuals, with much of this work done by Nisbett and his colleagues.
In the first study, westerners and Japanese were told to describe a fish tank. They look at a typical, rectangular fish tank with both water and fish in it. Westerners talked about the biggest fish that was in the fish tank. The Japanese talked about the context: they talked about the bubbles, the aquatic plants, and they talked about the other fish.
This is a transcript from the video series Mind-Body Medicine: The New Science of Optimal Health. Watch it now, on The Great Courses Plus.
When he looked at parents, he found that western parents, when teaching language to their kids, they tend to teach nouns first. Koreans, however, tend to teach their kids verbs and especially verbs about relationships. If you were to take someone from the U.S. and someone from Japan and show them a cow, chicken, and grass, and tell them to make a pair just with two of those, someone from Japan would pair the cow with the grass. It’s about the function.
Learn more about the effects of our social communities on health-related behaviors
Someone from the West would pair the cow with the chicken. It’s about the noun. It’s about the category. This may seem trivial, but remember that culture permeates every aspect of who we are. It’s how we piece the world together, how we see ourselves, and how we see each other. It also influences how we develop and shape our identity over time.
For identity to develop, we need three things to happen. First, we need some sort of categorization—there needs to be a sorting of some sort—we need identification, and we need comparison.
…It’s a natural human inclination to make sense of things, to draw connections, to look for relationships. That’s just how we think.
How do we define categorization? Research from Sue Estroff and her social medicine colleagues at the University of North Carolina in Chapel Hill tells us that it’s a natural human inclination to make sense of things, to draw connections, and to look for relationships. That’s just how we think. Part of the process is, essentially, sorting people and places into categories that either we or our cultures have created.
This seems deceptively simple, and you think it might be a no-brainer, but reflect on a few examples. Let’s say the category “dead or alive.” Sounds pretty simple, right? Not really. What about someone who is in a coma with little to no brain activity? Are they dead or are they alive? What about the category of male versus female? Fairly simple, right? Well, again, not really. What about intersex children that are born with ambiguous genitalia? What about racial categories? Now we’re really in trouble. Can you look at a person walking down the street and accurately put them in a racial category?
Race as a Category Central to Identity
Categories are complex, and some of the most complex categories are often central to our identity, but what are they made of? What are they based on?
Race is one of the central categories. So what is race? It’s defined as a classification system used to categorize humans into large and distinct populations or groups by anatomical, cultural, ethnic, genetic, geographical, historical, linguistic, religious, or social affiliation. That’s a mouthful. Essentially, it’s the attempt to categorize or to sort people into categories based on their skin color and based on a very small set of physical characteristics.
There’s currently a raging debate between geneticists and anthropologists about whether or not race is a biological construct.
If we were to ask the U.S. Census, they’d tell us that we have a rather short list of racial categories. The categories are white, black or African American, American Indian or Alaskan Native, Asian, and Native Hawaiian or other Pacific Islander. Latino or Hispanic is not considered a race, but rather an ethnicity, where ethnicity is more about a shared language or other cultural practices. There’s currently a debate raging between geneticists and anthropologists about whether or not race is a biological construct.
Could you look at someone’s genome, for instance, and determine what their race was without looking at where they’re from or looking at their ancestors? Maybe, maybe not. The anthropologists correctly point out that there’s often more genetic variation within one particular race than between the races with African Americans being a prime example. If race isn’t a biological construct, what is it?
Learn more about cognitive function
The American Association of Anthropology has a terrific collection of materials called “About Race” on their website. It helps us understand how these categories were created and some of the ramifications about using these particular categories. Related to cognition and the prevalence of self-serving biases, when we create categories, we open the door to making judgments. How we judge depends on how we self-identify. We tend to positively reappraise people who are in our in-group, and we tend to devalue people in another category, people in the out-group. Identification and comparison are the last two aspects of identity development.
Identification and Comparison—How to Identify or Join a Group
How do we identify or join a group? We’ve talked a lot about the biopsychosocial model and its spheres of influence. There’s a similar model, the social-ecological model, that talks more about social spheres of influence. Conceptualize your relationships and connections to your community as concentric circles, where the individual is in the center, their significant other, maybe their family is in the next circle, then their neighbors, their communities, and so on until we get to their political influences, the country, and the globe. All of those influences may be present at any particular time.
One image that comes to mind is an image of President Obama and a little African American boy who reaches up to touch his hair to see if their hair is alike. That little boy is in the process of identity formation. He’s looking for similarities; he’s looking for differences, maybe with profound psychological consequences.
But of course, our identity changes over time. Part of young adulthood is striking out on your own, taking your odyssey, and deciding who is in your tribe. So how do we compare in-groups versus out-groups? Of course, we start noticing, how we are similar and how are we different. We begin by asking others for feedback. We see which tribe opens the door, which tribe closes the door. In response, we begin to shift our thinking. As we are connecting with a particular group of people, we start to minimize our differences; we start to maximize our similarities. Those cognitive distortions start to kick in. Our in-group is terrific. Our tribe is terrific. The out-group is not so great. We make those generalizations.
How Does Identity Affect You?
So how does identity affect you and those around you? Obviously, it will affect your self-concept, your sense of value, and your sense of self-esteem. It will also affect your sense of perceived control. Remember, there’s a hierarchy in society, there’s a ladder of power. Where are you on that ladder based on what your identity is? Sometimes you can choose that; sometimes others choose it for you. There’s a number of social responses to your identity, sometimes known, sometimes implicit and unknown.
If you’re someone who happens to be lucky enough to be considered very physically attractive in a particular culture, then you’re probably going to get a lot of attention, a lot of resources and a lot more forgiveness than other people might receive.
An example would be unearned privilege, and usually, if you’re the one that’s receiving the privilege, you’re not aware of it. If you’re the one seeing other people privileged over you, you’re very much aware of it. For example, if you’re someone who happens to be lucky enough to be considered very physically attractive in a particular culture, then you’re probably going to get a lot of attention, a lot of resources and a lot more forgiveness than other people might receive. This could also mean being the recipient of stereotypes, potentially the recipients of bias, discrimination, or prejudice. This may be due to either hidden or visible identity. Visible identity would be an individual who is stereotypically African American, based on their skin color and their hair. A hidden identity might be someone who is Jewish. People don’t know someone is Jewish unless they say they’re Jewish, but there may be a cost of hiding if we don’t make that hidden identity visible.
Learn more: Seeing the Glass Half Empty—Depression
As an example, there was a heartbreaking study originally done in the 1960s and then redone just about 10 years or so ago. The experiment went as follows. A group of young African American girls, usually aged 3, 4, 5, 6 years old, were recruited and brought into the laboratory room. They put two dolls on the table in front of them. One was a white doll, and one was a black doll. The experimenter asked the little girl to point to the good baby. She pointed to the white baby. She was then asked to point to the bad baby. She then pointed to the black doll. These little girls have already internalized those stereotypes, presumably not from their families, but from the culture at large.
Identity Experiments—The Robber’s Cave: Phase One
Another seminal experiment on in-group, out-group experiences and distortions comes from Muzafer Sherif, a Turkish social psychologist, who in the 1960s did conducted a series of studies at a summer camp. His most famous series of experiments were called “The Robber’s Cave Experiments.” They were named Robber’s Cave after the name of the state park in Oklahoma. Sherif recruited 11- and 12-year-old preteen boys, and he brought them into this summer camp for free. Like they do in most summer camps, they were divided into groups. He had the Rattlers and he had the Eagles. In the initial part of the experiment, they were completely separate. He wanted those groups to develop a cohesive identity. He wanted those in-groups to begin to develop. He wanted positive cognitive distortions to begin to develop.
The Robber’s Cave Experiments: Phase Two
Phase two of the experiment, he brought the Rattlers and the Eagles together, but he put them in opposition to one another. He had them compete for prizes and resources. He began to see what would happen in terms of cognitive distortions between the in-group and between the out-group. We can predict what happened. The Rattlers and the Eagles started making all sorts of assumptions about each other. They made all types of generalizations and stereotypes: they’re mean, lazy, no good, they always cheat, they don’t care, and they’re underhanded. This is exactly what happens in society all the time.
The Robber’s Cave Experiments: Phase Three
They put the Rattlers and the Eagles together in this shared task. After a number of these shared tasks, guess what happens? The Rattlers start to get to know the Eagles as individuals, as people, and they see that they’re fairly similar.
The most interesting part of this experiment, though, was in phase three. In phase three, Sherif engineered all sorts of accidents where he needed the boys to help so that they would have to work together to correct the problem. An accident would be something like a tree falls across the road, and for them to take the bus out of camp, they have to get the tree off the road. However, it’s a big tree, and so they need kids with lots of axes to do hard work and haul the wood away. The researchers put the Rattlers and the Eagles together in this shared task. After a number of these shared tasks, something happened. The Rattlers started to get to know the Eagles as individuals, as people, and they saw that they were fairly similar. Those negative cognitive distortions begin to melt away as they began to cohesively bond with one another. They became one big in-group instead of the in-group and the out-group. This experiment is still taught in business school. If in a situation there are two warring tribes of some sort, the best thing to do to build group cohesion and have good teamwork is to have them roll up their sleeves and solve a problem together.
Stereotypes, Stigma, and Identity
Like in the Robber’s Cave, our perceptions can color our view of others’ identity, as well as our own, specifically stereotypes and stigma. One aspect common to stereotypes is a phenomenon called Stereotype Threat. Stereotype Threat refers to being at risk of confirming, as a self characteristic, a negative stereotype about one’s group. Say the stereotype is, if you’re African American, that you won’t do very well in school. The individual does not have to believe that stereotype at all. The fact that they know that stereotype is there when they sit down to take an exam may take up some of their headspace. They may be worried; what if I don’t do well? Or they may be angry. What if they’re thinking, I’m not going to do well? Regardless, it’s taking up cognitive resources, and it may create a self-fulfilling prophecy. But is the theory true?
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The Math Test—Gender Identity Studies
Several studies highlight how stereotypes impact our self-perception in daily tasks. Claude Steel, of Columbia University, conducted several different versions where he tested not only race but gender. He focused on the stereotype that men are better than women in math. In the study, he brought men and women into the lab and he gave them a math test. To activate stereotype threat, he first had them pay attention to whether or not they’re a man or they’re a woman with a simple interview talking about gender. The discussion activates the identity element of men or women. Steel found the men did better than the women on the math test. In the second condition, he brought in men and women and gave them a math test, but he didn’t prime them about gender. Steele told them this was a new kind of math test. What he found was that there were no gender differences between men and women. They took the test and performed equally. It was the same math test as in the first part of the experiment.
Understanding Identity with The Achievement Test
In his next experiment, Steele focused on race, looking at black, white, and its correlation to an achievement test. Again, he brought in students and gave them an achievement test. He first primed them to think about the fact that they’re black or they’re white, and then gave them the test. When primed, stereotype threat happens, and he saw a difference in terms of the achievement where the white students did better. If they were told that it’s a special test that isn’t sensitive to differences in gender or sensitive in differences to race, they performed equally at the same level.
There have been a few variants of this experiment. Many people seem not to believe these findings, but it’s been done in several different ways. Ryan Brown and Eric Day used something called Raven’s progressive matrices. It’s an old IQ test where instead of having verbal-type questions, it shows the test-taker pictures. It’s all visual, and it asks out of an array of particular choices to pick the two that match. It begins fairly easily by having the participants pick the two circles, followed by choosing two squares. Then, of course, it gets increasingly complicated and difficult. It’s sort of a fun puzzle to do. The point is, most people don’t know about it. It’s not verbal nor is it about math, so it is assumed to have little bias.
In the first part of the experiment, Brown and Day told black and white students that the test is about IQ. When they told the students it’s about IQ, white students did better than blacks, but when they’re told that it’s simply a puzzle, blacks and whites performed the same.
The next variant of the study, performed by Jeff Stone at the University of Arizona, presents an interesting wrinkle. He was interested in stereotype threat and wanted to look at black and white students. But Jeff Stone is a sports psychologist, so he’s interested in slightly different kinds of stereotypes. He had both black and white students, and he didn’t want to pick football or basketball where there are many different racial stereotypes. He wanted to pick a fairly neutral sport, miniature golf. He had black and white students come in and play a game of it. In one condition, he told them that it was a measure of social IQ, and in that condition, the blacks perform worse. In the next condition, he told them that it’s a measure of athletic ability, and in that condition, the blacks outperformed the whites. Of course, the stereotype is that whites are smarter; blacks are more athletic. Stereotype threat seemed to hold true in this particular instance.
The Obama Effect
One more example of stereotype effect, called the Obama Effect, can shed some interesting light on how our performance can shift. The study was done around the time of former President Obama’s first term by Ray Friedman at Vanderbilt University. The first version was published in a paper, in the Journal of Experimental Psychology in 2009. He called it the Obama Effect. What was it?
He recruited 500 students, both black and white students. He created a 20-item test, mostly about verbal IQ types of items. Before the Obama election, he found the usual performance gap where the white students were outperforming black students. The difference was about 30 percent. After the election of Obama, he gave another group of students the same test, and there were no racial differences whatsoever. It makes you think, and it makes you want a replication. But it’s also exciting to think, are there big environmental events that can reach into our psyches and change those stereotypes? If they do change those stereotypes, do they stay changed and how long does it last? Is there some sort of engineering or resilience factor that we can build in?
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Let’s go back and look at some of those cognitive errors. These errors are neither good nor bad, but they have consequences. They’re there for a reason, for a function, and sometimes we use them too much or too little. The first cognitive shortcut that we use is generalizations. Generalizations aren’t necessarily bad; we do them all the time. People look for patterns trying to save mental processing energy. This is all about system-one thinking that is efficient and helps us see connections. The second is about positive, or optimistic, bias. Most of us have a self-serving bias where we pretty much see ourselves above average in all sorts of different things. This is probably our psychological defense mechanisms. Of course, if used too much, then we have an unrealistic sense of who we are, what we’re able to accomplish, and maybe don’t see our weaknesses or work to improve ourselves. It does build pride. It gives us a sense of belonging and self-esteem, but it may come at a cost if used too much.
Devaluation of the Out-Group
Another common cognitive bias is the devaluation of the out-group. This frequently. We increase our opinions of our in-group and in turn, decrease our opinions and maybe even dehumanize individuals in an out-group. This probably eases guilt from competition between those two groups. It correlates to the labels and frames that we use and how they may subtly or not so subtly affect our opinions, our judgments, and our generalizations about others.
The study that comes to mind is a classic study that was done by van Ryn. This was a study looking at the impact of racial identifiers at the top of someone’s medical chart. In this particular experiment, van Ryn wrote a paragraph description of a patient. So it would be something like, a 45-year-old Caucasian male presents with left-sided chest pain, etc.. That was given to one group. The next group got a 45-year-old male, no race identified, presents with left-sided chest pain. He then asked those healthcare professionals several different questions, including what they thought caused the problem, what level of adherence they thought this patient would have, and if they thought he would be difficult or easy to get along with?
As it turned out, if there was a minority racial label at the beginning of that chart, those healthcare professionals made all sorts of negative reactions. This is why now it’s fairly standard, at least in the ID tag of a case, we don’t put the race. Not because race isn’t important, but because oftentimes in our society, that label is negative, and it influences that health professional’s judgment.
Another example, in 1995, the Metropolitan Museum of Art had an exhibit that they called Rembrandt/Not Rembrandt. There were many fake Rembrandts, several of which I thought were incredibly beautiful, but one was real, and one wasn’t. If you brought in a group of individuals and you say, this is the real one, this is not the real one, could you rate the quality of them? Everyone rates the real Rembrandt as much more beautiful. If you switch them so that you tell them the real Rembrandt is fake and the fake Rembrandt is real, however, people think the fake ones are now much more beautiful than the real ones. But this isn’t just about subjective opinion. They’ve shown these same pictures to people while they’re in a functional MRI machine, and when people look at fakes, different parts of their brain light up.
Whenever I go to Napa Valley with friends, we perform the same wine trick at different wineries. Two bottles of wine are brought out: a very expensive one and a cheap bottle. I remove the labels, then pour two glasses, and say this one is the expensive wine, and this one is the cheap bottle. Which do you like better?
People always believe the expensive one tastes better, even though we’ve switched the bottles so that the cheap bottle, actually the expensive wine, is the one that they’re saying tastes better. You can manipulate those judgments fairly easily, because in our culture, money equals value. If it costs more, it must be better. Right?
What about the labels that we put on people: old or young, black or white, male or female? What are the consequences, and what can we do about it? We can’t get away from cognitive biases and system-one thinking, but we can be explicit and open in reflecting on our identities and the groups that we belong to. We can be careful when we’re evaluating ourselves, and particularly careful when we’re evaluating our out-group. It’s critical that we leave our comfort zones and interact with people that maybe we’re not so drawn to so that we get to know them as an individual and not as a generalization or a stereotype.
At the University of California, San Francisco, we teach our students the work of William Carlos Williams, who is a physician and a poet. He tells us to find the poem in every person, to find and listen to their music. Know yourself. Get to know others. We’re not color blind. We all have identities, and we all have biases, or as a mentor once told me, find your enemies and take them to lunch.
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Diversity in all its many different forms can be vexing, but it can also be quite valuable, and this isn’t coming from an ideological perspective. When combined, the different perspectives, the different ways of thinking, the different life histories can reveal things that we wouldn’t have seen if we only hung around people that are similar to us. The National Institutes of Health has been pushing a program called Team Scientist, where biologists are working with psychologists, sociologists, and many different disciplines, not just other biologists, because each brings a particular lens to the question at hand. That level of diversity helps us find better answers.
Identity can be linked to health, and specifically, to health disparities. The 2002 Institute of Medicine report called Unequal Treatment distinguishes between health disparities, differences in the prevalence or outcomes of disease, and healthcare disparities, or when care is unequally provided to two people even though they have the same disease. Why do these occur? Studies have shown a correlation of health disparities with cancer and heart disease. We know that the life expectancy for a black man in the United States is about the same as a poor farmer in Bangladesh.
Why is this at play? We should be thinking about chronic stress, cardiovascular reactivity, allostatic load, or what Arline Geronimus has called weathering. We also need to think about how those social factors, using the biopsychosocial model, are connected to healthcare disparities. Most people that go into medicine or healthcare want to help other people. They don’t want to provide unequal care. It’s about implicit biases and how implicit biases can sometimes be made manifest, particularly if you’re tired, rushed, multitasking. When trying to measure implicit bias, we find that we all have biases regardless of our background, race, gender, or color. Our task is to be aware of them and do what we can to change them.
The book Outliers by Malcolm Gladwell reminds us it’s not just about implicit biases; it may be about societal biases as well. He noticed an interesting phenomenon that all of the Stanley Cup players, the hockey superstars, tended to be born in January, February, or March. Is it biology or genetics? Probably not. It’s about how kids are recruited into hockey leagues. To get in the 5-year-old hockey league you have to be born in that particular calendar year. A kid born in January competes with a kid born in December, and when you’re 5-years-old, that makes a huge amount difference. The kids born in January, February, and March make the cut, and the others don’t.
The various models—the biopsychosocial model, the life course developmental model, the social-ecological model—can tell us how these things change over time, especially our identities, and how we grow as years pass and variables change.
Common Questions About Identity and Health
Identity is defined as the various characteristics that come together to represent a person. The items on a job application make up part of your identity along with less objective characteristics such as sense of humor, taste in food, hobbies, and upbringing.
Identity does affect behavior. One’s identity becomes a source of self-esteem that either helps or hinders how one achieves life goals. How one views himself can also become defined by stereotypes which in turn affects behavior. Behaviors such as smoking, drinking, and participating in sports are all heavily tied to self-perception.
A health identity can be as simple as how one sees himself in terms of healthy or sick. Are you prone to illness? You might have a suffering health identity as well as habits that exacerbate illness. It can be also thought of as all the data about your health that would be obtained during a hospital visit or when purchasing health care.