Objective: The skin-deep resilience hypothesis suggests that Black Americans from disadvantaged backgrounds who attain academic or professional success despite social obstacles may paradoxically experience adverse physical health outcomes. This study examined skin-deep resilience among a sample of Black women with systemic lupus erythematosus (SLE), a disease sensitive to psychosocial stress. Method: Data were from 426 Black women with SLE from metropolitan Atlanta, Georgia, United States, recruited to the Black Women's Experiences Living with Lupus (BeWELL) Study. Multivariable linear regression models examined cross-sectional associations between adverse childhood experiences (ACEs) and SLE disease activity, and whether educational attainment and racial discrimination moderated this relationship. Results: There was a significant three-way interaction between educational attainment, ACEs, and racial discrimination, F(26, 399) = 2.92, p = .02. Racial discrimination was positively associated with disease activity; however, the relationship between discrimination and disease activity was the strongest among those who displayed high "resilience," indicated by those attaining a graduate degree despite experiencing high childhood adversity (>= 3 ACEs). There was no interaction between educational attainment and discrimination among those who experienced low childhood adversity (<3 ACEs). Conclusion: Findings indicate that among Black women living with SLE, resilience to childhood adversity conferred worse physical health resulting from greater exposure to racial discrimination. Although educational attainment is traditionally conceptualized as protective for health, it may come with unintended physiological tolls for high-achieving Black women with SLE from disadvantaged backgrounds. Interventions aimed at "building resilience" without addressing underlying structural and social inequities could exacerbate racial health inequities.
