Medicine in Color

It’s impossible to talk about sex and gender in medicine without touching on race, ethnicity, and cultural identity. However, it’s vital to understand that, while sex and genetics are biological factors, race—much like gender—is a social construct.3
As we’ve been learning throughout this book, women are understudied, undertreated, and underdiagnosed in medicine as a whole. But within the female population, other groups are even less studied and are repeatedly shown to have even poorer outcomes in multiple key areas.
For example, black, Latina, Muslim, and indigenous American women all experience statistically staggering differences in morbidity, mortality, and treatment outcomes when compared to white women. In fact, the Robert Wood Johnson Foundation estimated that Latino people experienced 30 to 40 percent poorer health outcomes than whites.4 Black women are three to four times more likely to die in childbirth,5 50 percent more likely to die of breast cancer, 50 percent less likely to be treated when they arrive at a hospital with symptoms of heart attack or coronary disease,6 and 30 percent more likely to die of heart disease than white women—and these are just the tip of the iceberg when it comes to statistics. On the whole, women of color are consistently less likely than white women to receive appropriate treatment in all medical settings, especially when it comes to pain and nonspecific symptoms—like those that, as we’ve learned, frequently precede female heart attack and stroke or accompany autoimmune and pain disorders.
This is due in part to the unconscious and often generational biases that providers carry with regard to who women of color are, how they behave, and how they communicate. For example, there are pervasive myths that black people have “thicker skin” and therefore feel less pain; this fallacy, along with other cultural myths about race, is apparently believed and acted upon by up to 40 percent of first-year medical students, according to a recent study.7 (Thankfully, that number is cut by half or more by the time those students get to residency, but the numbers certainly don’t zero out.) Cambodian women are considered unusually stoic; the collective belief is that if these women come to the hospital seeking treatment, there must be something really wrong, so we should pull out all the stops. On the other hand, women from Central and South America are considered more prone to drama and exaggeration. (Remember my story about “status Hispanicus” from Chapter 6?)
Now, I want to be clear: I study race, culture, and identity issues where they intersect with sex and gender in medical settings, but I’m not a specialist in racial matters in medicine. My focus is on biology and on the social determinants of health directly related to biological sex. Therefore, I can’t speak with authority to the root causes and cultural origins of gender- and race-related problems, the specific ways in which they play out on a person-to-person basis across the medical world, or how factors like socioeconomics and location feed into quality of care. I can say, however, both clinically and anecdotally, that regardless of where the stereotypes come from and how individual medical personnel embrace or deny them, our male-centric system serves women of color more poorly than it does any other group of people.
There are many reasons for this, a great number of which have to do with access to quality care. As one article published by Brookings observed, “African Americans are disproportionately treated at health care facilities with the fewest technological resources, the most poorly trained professionals, and [the] least experienced clinicians.” In general, Latina and black women are less likely to receive the regular care and screenings that help identify diseases like cancer early on, in part because many communities lack access to adequate facilities.
However, even the glaring issues in access don’t account for the disparities in outcomes for women of color.

As I shared in Chapter 3, many key studies in clinical research and pharmaceutical development include only a small number of women in general, let alone women of color. This leaves us with very little information on which to base our clinical decisions; we simply don’t understand what role racial genetics play in key processes like pharmacokinetics and disease development. We need more information in order to understand why some of our most common medical treatments work less well for women of color—and we need that information to go over and above the information we already need to gather about women in general.
Another factor that I believe plays an important role in how women of color receive care is communication. Even barring an actual language barrier, women of color often don’t feel heard or understood by their providers. This can happen whether or not the provider carries his or her own implicit bias—but when bias is present, it obviously amplifies the problem.
As we learned in Chapter 6, the “amplification effect” comes into play in many situations between women and their providers, particularly when it comes to pain. This factor is even more of an issue for women of color when racial bias is at play.
When women feel that their providers are ambivalent (or even antagonistic) toward them based on ingrained judgments and prejudices, they are less likely to communicate, which further impedes and obstructs their care. Studies show that black and Latina women are less likely to seek care for fear that they won’t be believed or that they’ll be endangered by biased or uncaring medical staff. There are plenty of awful stories circulating in the media that underscore this legitimate fear.
There’s also research evidence to suggest that the communication issue may be compounded by something called “stereotype threat.”8 This is a disruptive psychological state experienced when people feel like they are the receiving end of a negative stereotype about their cultural identity and are concerned that their behavior might reinforce that image. Basically, it feels like the person is “walking on eggshells,” trying to preempt judgment or confirmation of biases—and as a result, their cognitive performance and communication skills are negatively impacted. This phenomenon has been found to contribute to the score gap between white children and minorities in our educational system and children and minorities in our educational system and also plays out between patients and providers. Women of color should know that it’s not their fault if they feel challenged about communicating their symptoms while simultaneously attempting to police their behavior in order to avoid judgment from providers; this is stereotype threat in action.

References:

  • Audrey Smedley and Brian D. Smedley, “Race as Biology Is Fiction, Racism as a Social Problem Is Real: Anthropological and Historical Perspectives on the Social Construction of Race,” American Psychologist 60, no. 1 (2005): 16–26, https://psycnet.apa.org/buy/2005-00117-003.
  • Robert Wood Johnson Foundation, “Reducing Disparities to Improve the Quality of Care for Racial and Ethnic Minorities,” Quality Field Notes 4 (2014), https://www.rwjf.org/en/library/research/2014/06/reducing-disparities-to-improve-care-for-racial-and-ethnic-minorities.html.
  • Elizabeth Chuck, “How Training Doctors in Implicit Bias Could Save the Lives of Black Mothers,” NBC News, May 11, 2018, https://www.nbcnews.com/news/us-news/how-training-doctors-implicit-bias-could-save-lives-black-mothers-n873036.
  • American Heart Association, “Racial Disparities Continue for Black Women Seeking Heart Health Care,” Medical Xpress, April 5, 2019, https://medicalxpress.com/news/2019-04-racial-disparities-black-women-heart.html.
  • Sandhya Somashekhar, “The Disturbing Reason Some African American Patients May Be Undertreated for Pain,” Washington Post, April 4, 2016, https://www.washingtonpost.com/news/to-your-health/wp/2016/04/04/do-blacks-feel-less-pain-than-whites-their-doctors-may-think-so; Kelly M. Hoffman et al., “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 (April 4, 2016). doi: 10.1073/pnas.1516047113.
  • Joshua Aronson, PhD, “Unhealthy Interactions: The Role of Stereotype Threat in Health Disparities,” American Journal of Public Health 103, no. 1 (2013): 50–56. doi: 10.2105/AJPH.2012.300828.

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