Content warning: This article may be traumatizing for our Black community members. This article includes a discussion and examples of the historical and current experiences of anti-Black racism in healthcare institutions. Non-consensual removal of biological material, general violence, and discrimination are included. Please prioritize your personal well-being in your decision to read this post. We highly encourage allies to continue reading. It is our collective responsibility to learn Black history and listen to Black stories. We must acknowledge the anti-Black racism that saturates our social institutions and take sincere action to dismantle the racism embedded in these institutions.
Hi readers, my name is Han (she/they) and I am the author. I wrote this piece as a tribute to Black History Month and it is critical to acknowledge that I am a white-passing woman writing about Black experiences from a scientific context. I sit at the intersection of white settler and Haudenosaunee ancestry but am a white-passing individual. Importantly, I can never understand the experiences of Black folks as I do not live in a Black body and I do not intend to speak on behalf of diverse Black communities. It is my intention to inform and share research about the ongoing mistreatment of Black individuals and the racism perpetuated by our healthcare systems. While this article focuses on Black women, I want to acknowledge the negative health impacts for all racialized folks, especially Indigenous Peoples, as a result of the systemic racism within Western medical institutions.. My intention is to share the knowledge and lessons that I have access to because of my education and time availability. I hope not to detract from Black joy, but remind non-Black folks that it is our fight too. It is not Black folks' responsibility to constantly educate non-Black folks about the constant mistreatment and violence they face. It is the responsibility of non-Black people to advocate for adequate care of our diverse Black communities that thrive in the face of ongoing unjust treatment.
This piece focuses on exposing the institutionalized racism that persists in Western healthcare systems today and how it negatively impacts the health of Black women and gender-diverse folks. We will discuss:
The poor health outcomes associated with institutionalized racism for women and gender diverse people of colour is two-fold:
There is mistrust of the healthcare system within Black communities due to historical and present-day evidence of the medical and research industries manipulating Black people. This can lead to avoidance or delay in seeking necessary medical care and reluctance to participate in medical research.
When Black folks can and do access medical care, they often face discrimination and racism institutionally, and from healthcare providers, which can worsen poor health outcomes.
Mistrust in the Healthcare System that was Built to Exploit Black Folks
The use of Black communities in the name of ‘medical advancement’ for all
Experimentation on Black folks is one example of scientific racism. Scientific findings were often used to justify the mistreatment of Black communities within society. Further, Black people were often taken advantage of in research settings and not given the ‘courtesy’ of informed consent. The story of Henrietta Lacks is one which stands out in history; a Black woman whose cells were stolen from her and commercialized in the name of science, with no compensation or acknowledgement given to Henrietta or her family. Dr. J. Marion Sims, the “father of modern gynaecology,” is known to have experimented on the genitalia of enslaved Black women including Anarcha Westcott, Betsey Haris, and Lucy Zimmerman without any anesthesia. Dr. Sims then went on to do research on white women, with the inclusion of anesthesia (1*). In the U.S., there is a history of coerced sterilization of Black women. For example, in the U.S., in an effort to reduce Black women from having children and passing on their ‘deviant’ traits some doctors would only agree to give an abortion (even if medically necessary for maternal health) if these women agreed to become sterilized afterwards (2*). Again in the ‘90s, there was a widespread push for Black women and teenage girls to overuse Norplant, a long-lasting contraceptive method, in an effort to control reproduction (3*). Both of these tactics in the U.S. are examples of weaponizing scientific data to perpetuate the racist ideology that Black women, especially those in low-income neighbourhoods, were inherently bad mothers and ‘incapable’ of proper mothering.
Alternatively, we can look at the structural barriers such as transportation costs and lack of access to education that prevented these women from accessing social supports (1*, 3*). These examples are enough to make anyone skeptical of physicians, regardless of how recently those events took place.
Mistrust in social systems that help individuals access health care
Mistrust of institutions apart from the healthcare system is an exponential barrier to accessing medical treatment. The policing of Black folks in law enforcement and subsequent increased likelihood of violence has resulted in mistrust toward the police and emergency services. In a health crisis or emergency, Black people are less likely to call social systems for help (i.e. 9-1-1 for police or paramedics) because the structural racism within these systems can make it unsafe to do so. This distrust is exacerbated for trans women of colour (WOC), as they are further concerned about the compounded effects of gender and racial discrimination (4, 5).
In 2009-2010, the Trans PULSE Project revealed that in Canada, one-quarter of racialized (not only Black Africans/Canadians/Caribbeans) trans people had been harassed by the police because of their race or ethnicity (6). In 2019, 24% of racialized trans and non-binary individuals avoided calling 9-1-1 for emergency medical services in the past five years (5). In November 2020, a Black trans woman named Coco, died in Toronto police custody under unexplained circumstances (7). Further, the Toronto Police Service (TPS) adamantly misgendered her. In response, Black Lives Matter - Toronto wrote a letter to TPS and emphasized that “[Black trans people]...are often harassed and picked up by police simply for being trans in a public space” (7). When Black trans and cis-gendered women cannot access social services that are there to increase safety and access to health care, it’s their health lives at risk. There are countless stories that parallel Coco’s narrative and justify the Black community’s distrust in these social systems.
Racism and Discrimination Affects Quality of Care and Health Outcomes
Why we need an intersectional, anti-racist healthcare system
In 2004, the Canadian healthcare system was described as “an obstacle course for many” by the Ontario Human Rights Commission (8*). This blanket statement applies to all Canadian citizens regardless of identity. However, when we begin to look at health disparities, it becomes clear that BIPOC folks face a greater number of barriers (5). It is undeniable that social, economic, and political factors work together to permit how an individual experiences and interacts with life (9*, 10*). These factors extend into health care and health outcomes and the impacts are felt individually and generationally, both across and within communities (8*, 10*)
Black Canadian adults are disproportionately impacted by a variety of illnesses and diseases including diabetes, cancer, hypertension (i.e. high blood pressure), HIV, and mental illness (10*, 11*, 12*). Biological differences and genetics do not explain these glaring health inequities (12*, 13*). Instead, the systemic and structural racism that is woven into the fabric of Canada, and the broader Western society, is responsible. Lydia-Joi Marshall, president of the Black Health Alliance, concisely stated in an interview with the Toronto Star, “race is not the determinant of health. Racism is” (14*). The individual impacts of income, gender, and race on health disparities do not explain health inequities between Black and white people in Canada (10*). However, when we analyze these factors through an intersectional lens, we see that low-income Black women in Canada are at a substantially higher risk of having diabetes and hypertension compared to high or middle-income Black women and middle or low-income white women (11*). Without intersectional analyses, research is reductive and inaccurate.
Racism within healthcare and other systems is long-standing and often manifests as a form of blanketed indirect discrimination; wherein the same services are provided to all individuals, but distinct, often historically-oppressed communities do not benefit from these services equally (8*). An example of this is language barriers. In Manitoba, researchers interviewed 83 immigrant families that come from 15 different African countries about their experience accessing primary health care services (15*). Families consistently reported language and culture as a significant barrier which made them feel misunderstood by and frustrated with their health service providers. Across many languages, some words cannot be translated into English or the English words are simply not known. This can lead to confusion and inaccurate information may be given, or interpreted by the patient, which can lead to an improper treatment plan or mismanagement of medication. A language barrier makes a patient more vulnerable to giving uninformed consent to treatments and procedures. Sure, everyone is spoken to in scientific jargon in English, but the level of comprehension will vary widely depending on the individual’s primary language, level of health literacy, and cultural interpretation. Approaching healthcare as one-size-fits-all is not only dismissive of cultural health practices outside of Western medicine, but also ignorant of the intersectionality that exists in our social spheres including education levels and socioeconomic status.
How medical racism manifests in Black women’s health
The historical obsession with controlling and policing Black women’s reproductive rights has resulted in negative outcomes for reproductive health. Reproductive conditions such as fibroids and endometriosis are more prevalent among Black Canadian women (16*, 17*). They are also more likely to be underdiagnosed and undertreated for these conditions (16*).
In Canada, preventative medicine such as screening for cervical and breast cancer is inadequate among women of Sub-Saharan African descent compared to Caribbean and Latin American women (18*). Religious faith (namely, Muslim) and immigrant status are two more barriers that make it even harder to get adequate screening for these women (18*). In Canada, only one study examines breast cancer incidence among African immigrant women. The study concludes that African immigrant women are more likely to be diagnosed at later stages in the progression of their disease and that it is very unlikely for their breast cancer to be caught during Stage I compared to East Asian immigrant women (19*). This is troubling considering U.S. and U.K. data (as a comparison, because Canada does not currently collect this type of data) shows WOC have a higher incidence of “triple-negative breast cancer” - which is a more aggressive form of breast cancer with a younger age of onset and higher mortality (18*).
Looking at cancer in general, many studies of the Canadian population show that immigrant people have lower screening rates compared to non-immigrant populations (19*). A study of Black Nova Scotians, a unique ethnoracial subgroup of Black Canadians, showed significant differences in the screening rate of Black residents compared to white residents (19*). These communities typically live in rural areas, creating further transportation and health infrastructure barriers to accessing health care (1*, 20*). It is especially important that screening is culturally safe to ensure greater adherence among Black community members. Many Black communities are subjected to higher levels of environmental pollution (a form of environmental racism) which puts them at an increased risk of developing cancer (1*, 20*).
There are a variety of reasons the racist health care system allows these women to be underscreened and underserved. Language, structural poverty (income), transphobia, and transportation costs/geographical location are just a few (21*). In Canada and the U.S., research centring transgender WOC experiences in health care is limited. Much of the literature about health analyzes transgender people under umbrella categories; they are included within the broader LGBTQ2S+ label or included in “Black women” or “Black people”. There is no consideration of trans women’s unique gender experiences (not just as trans people, but as trans women). From the data we do have, we see that in the U.S., transgender WOC are more likely than the entire population to be living in poverty. This may be in part to discrimination at work and/or school, that makes racialized trans people less likely to have a reliable and sufficient income. In the Canadian Trans PULSE study completed in 2019, racialized trans folks were more likely to be harassed at work or school and more likely to be expelled or suspended from school compared to white trans people (5).
Unfortunately, attaining a high education level or being wealthy does not protect Black women from medical discrimination, as shown in Serena Williams’ birth story that she shared in Vogue. After feeling familiar symptoms of a blood clot shortly after giving birth (via a C-section), Williams clearly and specifically advocated for medical action. Her requests were dismissed by her doctors at first and she was made to undergo pointless tests. Eventually, her blood clots were discovered but it was too late to prevent further injury. Her wound from her C-section popped open due to excessive coughing from blood clots in her lungs that could have been caught earlier, had they listened to Williams’ concerns. According to the Centers for Disease Control and Prevention (22*), Black women in the U.S. are three times more likely than white women to die due to complications associated with pregnancy. Serena is not an exception, as income or education privileges cannot counter the impacts of structural and systemic racism.
Pain is another common experience that is routinely dismissed or ignored when coming from Black women (23*). A study of white medical students and residents revealed that their perceptions of pain experienced by different races, regardless of whether they were accurate or not, resulted in negative consequences for Black individuals only (23*). Black patients are less likely to be given pain medication and if they are, the dosage is often lower than what would be given to a white patient.
Take Serena Thompson, the Vice President of the Sickle Cell Association of Ontario. In a recent article, Thompson describes her routine to get ready to go to the hospital when she experiences a ‘crisis’ - a blockage in an artery due to sickle cell disease - and explains how she brushes her hair and changes out of her pajamas all while experiencing immense pain (24*). She does this because she knows “that [Black patients] don’t get treated right. They wouldn’t give [Black patients] the right medication, or the right dosage, because they think [Black patients] are going to get addicted” (24*). In Canada, racialized trans folks are significantly more likely to live with chronic pain and rate their health as poor compared to white trans folks (5). It is too easy to blame an entire community for their health disparities, citing culture, genetics, or just ‘blackness’ as the inherent cause of inequity in health outcomes as opposed to structural inequalities that hide in plain sight.
Mental health is just as important to a person’s quality of life as the previously mentioned physical disparities. Mental health can be made worse by ongoing physical illness compounded with chronic stress due to the effects of structural racism and discrimination (25*). The narrative of the ‘strong Black woman’ that equates blackness to unbreakable strength and resiliency is harmful because it dehumanizes Black women. This belief frames Black women only as caregivers as opposed to people who need to receive care the same as anyone else. In Canada, there is a 60% increased risk of psychosis if you are of Caribbean, East, and West African origin (26*). This can, again, be explained by discrepancies in access to and quality of care services. Black Ontarians of Caribbean descent are more likely to experience significant delays in receiving appropriate mental health services (BHA*). When they do receive treatment, Black Ontarians in the mental health and addictions systems experience more restraint and confinement compared to white Ontarians (26*, 27*).
Mental health in Black populations across Canada is misunderstood and stigmatized which creates bigger barriers to accessing the supports needed. This stigma is worse for racialized transgender people in Canada, due to the unique intersections of discrimination they face both from a racialized and gendered perspective (5, 28). It is common for mental health professionals and physicians to avoid and/or pathologize gender identity and refuse to provide care to transgender individuals (4, 29). In medical education, learning appropriate trans-specific and gender-affirming healthcare is not a priority. This is concerning given the fact that in Canada, primary care doctors are partially responsible for hormone therapy management and surgeon referrals if gender-affirming surgery is desired (28). When folks cannot access preventative care for their mental health needs - due to monetary barriers, mistrust of the medical system, and a lack of culturally appropriate care - Black people are often forced to engage with law enforcement during mental health crises; another system which continues to mistreat and murder Black people. Even in 2020, a variety of mental health crises where police were engaged were linked to cases of unexplained deaths among racialized community members; including the tragic loss of Chantel Moore, D'Andre Campbell, and Regis Korchinski-Paquet.
How Health Care Can Work Towards Being Anti-Racist
The United Nations has stated that institutionalized racism is prevalent in Canada and medicine is no exception (30*). Being in the midst of the COVID-19 public health crisis has further illuminated the health disparities that exist in Canada. In Toronto, COVID-19 has disproportionately devastated Black communities that make up almost 80% of the caseload for the city. (To read more about the impact of COVID-19 on women and gender-diverse folks, you can read our campaign here.)
In April 2020, Toronto’s Public Health Unit began developing a system to collect race and socioeconomic-based data in regards to COVID-19 (31*). This system having never been previously established speaks to Canada’s long-standing aversion to publishing race-based data - which is an injustice in itself. When questioned whether this would be a provincial initiative, the white, male-identifying Chief Medical Officer of Health, Dr. David Williams, maintained that those most at risk included elderly people, people with underlying health conditions, and those with compromised immune systems. He stated that “those [people] are all priorities to us, regardless of race, ethnic or other backgrounds. They’re all equally important to us” (31*). This is another example of a white person in a powerful healthcare-related position using the ‘I don’t see colour’ narrative that ends up harming those they claim to care ‘equally’ about.
Racism was declared a public health crisis in Canada in 2018 and therefore, it is imperative that the initiative to collect race-based data reaches beyond the scope of the COVID-19 pandemic. If race, ethnicity, and socioeconomic data is not collected in Canada, any conclusions from the data we do have are inaccurate and potentially dangerous. Hesitancy in collecting this type of data stems from groups in power weaponizing this data to justify the continued mistreatment of historically oppressed communities. Instead, investigating the unique health challenges of historically oppressed groups would improve healthcare for all. For example, data shows that there is a higher prevalence of substance misuse in Indigenous communities than in non-Indigenous communities. This information is incorrectly and harmfully rationalized as an inherent characteristic of Indigenous individuals. Instead, this data should be used to investigate what social, structural, and political factors make Indigenous folks more likely to misuse substances, with the goal of improving care for these communities.
Anti-racist care should be a pillar in healthcare guidelines and other social institutions. This type of care integrates culturally relevant information that acknowledges and works actively towards repairing the harm caused individually and intergenerationally by racial discrimination. The lack of racial data in Canada has created a homogenous group of Black individuals that is not representative of the diverse Black communities across the country. Black folks are not a monolith. Despite this fact, not only is Black health care not catered accurately to unique Black Canadian experiences, but the information we do have is steeped in racial bias and historical discrimination. Partnering with Black communities to conduct research about solutions to reduce health disparities is critical. Research that does not include the consultation of structurally vulnerable populations is inefficient and devalues the experiences and teachings of these populations.
Education Initiatives for the Younger Generation
In September 2020, Newtonbrook Secondary School in North York, Toronto, introduced a new course amidst the mixed in-person and online learning framework. Titled “Deconstructing anti-Black Racism in the Canadian and North American Context,” this course is for Grade 12 students and was co-created by four Black teachers; Tiffany Barrett, D. Tyler Robinson, Remy Basu, and Krysten Wynter. Most notably, this course was sparked by students raising concerns about conversations their peers were having about this past year’s Black Lives Matter protests in the U.S. and Canada. While these conversations made the students feel uncomfortable and unsafe, these four teachers determined that the likely reason some youth do not recognize George Floyd’s death as a murder at the hands of the police comes down to both a lack of understanding and blatant ignorance. This course aims to actively help young adults make sense of their micro and macro societal environments. The course covers a range of topics including defining language, historical experiences of Black folks, and how blackness is portrayed and exploited in the media (32*). Most importantly, it creates a safe space for students to learn about injustice and have active discussions about racism in Canada. In February 2021, the Toronto District School Board announced that it would be offering this course in seven additional secondary schools across the city with thirty more showing interest (33*). It is inspiring to see youth at the forefront of this offering, rising from their own self-advocacy and disclosure of unsafe feelings.
*These sources do not specify the gender identity of the women included. Historical representation leads us to believe only cisgender women were included.
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