Abstract

Introduction

The structural racism prevalent in the societies of the black diaspora is one of the factors that produces inequalities between whites, blacks and indigenous people in health, education as well as in the world of work. This non-white part of the population has less access to health and education, receives poorer quality care at Brazilian National Health System (SUS) units¹1 Geledés. Instituto da Mulher Negra. Centro Feminista de Estudos e Assessoria. Guia de enfrentamento do racismo institucional [Internet]. São Paulo: Geledés, Cfemea; 2013 [citado 2 Abr 2022]. Disponível em: http://www.onumulheres.org.br/wp-content/uploads/2013/12/Guia-de-enfrentamento-ao-racismo-institucional.pdf
http://www.onumulheres.org.br/wp-content... and has fewer chances of achieving higher education²2 Vaz LS. Cotas raciais. São Paulo: Jandaíra; 2022..

Brazil was one of the last countries in the world to abolish slavery, and after liberation, laws were created that prevented the newly freed and their children from accessing public education. The right to education was denied as a government policy in the 19th century²2 Vaz LS. Cotas raciais. São Paulo: Jandaíra; 2022.. Therefore, the racialization of educational opportunities promoted inequalities. According to Vaz²2 Vaz LS. Cotas raciais. São Paulo: Jandaíra; 2022., several restrictive laws were implemented for black men and women, including the Imperial Constitution of 1824 and Decree No. 7.03-1 of 1878. The former established that primary education would be free for all citizens, but citizenship was only granted to free and freed people, therefore excluding the black population.

These actions had repercussions for generations and prevented the black population from accumulating educational capital. And even today, the majority of black students only complete elementary school and have fewer opportunities to access higher quality secondary education. This inequality is concealed through the deleterious conception that they lack the ability to reach more advanced positions, based on the ideology of meritocracy. The latter argues that only individual effort, or the lack of it, can grant or prevent people access to university, and especially to what are popularly called “elite courses”, such as Medicine²2 Vaz LS. Cotas raciais. São Paulo: Jandaíra; 2022..

In order to minimize these inequalities in Brazil, racial and social Affirmative Policies have been implemented to reserve places at public universities and offer scholarships to students from the beneficiary social strata. These policies began in 2003 in some state and federal universities and were consolidated in 2012 with Law 12.711/2012, which governs admission to federal universities²2 Vaz LS. Cotas raciais. São Paulo: Jandaíra; 2022.. However, despite the racial and social quotas, the percentage of black students, both male and female, is still small in medical courses²2 Vaz LS. Cotas raciais. São Paulo: Jandaíra; 2022.^,33 Instituto Nacional de Estudos e Pesquisas Educacionais Anísio Teixeira. Sinopses estatísticas da educação superior. Brasília: INEP; 2020. .

Data from the National Student Performance Exam³3 Instituto Nacional de Estudos e Pesquisas Educacionais Anísio Teixeira. Sinopses estatísticas da educação superior. Brasília: INEP; 2020. shows a slight increase in the number of black students studying medicine. However, among these, those who declare themselves brown predominate. The proportion of black men and women is much lower³3 Instituto Nacional de Estudos e Pesquisas Educacionais Anísio Teixeira. Sinopses estatísticas da educação superior. Brasília: INEP; 2020. ^,44 Scheffer M. Demografia médica no Brasil 2020. São Paulo: Departamento de Medicina Preventiva da Faculdade de Medicina da USP, Conselho Federal de Medicina; 2020.. In 2019, university students were: 55.0% white, 34.6% brown and only 7.0% black in public universities, and in private universities 75.3% white, 20.8% brown and 2.2% black⁴4 Scheffer M. Demografia médica no Brasil 2020. São Paulo: Departamento de Medicina Preventiva da Faculdade de Medicina da USP, Conselho Federal de Medicina; 2020..

There are very few black students, teachers and researchers in medicine³3 Instituto Nacional de Estudos e Pesquisas Educacionais Anísio Teixeira. Sinopses estatísticas da educação superior. Brasília: INEP; 2020. , especially black women⁵5 Ávila RC. Formação das mulheres nas escolas de medicina. Rev Bras Educ Med. 2014; 38(1):142-9., even considering the feminization of medicine⁵5 Ávila RC. Formação das mulheres nas escolas de medicina. Rev Bras Educ Med. 2014; 38(1):142-9.^,66 Minella LS. Medicina e feminização em universidades brasileiras: o gênero nas interseções. Estud Fem. 2017; 25(3):1111-28.. The vast majority of students are white and come from the most privileged economic classes⁵5 Ávila RC. Formação das mulheres nas escolas de medicina. Rev Bras Educ Med. 2014; 38(1):142-9.^,66 Minella LS. Medicina e feminização em universidades brasileiras: o gênero nas interseções. Estud Fem. 2017; 25(3):1111-28., which can be seen as evidence of the limited educational opportunities for female black students.

In higher education institutions, the black population experiences racism expressed in differences of color and culture in the organizational and institutional environment. And black female quota students suffer discrimination because they are in a social position where race, gender and social class markers intersect⁶6 Minella LS. Medicina e feminização em universidades brasileiras: o gênero nas interseções. Estud Fem. 2017; 25(3):1111-28..

Empirical studies have been carried out on the subject and we wonder what contributions can be drawn from their results to reduce racial inequalities. The aim of this review study was to synthesize the knowledge produced in investigations in the field of health, focusing on the causes and consequences of structural/systemic racism and sexism in medical schools, inflicted upon the trajectory of black female medical students, in order to contribute to its dissemination and give resonance to its conclusions.

Methods

We carried out an integrative review of studies published in journals indexed in PubMed and the VHL (PAHO Virtual Health Library). These databases were chosen because they bring together the largest number of bibliographic sources from around the world in the area of Health, of recognized academic quality. The search criteria used were (“medical students”) OR (“medical, school”) AND (“racism”) OR (“bias, racial”) AND (“sexism”) OR (“discrimination, gender”) with a time frame of the last ten years. The inclusion criteria were: complete articles, empirical studies on the topics of medical education, racism and sexism, published in Portuguese, English or Spanish.

We found 190 articles in the VHL and 69 in PubMed. The titles, abstracts and articles were read separately by the authors. After a joint discussion, 53 studies were initially excluded on the basis of their titles, 35 on reading the abstracts and 52 on reading the full text because they did not meet the inclusion criteria, as detailed in the flowchart below. In the end, there were 50 articles that were included in this review study.

In addition to the 50 analyzed articles, 13 additional texts were included for the introduction and discussion of the data presented, which are not included in the tables of articles reviewed. We carried out a thematic analysis of the studies, following these steps: comprehensive reading and re-reading to familiarize ourselves with the content and get a sense of the whole; identification of convergent and divergent themes; classification of the themes into categories; comparative dialogue with the literature; and preparation of an interpretative synthesis⁷7 Minayo MCS. Qualitative analysis: theory, steps and reliability. Cienc Saude Colet. 2012; 17(3):621-26. ^,88 Taquette SR, Borges L. Pesquisa qualitativa para todos. Petrópolis: Vozes; 2020..

Results and discussion

The vast majority of the studies were carried out in the USA (n=42) and one more in co-participation with Canada. The remaining studies took place in Canada (n=2), England (n=2), Sweden (n=2) and the Netherlands (n=1). No studies were found in Brazil or in any other country in South America or on other continents. These data indicate that there is insufficient discussion of this issue in these regions, which have a large black population. The lack of scientific production on the effects of race and gender oppression in the field of health in Brazil and other countries of the black diaspora may be due, among other factors, to the colonizing process that naturalized racism and sexism as a form of domination. The issue of race and the oppression of women, especially black women, is a subject with little visibility in health, especially in the medical field, when compared to studies in the social and human sciences⁹9 Fredrich VCR, Santos HLPC, Rocha TP, Sanches LC. Percepção de racismo vivenciado por estudantes negros em cursos de Medicina no Brasil: uma revisão integrativa da literatura. Interface (Botucatu). 2022; (26):e210677. . Fredrich et al (2022)⁹9 Fredrich VCR, Santos HLPC, Rocha TP, Sanches LC. Percepção de racismo vivenciado por estudantes negros em cursos de Medicina no Brasil: uma revisão integrativa da literatura. Interface (Botucatu). 2022; (26):e210677. argue that there is a denial of racism in society and for this reason it is invisibilized. One of the effects of this process would be the perpetuation of white privilege, as well as discrimination against brown and black people. Therefore, racism in society ends up not being addressed in academic circles either.

Most of the studies included in this review are quantitative (n=35). Twelve were developed using a qualitative method and three with a mixed Quali-quanti approach. After reading and re-reading the articles comprehensively, we identified three main thematic nuclei: I- systemic-structural and structuring racial prejudice; II- racism as one of the factors of inequity in medical education; and III- genderized racism experienced by female black students. We separated the articles into three tables, in a didactic way, according to the main thematic categories in which they were classified. However, in some studies we identified characteristics of more than one thematic nucleus, as described and analyzed below.

Frames 1, 2 and 3 present the following summary data of the 50 studies analyzed: author(s), year of publication, country of study and method, thematic category –or categories- in which it was classified, objectives, sample and main results/conclusions.

Category I- Systemic-structural and structuring racial prejudice

We classified 24 articles in the first category, as described in frame 1 below.

Structural racism is the key factor beneath racial prejudice in medicine. It is a systematic form of discrimination based on race/skin color that structures all social relations between blacks and whites and determines the privileges of the latter, according to Fitzsousa, Anderson and Reisman¹⁰10 Fitzsousa E, Anderson N, Reisman A. This institution was never meant for me: the impact of institutional historical portraiture on medical students. J Gen Intern Med. 2019; 34(12):2738-39. and Burgess et al.¹³13 Burgess DJ, Burke SE, Cunningham BA, Dovidio JF, Hardeman RR, Hou Y, et al. Medical students’ learning orientation regarding interracial interactions affects preparedness to care for minority patients: a report from Medical Student CHANGES. BMC Med Educ. 2016; 16(1):254-61.. Racial prejudice is revealed in the education of black students, as evidenced by Morison et al.¹²12 Morrison N, Machado M, Blackburn C. Student perspectives on barriers to performance for black and minority ethnic graduate-entry medical students: qualitative study in a West Midlands medical school. BMJ Open. 2019; 9:1-11. and Burgess et al.¹³13 Burgess DJ, Burke SE, Cunningham BA, Dovidio JF, Hardeman RR, Hou Y, et al. Medical students’ learning orientation regarding interracial interactions affects preparedness to care for minority patients: a report from Medical Student CHANGES. BMC Med Educ. 2016; 16(1):254-61.. It also results in prejudice and institutional racial discrimination experienced by black students during the medical course¹³13 Burgess DJ, Burke SE, Cunningham BA, Dovidio JF, Hardeman RR, Hou Y, et al. Medical students’ learning orientation regarding interracial interactions affects preparedness to care for minority patients: a report from Medical Student CHANGES. BMC Med Educ. 2016; 16(1):254-61..

Institutional racism stems from structural racism. It takes place in the context of institutional relations and is characterized by the absence or difficulty of access for black people to social goods such as education, work and health. These barriers lead to less participation and unequal access for black men and women¹³13 Burgess DJ, Burke SE, Cunningham BA, Dovidio JF, Hardeman RR, Hou Y, et al. Medical students’ learning orientation regarding interracial interactions affects preparedness to care for minority patients: a report from Medical Student CHANGES. BMC Med Educ. 2016; 16(1):254-61..

This structural racial prejudice persists culturally in societies. It is present in people’s unconscious and will shape personal experiences, behaviors and values. It manifests itself, for example, through biased comments from white students and makes black men and women feel discriminated against, unaccepted and unrepresented on the course.

Racial prejudice is explicit among white students according to the studies by Burgess et al.¹³13 Burgess DJ, Burke SE, Cunningham BA, Dovidio JF, Hardeman RR, Hou Y, et al. Medical students’ learning orientation regarding interracial interactions affects preparedness to care for minority patients: a report from Medical Student CHANGES. BMC Med Educ. 2016; 16(1):254-61. and Dyrbye et al.¹⁵15 Dyrbye L, Herrin J, West CP, Wittlin NM, Dovidio JF, Hardeman R, et al. Association of racial bias with burnout among resident physicians. JAMA Netw Open. 2019; 2(7):1-15., as it appears in interracial relations during the course. In addition, it is one of the factors of discrimination in medical care for the black population, increasing inequity in health, as pointed out by Sanky et al.¹⁶16 Sanky C, Bai H, He C, Appel JM. Medical students knowledge of race-related history reveals areas for improvement in achieving health equity. BMC Med Educ. 2022; 22(1):1-10. and Pehlan et al.¹⁷17 Phelan SM, Burke SE, Cunningham BA, Perry SP, Hardeman RR, Dovidio JF, et al. The effects of racism in medical education on students decisions to practice in underserved or minority communities. Acad Med. 2019; 94(8):1178-89. .

According to Kristoffersson and Hamberg¹⁸18 Kristoffersson E, Hamberg K. I have to do twice as well: managing everyday racism in a Swedish medical school. BMC Med Educ. 2022; 22(1):235-41. and other authors¹⁹19 Ona FF, Amutah-Onukagha NN, Asemamaw R, Schlaff AL. Struggles and tensions in antiracism education in medical school: lessons learned. Acad Med. 2020; 95(12):163-8. ^,2020 Perdomo J, Tolliver D, Hsu H, He Y, Nash KA, Donatelli S, et al. Health equity rounds: an interdisciplinary case conference to address implicit bias and structural racism for faculty and trainees. MedEdPORTAL. 2019; 15:10858. ^,2323 Burke SE, Dovidio JF, Perry SP, Burgess DJ, Hardeman RR, Phelan SM, et al. Informal training experiences and explicit bias against african americans among medical students. Soc Psychol Q. 2017; 80(1):65-84., racial prejudice is based on negative stereotypes associated with black people and can lead to the exclusion of black students and micro-aggressions at university. Therefore, it has deleterious consequences for the trajectory of black students, since the existing learning environment perpetuates educational inequality²⁷27 Bright HR, Nokes K. Impact of a discussion series on race on medical student perceptions of bias in health care. PRIMER. 2019; 3:29. ^,2929 Grimm LJ, Redmond RA, Campbell JC, Rosette AS. Gender and racial bias in radiology residency letters of recommendation. J Am Coll Radiol. 2020; 17(1):64-71..

In the opinion of Perry et al.³⁰30 Perry SP, Hardeman R, Burke SE, Cunningham B, Burgess DJ, van Ryn M. The impact of everyday discrimination and racial identity centrality on african american medical student well-being: a report from the medical student CHANGE study. J Racial Ethn Health Disparities. 2016; 3(3):519-26., the psychological impact of racial discrimination on the well-being of black female and male medical students is great. Those who assume a black racial identity suffer greater discrimination and less acceptance. In addition, it can lead to an experience of exclusion, a feeling of incapacity and even emotional suffering, with female students being the most affected due to gender intersectionality.

Due to the intersection of gender and race power relations that underpin educational inequalities, black female students face double discrimination in these social contexts³⁰30 Perry SP, Hardeman R, Burke SE, Cunningham B, Burgess DJ, van Ryn M. The impact of everyday discrimination and racial identity centrality on african american medical student well-being: a report from the medical student CHANGE study. J Racial Ethn Health Disparities. 2016; 3(3):519-26..

Following the studies reviewed and classified in this category, racial prejudice takes the form of discrimination and translates into the negative view that black men and women have lower intellectual capacities, which persists in society and reduces their chances of getting a place in the best medical residencies.

Category II- Racism as one of the factors of inequity in Medical Education

In the second category, we included 16 articles dealing with the under-representation of black students in medical schools, shown in frame 2 below.

Systemic racism is identified as one of the factors contributing to the inequality of access for black students, both men and women, in medical schools, since racial discrimination influences the educational process of this part of the population from the beginning of their school life. Therabi et al.³⁵35 Teherani A, Harleman E, Hauer KE, Lucey C. Toward creating equity in awards received during medical school: strategic changes at one institution. Acad Med. 2020; 95(5):724-9. as well as other researchers³⁶36 Polanco-Santana JC, Storino A, Souza-Mota L, Gangadharan SP, Kent TS. Ethnic/racial bias in medical school performance evaluation of general surgery residency applicants. J Surg Educ. 2021; 78(5):1524-34.^,3737 Colson ER, Pérez M, Blaylock L, Jeffe DB, Lawrence SJ, Wilson SA, et al. Washington University School of Medicine in St. Louis case study: a process for understanding and addressing bias in clerkship grading. Acad Med. 2020; 95(12):131-5. have identified that the representation of black students in American universities is small compared to the representation of the black population in the general population.

The institutional racism present in medical schools has an impact on relationships between teachers, students and patients. It also influences the educational environment, as emphasized by Newcomb et al.³⁸38 Newcomb AB, Rothberg S, Zewdie M, Duval M, Liu C, Mohess D, et al. Managing patient bias: teaching residents to navigate racism and bias in the workplace. J Surg Educ. 2021; 78(6):1791-5. when they reported racial abuse at the institution they researched. In a hegemonically white educational context, black male and female students are discriminated against and less valued in terms of their intellectual potential than their white peers. This unequal treatment can be seen in the lower scores in admissions processes at American, English and Dutch universities and in letters of recommendation from American universities, as pointed out by Kukulski et al.³⁹39 Kukulski P, Schwartz A, Hirshfield LE, Ahn J, Carter K. Racial bias on the emergency medicine standardized letter of evaluation. J Grad Med Educ. 2022; 14(5):542-8. and another study⁴⁰40 Onyeador IN, Wittlin NM, Burke SE, Dovidio JF, Perry SP, Hardeman RR, et al. The value of interracial contact for reducing anti-black bias among non-black physicians: a cognitive habits and growth evaluation (CHANGE) study report. Psychol Sci. 2020; 31(1):18-30.. This discrimination can influence the low educational performance of some students, according to Loue et al.⁴¹41 Loue S, Wilson-Delfosse A, Limbach K. Identifying gaps in the cultural competence/sensitivity components of an undergraduate medical school curriculum: a needs assessment. J Immig Minor Health. 2015; 17(5):1412-9..

Some universities provide training for teachers⁴⁵45 Wusu MH, Tepperberg S, Weinberg JM, Saper RB. Matching our mission: a strategic plan to create a diverse family medicine residency. Fam Med. 2019; 51(1):31-6.^,4747 Robinett K, Kareem R, Reavis K, Quezada S. A multi-pronged, antiracist approach to optimize equity in medical school admissions. Med Educ. 2021; 55(12):1376-82. with the aim of clarifying what racism is and its harmful effects on society. They also promote changes in the medical curriculum. The study by Mujawar et al.⁴⁸48 Mujawar I, Sabatino M, Mitchell SR, Walker B, Weissinger P, Plankey M. A 12-year comparison of students’ perspectives on diversity at a jesuit medical school. Med Educ. 2014; 19:23401. showed that the inclusion of anti-racist education brought about changes in the medical curriculum and greater racial diversity in the course.

The inequity in medical education resulting from structural racism, according to the articles reviewed, is evidenced by the under-representation of black students in medical courses, in interpersonal relationships between whites and blacks in educational and health contexts and in stereotyped and prejudiced views about the ability of black people, which support a preconceived idea of the existence of differences based on race/color.

Category III- The “genderized racism” experienced by female black students

In the third category we classified ten articles, described in frame 3 below:

The studies reviewed show the intersection of gender and race prejudice in medical courses, as evidenced by the small number of black female medical students and teachers in medicine⁵⁰50 Brown O, Mou T, Lim SI, Jones S, Sade S, Kwasny MJ, et al. Do gender and racial differences exist in letters of recommendation for obstetrics and gynecology residency applicants? Am J Obstet Gynecol. 2021; 225(5):554-65. .

Researchers have identified situations during the course such as bullying, verbal micro-aggressions from colleagues and teachers and even sexual abuse, with the consequences being depression and/or anxiety on the part of some female students⁵¹51 Gerull KM, Parameswaran P, Jeffe DB, Salles A, Cipriano CA. Does medical students sense of belonging affect their interest in orthopaedic surgery careers? a qualitative investigation. Clin Orthop Relat Res. 2021; 479(10):2239-52..

According to some researchers⁵²52 Wijesekera TP, Kim M, Moore EZ, Sorenson O, Ross DA. All other things being equal: exploring racial and gender disparities in medical school honor society induction. Acad Med. 2019; 94(4):562-9., medicine still culturally represents professionals as white and male, associating these white males with professional competence and ability⁵²52 Wijesekera TP, Kim M, Moore EZ, Sorenson O, Ross DA. All other things being equal: exploring racial and gender disparities in medical school honor society induction. Acad Med. 2019; 94(4):562-9.^,5353 Royal KD. Medical students rate black female peers as less socially connected. J Natl Med Assoc. 2018; 110(2):157-62., which contributes to black students feeling uncomfortable, less capable and excluded on the course⁵³53 Royal KD. Medical students rate black female peers as less socially connected. J Natl Med Assoc. 2018; 110(2):157-62..

According to Gwayi-Chore et al.⁵⁴54 Gwayi-Chore MC, Del Villar EL, Fraire LC, Waters C, Andrasik MP, Pfeiffer J, et al. Being a person of color in this institution is exhausting: defining and optimizing the learning climate to support diversity, equity, and inclusion at the University of Washington School of Public Health. Front Public Health. 2021; 9:642477., there is an under-representation of black people, especially women and indigenous people in higher education and a structural hierarchy persists which perpetuates white privilege and reproduces discrimination based on race and gender.

Racism and sexism produce experiences of discrimination and oppression for these black female students, due to the intersection of these systems structured by racist perceptions of gender roles, which was named by researcher Grada Kilomba⁶⁰60 Kilomba G. Memórias da plantação: episódios de racismo cotidiano. Rio de Janeiro: Cobogó; 2019. as “genderized racism”.

“Genderized racism” presents itself in the institutional environment of medical schools, which is extremely hierarchical and historically a social space with low racial-ethnic diversity and fewer opportunities for them during the course⁶¹61 Raj A, Kumra T, Darmstadt GL, Freund KM. Achieving gender and social equality: more than gender parity is needed. Acad Med. 2019; 94(11):1658-64..

As a result of “genderized racism”, female black students face many more institutional barriers than their white colleagues⁶¹61 Raj A, Kumra T, Darmstadt GL, Freund KM. Achieving gender and social equality: more than gender parity is needed. Acad Med. 2019; 94(11):1658-64.^,6262 Fredrich VCR, Coelho ICM, Sanches LC. Desvelando o racismo na escola médica: experiência e enfrentamento do racismo pelos estudantes negros na graduação em medicina. Trab Educ Saude. 2022; 20:e00421184.. This is also true of teaching staff, as fewer of them are professors at the university and in specialties considered to have a higher medical risk.

Discrimination based on race and gender power relations⁶³63 Collins PH. Pensamento feminista negro: conhecimento, consciência e a política do empoderamento. São Paulo: Boitempo; 2019. contributes to the low representation of black women on the course, which highlights the numerous barriers faced by students in the educational context.

Final considerations

The studies reviewed show how the journey of black students in medical training is arduous, with numerous barriers. The very small number of black female doctors, university professors and professionals in senior positions may reflect the difficulty of facing these barriers.

The knowledge produced in the research reviewed reveals that discrimination based on racial and gender prejudice can lead to fewer opportunities during the course. The teaching environment in medical courses is strongly hierarchical and hegemonically white, made up of unequal power relations between men and women and based on racial prejudice. These are even perceived during the course in situations of violence such as moral and sexual harassment and verbal micro-aggressions, in some cases damaging the mental health of students who often come to feel like outsiders, i.e., not part of the university.

The data from this study, limited to a review of research by other authors, shows that actions can and should be implemented to reduce/eliminate these inequities within higher education institutions and the medical courses themselves in order to reduce the barriers faced by black female students.

Acknowledgments

We would like to thank Faperj - Cientista do Nosso Estado Program and UERJ - Prociência Program for their support in developing the research.

References

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