By Daphne O. Martschenko, PhD and Jennifer L. Young, PhD
June 12 was Loving Day – a celebration of the 1967 landmark court case that finally allowed interracial couples to marry. As multiracial people of color and as scholars, we reflect on our diversity – not just in our features – but in our experiences as Americans, particularly in healthcare.
Reassuring Results?: Dr. Martschenko’s Reflection
In 2019, on a cold snowy night in Chicago I got a call from my primary care physician. She shared the results of my blood work from my annual physical: All was normal, except my creatinine, which was slightly elevated. My physician assured me that because I am African American, this higher creatinine level was normal for me. My kidneys were healthy.
I hung up, initially reassured. A moment later, however, I realized that my physician had made a sweeping generalization. A generalization I may have even led her to make. She was right– I am African American. But, I am also biracial – the daughter of immigrants from Ukraine and Nigeria. Was my creatinine level still normal? Instead of exploring whether my dietary and/or lifestyle habits (e.g., my career as an athlete) might explain a higher creatinine level, race became the sole explanation for what my doctor was seeing in my bloodwork.
Checking Boxes: Dr. Young’s Reflection
I hesitate. Every time I have to select my race on a form, I hesitate. Which one race am I? I feel tangible relief when I see the option to “select all that apply.” The ability to check two boxes validates the wholeness of who I am. But the option to select multiple races has only recently become more common practice.
Growing up, my Chinese mother always selected “White” for my race on forms at the doctor’s office. When I asked her why, she says she doesn’t remember, but probably because it was easier to explain. As a child, I followed her lead, not only because she was doing it, but because I also knew that I look more like my British father. As a White-presenting Asian American, I always felt guilty for solely checking the Asian box. I felt that I had not earned the right to identify with the culture that is only a shadow on my face, and I feared being an imposter. But what information were my healthcare providers missing about me because they only had half my story?
How many others hesitate when they are asked that simple question that is anything but simple for people who are multiracial? What question are we really trying to answer when we ask patients about their race?
A Growing and Diverse Population
As multiracial individuals, we represent one of the fastest growing populations in America. In 2000, the US Census Bureau began allowing people to select more than one racial category to describe themselves. Since then, the percentage of the US population identified as belonging to “two or more races” has grown. There is even evidence to suggest that the size of America’s multiracial population is understated. Recognizing individuals’ multiracial identities is important; the social construction of race impacts individuals’ social, economic, and health experiences in positive and negative ways.
We need to ask ourselves, what are the consequences of grouping together bi-racial or multiracial individuals into a single homogenous category or of ascribing them to a single crude racial category?
Our shared background in biomedical ethics and longstanding interest in understanding how race and science intersect in problematic ways alerted us to the gaps in clinical care we are likely to receive. Despite the growing number of multiracial individuals in the United States, little attention has been paid to how American researchers and clinicians categorize, measure, calculate risk for, and treat them. We need to ask ourselves, what are the consequences of grouping together bi-racial or multiracial individuals into a single homogenous category or of ascribing them to a single crude racial category? Are we instituting a one-drop rule in medicine – a system for racial classification traditionally used to describe the process by which individuals are racialized as Black regardless of their other forms of heritage? Or are we altogether ignoring a group that itself is not monolithic?
Mind the Gap
Clinical decision making is shaped not only by clinician attitudes and biases but also by research sampling and research findings. There are still no clear guidelines or recommendations for how researchers categorize multiracial participants or use the data collected from multiracial participants. Multiracial individuals do not fall neatly into one racial/ethnic category or another. The diverse ancestries of multiracial individuals challenge our conception of racial categories and its connection to differences in genetic risk, health outcomes, and health disparities. Often put into the “other” category or discarded entirely from a study, the unique characteristics of multiracial populations are severely understudied. This poses serious challenges for the generalizability of research involving multiracial individuals like us. The lack of accurate (or any) representation for multiracial participants in clinical research has repercussions when it is translated into clinical practice.
In 2014, Charmaraman et al. conducted a 20-year methodological review on how multiracial populations have been studied in fields such as psychology, sociology, social work, education, and public health. They conclude that “it is now time to view the inclusion of multiracial populations as something that should be standard,” highlighting gaps in the existing literature. At the same time, an emerging conversation on how and whether race should be used in research and clinical care is gathering steam. In particular, scholars are concerned that the study of, and use of race in research and clinical care can reinforce an incorrect and persistent narrative that there are biological differences between racial groups. This challenge is compounded by the fact that fields like clinical genetics lack standard definitions, protocols, and measures for diversity measures such as race, ethnicity, and ancestry. Studies have established a relationship between implicit racial bias and clinical decision making and documented the role of non-clinical influences on clinician decision making. This literature illustrates that whether appropriate or not, the social construct of race shapes clinical care decisions.
Instead of neglecting multiracial individuals because we don’t fit neatly into one category or another, clinicians should work to understand their patients and study participants as individuals with unique social, cultural, economic, and lived experiences.
Instead of neglecting multiracial individuals because we don’t fit neatly into one category or another, clinicians should work to understand their patients and study participants as individuals with unique social, cultural, economic, and lived experiences. We should see people as beautifully complex individuals rather than categories and take time to learn each other’s stories. Multiracial individuals have to navigate different cultural environments; we are often more creative. Clinicians and researchers stand to benefit from better learning how to do both of these things. When those of us in science and medicine fail to listen to or learn from those we aim to serve, we alienate them from the care they deserve.