Definitions of “Race,” Racism, and Ethnocentrism

While human racial groups are not biological categories, “race” as a social construction is very real, both now and throughout human history [Reference Sternberg, Grigorenko and Kidd6]. Incorrect categorical classifications, such as the term “race,” are regularly and frequently used to discriminate against people and exclude them socially. The original colonial concept was turned into a (pseudo) genetic one to explain the differences. The overwhelming portion of the literature on intelligence, “race,” and genetics is based on folk taxonomies rather than on scientific analyses [Reference Sternberg, Grigorenko and Kidd6].

Ethnocentrism is the overvaluing of one’s own culture in relation to other cultures, thereby leading to biased judgments. Racism is defined by falsely explaining psychocultural traits as being grounded in categorical biological differences, although there is no valid biological “race” concept, thus proclaiming an inherent superiority of a perceived “race” and its right to domination over others [Reference Heinz, Müller, Krach, Cabanis and Kluge7,Reference Bhugra, Watson, Clissold and Migrants8].

Racism can occur at structural, institutional, interpersonal, and internalized level. It can refer to any number of minority groups, for example, anti-Semitism, homophobia, Islamophobia, and xenophobia [Reference Heinz, Müller, Krach, Cabanis and Kluge7,Reference Paradies, Ben, Denson, Elias, Priest and Pieterse9–Reference Butler, Tull, Chambers and Taylor11]. The construct of “race” is socially important because it underlies social oppression and exclusion [Reference Song12], which can have strong negative effects on mental health and well-being [Reference Paradies, Ben, Denson, Elias, Priest and Pieterse9,Reference Bailey, Krieger, Agénor, Graves, Linos and Bassett10,Reference Henssler, Brandt, Müller, Liu, Montag and Sterzer13]. In this line, racial discrimination and exclusion play a causal or mediating role in these mental health problems. It is still the subject of scientific debate [Reference Veling and Susser14], and has a central role as a social stressor in the affected groups, which may increase the risk of developing psychotic symptoms [Reference Veling, Pot-Kolder, Counotte, van Os and van der Gaag15] and may exacerbate other forms of suffering at micro-, meso-, and macro-levels [Reference Nazroo, Bhui and Rhodes16,Reference Phillips17]. Micro-level racialization is inextricably framed by the influence of familial socialization and shared cultural values, which are manifest in individuals positioned within various ethnic, classed, and gendered groups. These are themselves shifting rather than static, shaping and shaped by interactions with other identity groups, and influenced significantly by local environmental conditions [Reference Phillips17]. Micro-level refers to interpersonal and internalized racism (individual/clinical). Meso-level (professional), institutional racialization recognizes cumulative disadvantage experienced across interrelated welfare experiences (housing, education, employment, etc.), produced through institutions’ routine operations, regardless of the intentionality of individual actors [Reference Phillips17]. Macro-level racism includes social structures and ideologies of a society or institution [Reference Paradies, Ben, Denson, Elias, Priest and Pieterse9,Reference Phillips17,Reference Gee and Ford18].

Racisms are fundamental causes of observed “race”/ethnic inequalities in risk of severe mental illness and in outcomes relating to severe mental illness. In order to account for these inequalities, it is important to examine the ways in which structural, institutional, and interpersonal racisms operate and mutually constitute one another. Thus, “race” and “races” are social constructions that have no biological counterpart but represent human-made categories of power and dominance.

The Role of Genetics in the Concept of “Race” and Racism

The concept of “race” has historically been used as a taxonomic categorization based on common hereditary traits (such as skin color) to elucidate the relationship between our ancestry and our genes. This question does not relate only to philosophical, ethical, or political aspects, but also to health ones, as clinicians taking care of patients with mental disorders need to take into account the connections between “race,” ethnicity, genetics, and health [Reference Collins19]. Proponents of maintaining “race” identifiers argue that even if the genetic component of health disparities is small, self-identified “race” or ethnicity is a useful proxy for other correlated nongenetic variables, and to lose the opportunity to explore these would be detrimental to the public; for example, the polygenic risk scores of schizophrenia in two samples with East Asian or European ancestries had reduced scores when transferred across ancestries [Reference Lam, Chen, Li, Martin, Bryois and Ma20]. Self-identified “race” raises an important issue: racial categories are often not self-identified but imposed by others; they vary with context (e.g., depending on previous colonial rule, a person from the Carribeans may be classified as Hispanic or Black) and, importantly, unlike some other facets of identity, they generally cannot be chosen, picked up, and changed as one’s affiliations change [Reference Roth21].

Human “races” have no taxonomic meaning that warrants granting them an objective biological existence. Indeed, genetic patterns from all four modes of human inheritance (mtDNA, Y-chromosome, X-linked, and autosome), along with protein markers, showed that continental clustering represents no natural classification of humans [Reference Maglo, Mersha and Martin22]. Epidemiological research and pharmacogenomic studies indicate that biomedical and statistical values of “race” are generally vanishing when relevant covariates are controlled for geographical and/or social variables. Interestingly, racism per se might directly account for specific morbid traits that are supposed to be associated with race. An analysis of very low birth weight in African American infants was, for example, attributed to the level of maternal lifetime exposure to interpersonal racism [Reference Collins, David, Handler, Wall and Andes23,Reference Zhivotovsky, Underhill, Cinnioğlu, Kayser, Morar and Kivisild24]. Indeed, the genomic and statistical evidence currently available shows that phylogenetic and genetic similarity-based concepts of “race” fail to be applicable to humans even under minimal rational theoretical principles currently accepted in population genetics/genomics [Reference Maglo, Mersha and Martin22]. For instance, “race” accounts for 14.2% of the variance in warfarin dosing when not considering other factors. Yet, when pharmacogenomic and relevant biomarkers are taken into account, the statistical value of “race” is markedly attenuated to 0.3% [Reference Kahn25].

But how genetics correlate with “races?” It was initially proposed that the genetics of “race” could be mainly explained by geographical aspects, as inferences on population genetics often rely on models that do not take into account the geographical distribution [Reference Handley, Manica, Goudet and Balloux26]. This would assume that in each geographical region or continent, common ancestry of the local population shapes regional or at least continental genetic variations, resulting in more or less sharp-cut gene “clusters.” However, the hypothesis that attributes the clustering of human populations to “frictional” effects of landform barriers at continental boundaries was tested and considered as empirically incoherent [Reference Maglo, Mersha and Martin22]. Instead, human populations have a common ancestry in accordance with the “out of Africa” hypothesis, with highest genetic variability in the regions of origin (Africa) and inclines and declines due to multiple migrations (including Neanderthal and Denisova Humans) and diverse population interactions [Reference Heinz, Müller, Krach, Cabanis and Kluge7]. Therefore, to describe human variability, Maglo et al. [Reference Maglo, Mersha and Martin22] suggest using the term “clines” [Reference Livingston and Harding27] instead of “clusters.” The link between genetics and “races” was then analyzed the other way round, not bottom-up (i.e., do races have specific genetic settings?), but top-down (i.e., are genes able to distinguish between races?), using statistical cluster-based methods (seeking to group individuals together who are genetically similar). In this context, multilocus genetic markers, about 93% of the total human genetic variation was found at the individual level, while 4.3% was apportioned to continental regions [Reference Rosenberg, Pritchard, Weber, Cann, Kidd and Zhivotovsky28].

The biological concept of “race” is based on false assumptions regarding categorical differences between populations and has to be rejected. Therefore, the implicit racism that underlies many established “scientific” paradigms should be changed. As the French writer Albert Camus said, “To name things wrongly is to add misfortune to the world.”

Racism and Mental Health

A meta-analysis and systematic review underlined that racism is significantly related to poor health, with the relationship being particularly strong for mental health and less robust for physical health [Reference Paradies, Ben, Denson, Elias, Priest and Pieterse9]. Several studies have highlighted the negative impact of racial discrimination on mental health, particularly in relation to the development of affective, psychotic, and substance use disorders [Reference Heinz, Müller, Krach, Cabanis and Kluge7,Reference Henssler, Brandt, Müller, Liu, Montag and Sterzer13]. Depression was the most commonly reported outcome, which had the same magnitude of association as the broader category of negative mental health [Reference Paradies, Ben, Denson, Elias, Priest and Pieterse9]. A more detailed examination of health outcomes indicates a twofold variation in the strength of association between racism and poor mental health (for suicidal ideation, planning, and attempts, for post-traumatic stress and formal post-traumatic stress disorder). The strong association between racism and poor mental health raises questions about the underlying mechanisms by which racism affects health. Being victim of racism can cause brain changes on the dysregulation of cognitive–affective regions, such as the prefrontal cortex, anterior cingulate cortex, amygdala, and thalamus, which share similarities with pathways leading to anxiety, depression, and psychosis [Reference Berger and Sarnyai29]. These regions became more active in response to social rejection, and their activity was correlated with self-reported levels of distress. In several studies moderation analyses for participant subgroups showed that age, sex, current educational level, and birthplace do not significantly moderate the association between racism and any of the health outcomes examined. However, the associations of racism with depression, negative mental health, and physical health were significantly different across US ethnic groups [Reference Paradies, Ben, Denson, Elias, Priest and Pieterse9]. For physical health, US Africans and US Latins were the only groups for which sufficient numbers of associations were reported to allow for moderation analyses. Obviously, chronic exposure to racism may be implicated in the hypothalamic–pituitary–adrenal axis dysregulation that, in turn, can damage bodily systems and lead to physical negative outcomes, such as cardiovascular diseases and obesity [Reference Paradies, Ben, Denson, Elias, Priest and Pieterse9].

Discriminatory experiences may influence health through the stress responses they engender [Reference Pascoe and Richman30]. Perceived and experienced discrimination produces significantly heightened stress responses and is related to participation in unhealthy behaviors and nonparticipation in healthy behaviors [Reference Henssler, Brandt, Müller, Liu, Montag and Sterzer13,Reference Pascoe and Richman30]. Thus, stigma and social exclusion commonly affect a person’s recovery process as well as their opportunities for societal participation. Improving working conditions, promoting organizational strategies that support coping behaviors, and challenging discrimination will improve mental health [Reference Bhui, Stansfeld, McKenzie, Karlsen, Nazroo and Weich31]. Stigmatization of mental health problems and discrimination of migrants, refugees, asylum seekers, ethnic minorities, and people of color are strong influencing factors of mental health consequences. Additionally, perceived and experienced discrimination is associated with underutilization of medical care services, delays in accessing mental and general medical healthcare, as well as nonadherence to treatment. Furthermore, patient-reported discrimination in the health care setting is associated with worse health, lower satisfaction with healthcare and lower utilization of health services in all racial/ethnic groups in a nationally representative sample of old adults with chronic diseases [Reference Nguyen, Vable, Glymour and Nuru-Jeter32]. Delays in prescriptions and medical tests can lead to seek for alternative health care [Reference Nápoles-Springer, Santoyo, Houston, Pérez-Stable and Stewart33]. Finally, increased diversity among students and trainees may have influenced the culture of health care. They are markers of increased consciousness regarding health equity and justice [Reference Schulson, Paasche-Orlow, Xuan and Fernandez34]. The results and meanings of studies on racism depend of the place where the studies have been performed, with the consequence that antiracists approaches will probably benefit of an adaptation process, taking into account the local history, demography, migration patterns, and policy.

Institutional Racism

Institutional racism is defined as the meso- and macro-level systems, institutions, ideologies, and processes that interact with one another to generate and reinforce inequities among racial/ethnic groups [Reference Powell55]. Institutional racism refers to overt and covert policies, practices, and laws that reinforce racial inequality, white superiority and subordination of certain racial groups in relation to access to resources, opportunities, and power [Reference Williams and Collins48]. Institutions follow these unwritten rules and through a number of parameters start to discriminate in employment, investigations, and treatment. An important example of this is the racial residential segregation, which is a fundamental cause of racial disparities in health. For different migrant groups, living in an area with a few people from the same ethnic background is associated with increased incidence of psychosis (the so-called ethnic density effect). Although the evidence of the ethnic density effect on psychosis incidence for second-generation migrants is strong, this is either weak or absent for the first generation [Reference Schofield, Thygesen, Das-Munshi, Becares, Cantor-Graae and Agerbo49]. Furthermore, evidence suggests that segregation is a primary cause of racial differences in socioeconomic status (SES) by determining and limiting access to education and employment opportunities. SES remains a fundamental cause of racial differences and variations in health [Reference Williams and Collins48]. Thus, workers often live in racially segregated neighborhoods. In these communities, structural factors such as overcrowded housing increase exposure and transmission of infectious diseases, which is compounded by limited access to quality health care through discrimination within the health care system [Reference Barber50]. Furthermore, institutional racism has a high impact on health care disparities and on the gap between the need for and the utilization of mental health services by disadvantaged and vulnerable groups. Discrimination, stigma and shame regarding mental illness, poor knowledge about healthcare systems, and poor language proficiency can lead to poor mental health outcomes in disadvantaged and vulnerable groups [Reference Schouler-Ocak, Laban, Bäärnhielm, Kastrup, Dein and Wintrob56]. The culture of an institution and unconscious bias of people forming this institution constitute racist attitudes and behaviors, which can be dangerous, irrespective of knowledge. Within an institution, this bias is about gaining and retaining power, irrespective of the qualifications of minority group individuals [Reference Bhugra, Watson, Clissold and Migrants8].

Our understanding of how racism and racial discrimination function at an institutional level (i.e., in our structures, institutions, policies, and practices) is related to individual and population health, health outcomes of a group of individuals, including distribution within the subgroup [Reference Hochman57]. Institutions are organizations made up of individuals and traditions [Reference Bhugra, Watson, Clissold and Migrants8]. The culture of an institution and the unconscious bias of the people who make up that institution make up racist attitudes and behaviors. Institutional racism is found in processes, attitudes, and behaviors that lead to discrimination through unintentional prejudice, ignorance, thoughtlessness, unconscious bias, and racial stereotyping that disadvantage people from ethnic minorities. It refers to the whole institution, including people, to create and reinforce inequalities between ethnic groups (see Table 1 for a summary of the different types of racism and the manifestation of these dimensions). It is about gaining and retaining power, regardless of the qualifications of people from minority groups.

Table 1. Summarizing of different types of racism and the definition of these dimensions.

Structural Racism

Racism is a multidimensional concept [Reference Bhugra and Bhui52] with a negative attribution made by people of one social group toward people of a different group. It delineates systemic racism as a set of policies and structures that spawn toxic environments and identifies behavioral and physiological pathways that mediate the social and spatial concentration of disease [Reference Gravlee53].

Structural racism is defined as the macro-level systems, social forces, institutions, ideologies, and processes that interact with one another to generate and reinforce inequalities among racial and ethnic groups [Reference Powell55]. It refers to the ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, health care, imprisonment, and juvenile custody [Reference Wallace, Crear-Perry, Richardson, Tarver and Theall54]. Furthermore, these patterns and practices reinforce discriminatory beliefs, values, and distribution of resources [Reference Bailey, Krieger, Agénor, Graves, Linos and Bassett10]. Structural racism, the system-level factors related to interpersonal racism, increases mortality and reduces overall health and well-being [Reference Gee and Ford18]. It is a threat to the physical, emotional, and social well-being of every individual in a society that allocates privilege based on “race” [Reference Bonilla-Silva58]. The term “structural racism” emphasizes the most influential socioecologic levels at which racism may affect racial and ethnic health inequalities. It does not require the actions or intent of individuals [Reference Bonilla-Silva59]. It is present both in institutions, social structures and tacit modes of perception and social interaction could be brought out more clearly, this is important in clarifying that racism can persist even when individuals are not overtly or intentionally racist [Reference Hochman57]. Even if interpersonal discrimination is completely eliminated, racial inequalities would likely remain unchanged due to the persistence of structural racism, to which many other forms of racism belong, including the prison industrial complex, historical trauma, emotional rules, and media portrayals [Reference Jones60]. This means that research on structural racism should not only focus on independent effects but should also address interactions among multiple forms of racism [Reference Gee and Ford18].

Internalized and Interpersonal Racism

Internalized racism is defined as the incorporation of racist attitudes, stereotypes, prejudices or discrimination, beliefs or ideologies, into one’s worldview. Members of stigmatized racial populations respond to the pervasive negative racial stereotypes by accepting these to be true. This endorsement of the dominant society’s beliefs about their inferiority is seen as internalized racism or self-stereotyping. Inevitably, this can lead to lower psychological well-being and self-esteem and has been associated with higher levels of alcohol consumption, depressive symptoms, and obesity [Reference Williams and Mohammed42]. Furthermore, it can lead to self-injurious incorporation of racist stereotypes about the self, adverse effects on those who experience it. For example, high internalized racism scores have been linked to poor health outcomes among Caribbean black women, higher propensity for violence among African American young males [Reference Mouzon and McLean43,Reference Bryant44].

Interpersonal racism is defined as the interactions between individuals at individual levels. Discrimination at the individual level in the form of everyday microaggressions can occur up to exceptionally stressful events with potentially traumatizing effects and can have an individual impact that promotes disease [Reference Nadal, Griffin, Wong, Hamit and Rasmus45]. Given the diverse and often very subtle forms that interpersonal racism takes, it is difficult to quantify the level of risk faced by ethnic minority people [Reference Karlsen, Nazroo and Kaufman46]. Mental health professionals may carry their own prejudices and unconscious bias toward other “races” and cultures. Furthermore, on occasion they may illustrate what has been described as missionary racism, that is, that the professional knows what is good for the minority individuals who cannot think for themselves. Missionary racism occurs when a person assumes that minorities are unable to think for themselves and thinks on behalf of minority communities [Reference Bhugra, Watson, Clissold and Migrants8]. Socioeconomic and educational status contribute to a degree of mitigation whereas stress, feeling trapped or powerless may exacerbate effects of racism on disadvantaged and vulnerable groups.

At an individual level, mental health professionals may also stereotype other backgrounds and unwittingly reject individuals of these groups. The process of marginalization can reduce the identity of the individual to that of a migrant or foreigner and thus, may contribute to a sense of feeling devalued. Migrants, refugees, asylum seekers, ethnic minorities, or people of color may be more visible and therefore vulnerable to being attacked and stereotyped [Reference Bhugra, Watson, Clissold and Migrants8,Reference Dykxhoorn, Lewis, Hollander, Kirkbride and Dalman61].

How to Overcome Institutional, Internalized, and Interpersonal Racism in Mental Health Care

Social determinants of health are important factors to bear in mind. As the Equality and Human Rights Commission [62] highlighted, an individual from Black, Asian, or minority background is more likely to experience poverty, to have poorer educational outcomes, to be unemployed and to come in contact with the criminal justice system. These variables may show cumulative exposure to racial discrimination with incremental negative long-term effects on the mental health of ethnic minority people [Reference Henssler, Brandt, Müller, Liu, Montag and Sterzer13,Reference Berger and Sarnyai29]. Even if institutionalized racism and its effects are increasingly reported in the news, television, and social media, its presence in research is often ignored. Researchers need to gather more comprehensive data on the effects of institutionalized racism by analyzing residential segregation, mass incarceration, housing discrimination, concentrated poverty, food insecurity, and other relevant factors. To understand how institutionalized racism affects health and well-being, innovative methods and measures are needed to capture data on the exposure to and health effects of institutionalized racism [Reference Hardeman, Murphy, Karbeah and Kozhimannil63]. These should ultimately challenge the implicit biases that perpetuate institutionalized racism. Physiological and public health consequences of interpersonal racism are well studied, but there is little investigation in the mental health on how institutionalized racism influences outcomes [Reference Hardeman, Murphy, Karbeah and Kozhimannil63]. Therefore, to find effective solutions, the first step is to measure institutionalized racism in a systematic way. Thus, clear focused research on institutionalized racism and its impact on mental health is urgently needed to overcome its substantial, longstanding effects on health and well-being.

Recommendations

Mental health professionals are enmeshed in society and institutions and are thus just as likely to unknowingly harbor unconscious biases, interpersonal and internalized racism as anyone else. They need to advocate against racism as they bear a great responsibility to provide good healthcare and be good role models. Recognizing and naming racism, in the work, writing, research, and in interactions of mental health professionals with patients and colleagues will advance understanding of the distinction between “race” and racism and will allow for efforts to combat racism [Reference Hardeman, Murphy, Karbeah and Kozhimannil63].

On the bases, we make the following recommendations, keeping in mind that racial discrimination of any group designated to be “the other” in a society increases the risk of discrimination in general.