Does Dermatology Have a Race and Gender Problem?
When my now five-year-old daughter was an infant, she developed an odd rash. Clusters of tiny bumps and discolored patches were splotched across her bronze-brown skin. I promptly headed to Google to search all things baby skin, but nearly all of the “helpful” images I could find only featured white children. By the photos, I couldn’t tell what my daughter’s skin affliction was, and neither could a 'dermatologist' when I brought her in for a consultation.
The doctor stuttered as he fumbled for an answer as to what was happening to my child. When he resorted to the same Google search that had been so unfruitful for me, any confidence I had in his capability was shot. He finally came to the conclusion that the condition could be eczema, psoriasis, or merely baby acne, then he asked me: “Can I be honest?”
“I‘m not confidently familiar with how certain conditions present on darker skin,” he said.
That's how visits to the dermatologist can go for people who are not white, or gender-conforming — and medical professionals agree. Many doctors aren't up to speed when it comes to caring for skin of color or the concerns of trans and non-binary patients — and it all comes down to a gap in dermatology education, as people working within the field and those trying to access care have told InStyle.
While I appreciated the honesty of the dermatologist who was unable to treat my child, the entire situation made me wonder how prepared dermatologists are to care for people who exist in the margins. In fact, a 2016 report published in the Journal of the American Academy of Dermatology broke down the racial demographics of dermatologists in the U.S. and found 3% were Black (compared to 12.8% of the overall national population) and 4% were Hispanic (compared to 16.3% of the overall national population). So dermatologists are far more likely to be white and, as many consulted for this story attest, so was all of the skin in their textbooks.
"Believe it or not, some doctors can go through their whole training without having exposure to a diverse population including certain races and ethnicities," Dr. Sarika Snell, a D.C-based dermatologist shares, adding that whether a doctor is familiar with different skin types and tones is usually dependent on the demographics of where they've practiced. "A red rash can appear a different color on a Caucasian patient versus on a patient with skin of color — clinical dermatology is not one-size-fits-all. The way you treat one condition in one race may not be the same way you treat that diagnosis and treatment in another race and I believe it’s important to gain that well-rounded education during training."
Tina Y.*, an Ohio-based biracial woman who sought dermatology treatment for acne when she was 16 years old says she had a similar experience to mine. Now 42, she still thinks of that time as a nightmare. “Many of my white friends had already received treatment,” she says. “At the time, I believe Accutane was a common treatment, but my acne was not that severe. My dermatologist was a middle-aged white woman who barely examined me. She said she could not treat me because I had Black and Asian ‘mixed’ skin.”
While the abrupt nature of the appointment left Tina feeling uncomfortable, it was the doctor’s explanation of why she couldn’t treat her that truly left her distraught. “I remember her saying she was not trained in treating 'mixed skin' because Black skin behaved one way, and Asian skin another,” she remembers. “She did not offer any further explanations or solutions. She didn’t even refer me to another doctor who could have helped me — maybe a Black or Asian or ‘mixed’ doctor who could have studied non-white skin.” Instead, Tina didn't visit another dermatologist for decades, saying she internalized the shame that her own skin was faulty.
These experiences come as no surprise to physicians like Dr. Fran Cook-Bolden, a Bronx-based dermatologist who has been practicing in New York City since 1996. A graduate of Howard University Medical School, Dr. Cook-Bolden was one of the founding directors of the Skin of Color Center at St. Luke’s-Roosevelt in New York City, which was established in the late 1990s. “We were actually trying to address issues pertaining to skin of color, but in a broad way,” she tells InStyle. When she first started practicing, a number of patients would tell her horror stories about not being able to be treated. “They’d say, ‘I’ve gone to a white dermatologist and they said either that there’s no treatment for me or they don’t know what to do’ — but what’s disappointing is that that’s what’s still being said to patients.”
Dr. Cook-Bolden now specializes in skin of color, regardless of someone’s gender, but getting to a place where she can treat anyone wasn’t easy. In 2018, Harvard reported that nearly a sixth of LGBTQ adults have experienced discrimination at a doctor’s office, which has subsequently led a fifth of those surveyed to avoid seeking medical attention in general. On top of that, an April 2019 article published in Practical Dermatology also recognized that there’s low representation for this group when it comes to conducting clinical trials and research studies; further stunting the on-going education of doctors who are currently practicing. “In terms of the LGBTQ community today, we’re probably where we were, unfortunately, 15 to 20 years ago with skin of color,” Dr. Cook-Bolden says.
There have been slow strikes to make dermatology school curriculums more inclusive in terms of skin tone. But the MD notes that there’s still a long way to go when it comes creating nuanced courses to fully incorporate the needs of the trans community, specifically. Issues from how to safely perform laser hair removal treatments, to avoiding misgendering a patient still present barriers.
“In general, there has not been any formal entry of these topics in the curriculum,” Dr. Cook-Bolden says. “However, through organizations, through regional meetings, through our national meetings where we go to hear lectures about new and cutting-edge information, that’s where the core of the training was.”
York, PA-based dermatologist Dr. Patricia Oyetakin says she’s felt the brunt of these disparities within her own day-to-day work. While the number of trans and gender non-conforming patients she’s seen has increased, the resources and education to properly care for them have not. “You have a trans woman who has acne and you’re like, ‘OK, I have all these hormonal treatments I can give her that I normally give my teenagers for acne, but now I have to be very mindful of where we are in her treatment and what feminizing hormones she’s on.’ Or if I have a trans man who is complaining about hair loss, I’m like ‘I can’t totally take away those male hormones.’ So it has actually created some new clinical concerns and a re-thinking of our usual treatment algorithm.”
For Dr. Oyetakin, while she admits there was a gap in her formal education when it came to caring for trans individuals, her solution has been to be as open and honest as possible with her patients. She says that she sometimes will ask trans patients for their permission to consult with their endocrinologists in order understand their hormonal treatment plans and thus better serve them.
A 2019 review of research in the Journal of the American Academy of Dermatology concluded that: “Dermatologists have the ability to greatly affect the care of transgender patients, and there are ample opportunities for dermatologists to expand the literature pertaining to this population.” However, at this point, “there is limited literature on the treatment of transgender patients relevant to dermatology.” Indeed, the othering of gender-noncomforming patients leads to a lack of representation in medical research, which is then a straight-line to lesser medical care. To her peers in medicine, Dr. Cook-Bolden says, “Instead of thinking of LGBTQ community issues as a pathology, think of it as a norm.”
There’s no question that the lack of training and research can make certain patients feel unwelcome in their dermatologist’s office, but the lack of education can quite literally be deadly. Trans people have been found to avoid seeking health care in the first place for fear of ill treatment (or after having experienced it), according to a 2017 poll by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health. And a 2016 study, published in the Journal of the American Academy of Dermatology reported negative outcomes for people of color, as well. It found that while white Americans are more likely to develop skin cancer, African Americans are often diagnosed at later stages and with higher mortality rates. (On that note, InStyle's 2019 State of Skin survey found Black women to be the least likely to wear sunscreen.)
The problem starts with doctors not knowing what melanoma looks like on dark skin — most textbooks and studies only provide photos of skin conditions on white skin — right down to the fact that “many physicians are not aware that Black patients can get melanoma,” Dr. Jeremy Bordeaux of Case Western Reserve University in Cleveland told Reuters when the publication covered the research. It goes without saying that this is a serious problem.
“We have our classic textbooks that get updated from time to time, but the textbook on the shelf today was written two to three years ago,” says Dr. Oyetakin. “So keeping up with evidence and data hot off the press, we rely heavily upon the research, because those are the things that will actually impact patient care in real time.”
Even for low-risk skin conditions, gaps in research and education still exist to this day. A January 2019 study published in the Annals of Allergy, Asthma, and Immunology showed that 19% of African Americans and 16% of Americans of European descent are diagnosed with atrophic dermatitis, also known as AD or eczema. And while a process called molecular profiling is being used to develop more effective treatments for eczema, this study uncovered that only white American patients had been part of the research and development of this technique.
But with these problems starting in the classroom, Dr. Cook-Bolden notes that historically, the onus has been on HBCU medical schools like Howard University, or the now-closed King/Drew Medical Centre, which was opened in California after the 1965 Watts riots, to do research and present data around caring for skin of color. But in recent years, there have been strides to make the field more diverse across the board at certain schools — not only for non-white patients, but also for trans and gender-nonconforming people.
“At the Icahn School of Medicine at Mt. Sinai, they do have a courses addressing racism and bias and health disparities in general, and those topics are threaded through the curriculum,” shared Dr. Cook-Bolden. “They also have two sessions on LGBTQ patients, in the first and second year of medical training, including a specific session on trans health.” But these courses are still not reflected in the general curriculum, which depending on location, leaves millions of patients with skin concerns hanging.
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“The core curriculum for dermatology is managed by the ACGME (Accreditation Council for Graduate Medical Education),” Dr. Oyetakin says. “If you look online, they have very detailed rules and requirements, with a statement around competency and making sure that there’s a commitment to serve the needs of a wide variety of patients and respect diverse patient populations. So, it’s kind of this statement, but [in reality] it’s up to each residency on how they want to execute that. And that part is not clearly defined.”
But the good news is there is an increasing number of elective learning opportunities in medical school, and physicians of all races and genders want to get involved in creating a more inclusive field for patients. “Now, we’re seeing speciality clinics for skin of color, so residents are being exposed more in terms of non-white patients,” Dr. Cook-Bolden explains, speaking on classes focusing specifically on pigment disorders or skin cancers.
The motivating factor? Both doctors believe it has to do with the increasing brownness of America. “If we look at the results of the US Census Bureau, by the year 2050, more than half of the population will [have] skin of color,” Dr. Cook-Bolden shared. “So it would behoove doctors to be able to handle that kind of population.” And that means medical institutions should be as diverse as the communities they serve.
As for the LGBTQ community, some institutions are working toward improvements. Cornell is one example. “They do have a group lecture on addressing [LGBTQ] patients, and that’s something that all residents do attend,” Dr. Cook-Bolden explains.
The physician also notes that though the aim is to have residency programs with a mandatory focus on diversity, the main opportunity for this learning is through professional organizations. Many students and physicians attending regional and national conferences are choosing to educate themselves, and they’re finding more resources to do so. “In our American Academy of Dermatology meetings, the number of lectures on skin of color has just grown by leaps and bounds over the years,” she says. “And this year in particular, I noticed in our summer session they had a special session addressing LGBTQ patients and their concerns — and they gave that course six times over the meeting to ensure they accommodated the number of attendees that might want to get that education.”
For anyone who has been having trouble finding a suitable physician, Dr. Jason Chouake, a New Jersey-based dermatologist, suggests patients should call ahead to make sure the doctor is able to address their concerns. "Additionally, if you have a doctor that you already trust, it’s probably best to ask them for a recommendation for a doctor who can be sensitive to your particular needs," he adds.
As for the overall future of the practice, many physicians remain hopeful that inclusive care will soon become the norm. Dr. Cook-Bolden says that today, “the room is packed” when special lectures and additional trainings on caring for marginalized communities are offered — and those attending come from a wide variety of backgrounds.
Dr. Oyetakin agrees, and says any pushback she has witnessed has come from more seasoned white physicians. But, “As for us younger dermatologists, we’re driven by what we know to be true: The world is becoming more diverse. Enough is enough and we need to address this head-on.”
*name has been changed
Ed. note: Several board-certified dermatologists reached out to InStyle to explain that, as with many medical fields, theirs requires lifelong learning — attending conferences and lectures, and sharing case studies across institutions with one another for greater exposure to different skin types and ailments is the norm rather than the exception. Additionally, several clarified that a residency program — three years working at a hospital in which they learn the medical, surgical, and cosmetic aspects of the specialty — is where the bulk of one’s dermatology training takes place. Many felt strongly that InStyle readers know that finding a board-certified dermatologist (which you can check here) is the best way to ensure receiving the highest quality care.