Racial, ethnic, sexual, and gender minoritized groups have historically been excluded from many benefits of society. Most recently, these groups were disproportionately affected by COVID-19 pandemic. This has shined a light on the disparities within our healthcare system and has led healthcare organizations and workers to examine attitudes and practices that affect the care and outcomes for these groups of people.

Central to the effective care of historically excluded communities is an appreciation for cultural responsiveness, sometimes called cultural competence. In the context of healthcare, culturally responsive communication refers to a provider’s ability to engage with patients based on views of culturally diverse patients rather than the views of health care professionals (Xavier et al., 2023).

Cultural responsiveness centers unique patient experiences and understandings of health and illness, recognizes the individual biases that clinicians may hold, and seeks to work productively with patients who are not typically represented or valued in the Western understandings of care. This approach allows healthcare practitioners to work consciously and effectively toward cultivating health equity for historically marginalized groups (Xavier et al., 2023).

The influence of social determinants of health, including access to screening and treatment, and other systemic and structural factors are largely responsible for these disparities. Provider competence in culturally responsive screening practices will be critical to reducing the impact of systemic and structural factors serving as barriers to screening and treatment. Improving the capacity of providers to communicate with patients in a culturally responsive manner may influence improved screening and treatment outcomes for minoritized groups (Kalita et al., 2023).

6.1 Gender and Culture

Gender refers to the roles, behaviors, activities, and attributes that a given society at a given time considers appropriate for men and women and people with nonbinary gender identities. These attributes, opportunities, and relationships are socially constructed and are learned through socialization. They are context and time-specific and changeable (Global Health 50/50, 2020).

Gender norms, gender identity, and gender relations together encompass the socially constructed roles, relationships, behaviors, relative power, and other traits that societies routinely ascribe to women and men. Gender identities other than those of men and women (who can be either cisgender or transgender) include transgender, nonbinary, genderqueer, gender neutral, agender, gender fluid, and “third” gender, among others (Peters and Woodward, 2023).

Gender determines what is expected, allowed, and valued in a woman or a man. In most societies there are differences and inequalities between women and men in responsibilities, activities, access to—and control over—power and resources, as well as decision-making opportunities. Gender is part of the broader context of sociocultural power dynamics, as are class, disability status, race, poverty level, ethnic group, sexual orientation, and age (Global Health 50/50, 2020).

Gender equality means having the same opportunities, rights, and potential to be healthy and benefit from the results. Inclusion means actively building a culture of belonging, inviting the contribution and participation of all people, and creating balance in the face of power differences (Global Health 50/50, 2020).

Sex and gender are integrally related and influence health in different ways. According to the World Health Organization, sex refers to “the different biological and physiological characteristics of females, males and intersex persons, such as chromosomes, hormones and reproductive organs”, while gender refers to “the socially constructed characteristics of women, men, girls, and boys” (Peters and Woodward, 2023).

6.1.1 Reproductive Justice

The ability of any woman to determine her own reproductive destiny is directly linked to the conditions in her community, and these conditions are not just a matter of individual choice and access. For example, a woman cannot make an individual decision about her body if she is part of a community whose human rights as a group are violated, such as through environmental dangers or insufficient quality healthcare.

Fleming et al, 2019

At United Nations conferences in 1994 (Cairo) and in 1995 (Beijing), participants considered the status of women, population, and development. They adopted the principles of reproductive justice, i.e., that it is a fundamental right to be able to control the number and timing of childbearing. This requires access to family planning information, contraceptive services, and abortion (Speidel and Sullivan, 2023).

The concept of reproductive justice represents a significant shift from traditional notions of reproductive rights. Reproductive justice calls for the right to have children or not have children, to choose their number and timing, and the right to live in supportive environments that provide reproductive rights, equal opportunities for women, education, fair wages, housing, and healthcare (Speidel and Sullivan, 2023). 

The recent Supreme Court ruling overturning Roe v. Wade has already affected pregnancy-related healthcare for many women. It has also impacted OB/GYN training in the states that have restricted abortion services. This means some hospitals will no longer offer vital training used to manage miscarriages and other pregnancy-related complications.

6.1.2 Health Inequities in Perinatal Care

Recognizing the need to humanize birth, the World Health Organization and leading scholars have incorporated “respectful maternity care” as a central tenet of high-quality care. Person-centered maternity care is “care that is respectful of and responsive to women’s preferences, needs, and values and is a core component of quality maternity care” (Ibrahim et al., 2022).

Inequities in the quality of preconception, prenatal, intrapartum, and postpartum care contribute to racial disparities in maternal health outcomes. Notably, when mode of delivery is disaggregated by race, Black women in the U.S. have the highest rates of cesarean birth, despite similar predisposing factors (Ibrahim et al., 2022).

Black and Indigenous women in the U.S. are significantly more likely to die within a year of giving birth than White women. They also experience disproportionately higher rates of severe maternal morbidity. Nearly half of these maternal events are preventable (Ibrahim et al., 2022).

Improving maternal health and health equity is a key priority. Racism and racial discrimination are linked to poor health, and specifically, negative birth outcomes for women of color and their infants. Mistreatment during pregnancy and childbirth has been associated with both short- and long-term adverse mental health outcomes that include pain and suffering, postpartum depression and post-traumatic stress disorder, fear of birth, negative body image, and feelings of dehumanization (Ibrahim et al., 2022).

6.1.3 Health Equity and Children

[Unless otherwise noted, the following section is from Rattermann et al., 2021].

Health equity is a major concern for pediatric and adolescent children. Despite the great gains made in access to healthcare since the passage of the Affordable Care Act, children from poor communities often lag behind their peers in more affluent communities in access to quality healthcare.

Over one quarter of poor children under 18 years of age in the U.S. have gone more than 6 months without having contact with a doctor or other healthcare professional, with 4.2% of those children having no contact with a doctor or healthcare professional in over five years.

Many schools are addressing the lack of access to healthcare through school nurse programs and school-based health centers. School-based healthcare provides access to primary and preventive healthcare services for students who are at risk for negative medical, social, and academic outcomes. For children of poverty, the school nurse and the school-based health center are often the only medical care that is available to them.

Training future generations of pediatricians to deliver culturally appropriate care and promote health equity has become a priority, especially in the context of COVID-19-related racial and ethnic disparities and the increased recognition of racism as a public health crisis. Recently, funding agencies have focused on defining key terms, introducing a definition of pediatric health equity reflecting a collective goal (Hernandez et al., 2022):

• Ensuring every child has a fair and just opportunity to be as healthy as possible.
• Removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs.
• Providing fair pay, quality education and housing, safe environments, and healthcare.
• Developing curricula that are accountable to community needs and that more comprehensively address health inequities.
• Creating competency among pediatricians that address racism, discrimination, and other contributors to inequities.

6.2 Race and Ethnicity

Implicit racism is a form of power and oppression that has a profound impact on how patients experience healthcare. Research has shown that Black and Indigenous peoples and other minority groups are more likely to experience poorer health outcomes, be given less-effective treatments, and have a lower quality of care than white Americans.

There is a growing desire to acknowledge and abolish racism and disparities in healthcare institutions. Healthcare advocates have sought to rid clinical care of the pervasive legacy of the biologic determinism of race and have encouraged care providers to understand that race is a sociopolitical construct (Essien and Ufomata, 2021).

Strategies that can reduce racism and improve cultural competency in healthcare include (Essien and Ufomata, 2021):

1. Committing to desegregation of the healthcare system.
2. Divesting from racist practice and policy.
3. Diversifying the healthcare workforce.
4. Ensuring antiracist public health training for health professionals.
5. Deepening our investments in the community.

6.3 The Impact of Slavery on Black and Indigenous Peoples

Early travelers to the American West encountered unfree people nearly everywhere they went—on ranches and farmsteads, in mines and private homes, and even on the open market, bartered like any other tradeable good. Unlike on southern plantations, these men, women, and children weren’t primarily African American; most were Native American. Tens of thousands of Indigenous people labored in bondage across the western United States in the mid-19th century.

Kevin Waite
The Atlantic, November 25, 2021

Slavery has cast a long shadow over healthcare for Black and Indigenous Americans. Enslaved people were often denied any form of medical care, while also being subjected to medical experimentation without their consent. Both practices have had long-lasting effects, resulting in ongoing disparities in access to healthcare, and perpetuating the systemic racism that has plagued the healthcare system for centuries.

The American medical establishment has a long history of unethical treatment of Black research subjects. Medical ethicist Harriet A. Washington details some of the most egregious examples in her book “Medical Apartheid.” There’s the now notorious Tuskegee syphilis experiment, in which the government misled Black male patients to believe they were receiving treatment for syphilis when, in fact, they were not. That study went on for a total of 40 years, continuing even after a cure for syphilis was developed in the 1940s (Jones, 2021).

Perhaps less widely known are the unethical and unjustified experiments J. Marion Sims performed on enslaved women in the U.S. in the 1800s that helped earn him the nickname the “father of modern gynecology.” Sims performed experimental vesicovaginal fistula surgery on enslaved women without anesthesia or even the basic standard of care typical for the time (Jones, 2021).

J. Marion Sims experimented on Anarcha, a 17-year-old slave, over 30 times. His decision not to give anesthesia was based on the racist assumption that Black people experience less pain than their white peers—a belief that persists among some medical professionals today (Jones, 2021).

Cases of medical malfeasance and malevolence have persisted, even after the establishment of the Nuremburg code, a set of medical ethical principles developed after World War II and subsequent trials for crimes against humanity (Jones, 2021).

For Indigenous peoples, colonization resulted in the destruction of their existing health practices and the introduction of unfamiliar and inadequate systems, while also resulting in the displacement, exploitation, loss of homelands, and widespread murder of Indigenous peoples. Colonization led to loss of cultural practices, language, traditional medicines, and ways of knowing and being.

When European explorers arrived in the Americas in the late 1400s, they introduced diseases for which the Indigenous peoples had little or no immunity. The impact was rapid and deadly for people living along the coast of New England and in the Great Lakes regions. In the early 1600s, smallpox alone (sometimes intentionally introduced) killed as many as 75% the Huron and Iroquois people.

The exploitation and loss of tribal lands reflects the lasting impact of historical racist policies. Indigenous peoples have been exposed to racist reproductive policies, limited access to reproductive health services, and environmental contamination (Yellow Horse et al., 2020).

Forced onto reservations, Indigenous peoples have been exposed to pollution, pesticides, and lack of clean water. As a group, they are less wealthy, are more often homeless, and experience food insecurity on levels greater than their White counterparts. For example, the Pine Ridge Sioux reservation, home of the Oglala Lakota Nation, has the lowest life expectancy in the U.S, and the second lowest in the entire western hemisphere (Jensen and Lopez-Carmen, 2022).