Impact of colorism on communities of color

There is a colorism problem in dermatology.[1] Colorism is defined as differential or discriminatory treatment of an individual based only on skin shade.[1] Among racialized communities, colorism is far too often the skeleton in the closet, or, perhaps more explicitly, the skeleton at family gatherings, in children’s classrooms, at places of employment, in health care settings, and in criminal justice institutions.[2] While it can be associated with racism, it is not necessarily the same.[3] For example, Black individuals may experience discrimination due to their race (racism), but the extent of discrimination may vary based on skin shade, with those of darker shades often experiencing more discriminatory treatment (colorism).[4] Additionally, due to the degree to which colorism is entrenched in the histories of many racialized communities, discrimination based on skin shade often propagates intraracial disparities in addition to interracial disparities.[4] Dermatology has recently started to acknowledge the harmful impacts of racism and racial disparities on health care outcomes and experiences.[5,6] However, we have largely neglected to identify examples of colorism within dermatology.[7-9]

Physical health impact of colorism

Perhaps the most direct example of colorism that impacts patients’ physical health is skin lightening—the purposeful lightening of an individual’s skin tone without medical supervision.[10] It is done using agents that block the production of melanin and that often contain drugs such as hydroquinone, potent topical steroids, or mercury, which can cause serious health complications.[10] While such compounds are illegal in most countries, as of 2020, communities of color around the globe spent more than US$8 billion on skin-lightening creams every year, with demand for such products projected to grow to US$12.3 billion by 2027.[11] Although Health Canada is alerting consumers that over-the-counter skin-lightening products are unauthorized, these toxic products are still widely available on e-commerce platforms such as eBay, Amazon, and Alibaba, rendering them highly accessible.[12,13] In addition, natural skin-lightening compounds, such as lemon extract, are regularly supplemented into skin care products and often used for skin-lightening purposes; however, they can cause skin irritation.[14]

Mental health impact of colorism

Studies have consistently highlighted that colorism is also harmful to the mental health of people of color.[15] A UK study showed that perceived colorism was associated with worse body image and psychological distress for Black, Asian, and other racialized or ethnic minority people, while a Canadian study showed that Black adolescents with darker skin tones had higher levels of depressive symptoms than their peers with lighter skin tones.[16,17] The significant influence of intraracial rather than interracial inequities in mental health outcomes due to colorism was highlighted by a study that found that darker-skinned Black respondents were at a significantly higher risk of poorer self-rated overall mental health outcomes than lighter-skinned Black respondents.[17]

Social impact of colorism

Academics and historians have emphasized the negative consequences of colorism on people’s relationships and life opportunities starting from an early stage of life.[2] According to a 2005 survey, White Americans between 25 and 44 years of age have an average of 10.2 more months of education than Black Americans.[18] In comparison, the gap in educational attainment between the lightest- and darkest-skinned Black Americans aged 25 to 44 was 15.4 months between 2001 and 2003, highlighting that the educational gap appears to be larger among Black Americans of varying skin shades than between White and Black Americans.[18,19] Furthermore, one study among British Asian and African Caribbean young adults found that they generally experienced skin tone dissatisfaction and desired lighter skin tones than they currently had.[20]

Taken together, discussions of colorism remind us that racialized communities are made up not of monolithic racial or ethnic identities, but rather of unique subjectivities colored by varied shades and hues.

Role of dermatologists in combating colorism

Dermatologists can intervene at the clinical and systems levels to combat colorism through their practices and collaboration with interested parties.

Clinical interventions

Historically, there has been a lack of focus on providing culturally safe care for racialized communities in dermatological settings in both Canada and the US.[5,21] The reasons for this gap in care may be related to a lack of representation. Black and Hispanic dermatologists make up only 3% and 4.2% of dermatologists in the US, respectively, which contributes to a lack of awareness and investment in skin concerns that disproportionately impact racialized communities.[22]

Accordingly, culturally safe preventive and clinical care for racialized patients who may have experienced colorism has not been widely implemented. For example, screening patients for skin-lightening product use is not routinely integrated into many dermatologists’ workflows, despite a high prevalence of harmful skin-lightening product use in racialized communities both in Canada and globally.[23-25] Dermatologists might consider implementing additional screening questions when gathering patient histories to assess for the use of skin-lightening products, especially for racialized patients who are at increased risk. Nonjudgmental questions to incorporate into a history-gathering session might include: Do you put anything on your skin to help even out, brighten, or lighten your skin? Are any of those products prescribed or recommended to you by a dermatologist? While the average skin exam lasts approximately 6 minutes, integrating these questions into related conversations about sun safety or general skin product use would preserve efficiency without compromising comprehensiveness.[26]

To illustrate, discussing safe-sun practices is an important and frequent part of a dermatologist’s work and an opportunity to correct colorist beliefs, attitudes, and behaviors. For example, in Asia, sun umbrellas, full-face visors, arm warmers, and long sleeves and pants are often used to shield skin from sun exposure.[27,28] However, the practices are often rooted in concerns for skin darkening, not skin cancer.[29,30] By explaining the link between sun exposure and risk of skin cancer, dermatologists can separate these practices from their colorist origins while still promoting sun safety. Likewise, while encouraging the daily use of sunscreen, dermatologists should take care to recommend inclusive formulas that complement skin color and do not leave unsightly white casts or masks.[31] Beyond decreasing adherence to use, these inappropriate sunscreens can further promote colorism by marginalizing patients and causing them to internalize feelings of otherness.

If a patient uses skin-lightening agents, dermatologists should approach the situation with cultural humility. They should acknowledge the societal pressure of colorism and understand the patient’s motivations to use such products. They should also encourage cessation of use and counsel patients on the adverse consequences of unsupervised skin lightening.[1] In light of the association of skin lightening with poorer mental health outcomes and body image concerns, psychosocial screening with patients using skin-lightening agents may be important.[32]

Systems-level interventions

At the systems level, it is important to develop and implement clinical referral pathways and standard interprofessional collaboration practices to provide patients who use skin-lightening products with the psychosocial supports they need. For example, given that colorism can manifest as bullying from peers or abuse or neglect from parents, pediatric dermatologists can play an important role in identifying such cases and collaborating with the patient’s primary care team to advocate for safer school and home environments.[2,3,33]

Skin-lightening products are disproportionately marketed and sold to Asian, African, and Middle Eastern populations using colorist language such as “white,” “fair,” and “light.” For example, Unilever sold its skin-lightening product line under the name Fair & Lovely—equating fair skin with beauty—until mounting criticism forced the company to rename the product in 2020.[34] Dermatologists, as the experts on skin health, are uniquely positioned to advocate for these companies to eliminate colorism from their marketing and advertising. To assist in preventing the illegal sale of unauthorized and prescription-only skin-lightening agents, dermatologists can also report their concerns to Health Canada [9]. Furthermore, since a visit to the dermatologist often exposes patients to advertisements for dermatologic products in waiting rooms and exam rooms, it is also important that the advertisements show people with darker skin shades and products that can be used by people with darker skin shades (e.g., tinted sunscreens).

To build consensus and create formal national guidelines regarding screening for skin lightening, dermatologists can work within societies such as the Canadian Dermatology Association,[35] Skin of Color Society,[36] and Women’s Dermatological Society.[37] Finally, given dermatology’s presence on social media and in pop culture—a presence unique among medical specialties—dermatologists can consider using their platform to partner with influencers and celebrities to disseminate the harms of skin lightening and colorism.[38]

Competing interests

None declared.

This article has been peer reviewed.

[10]

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License [10].

Ms Gao is an MD/PhD student in the Department of Medicine at the University of British Columbia.

Corresponding author: Ms Chloe Gao, gaoc1234@student.ubc.ca [18].