Who cares for Black women in health and health care: Reimagining the strong Black woman trope to advance Black women’s health equity

Abstract

This editorial serves as an interpretive synthesis of the special collection, Who Cares for Black Women in Health and Health Care, featured in Women’s Health. The key objectives of the collection were to (1) explore the experiences of Black women healthcare educators and providers to promote well-being and retention among this group of key stakeholders in population health and to (2) uncover barriers to care that perpetuate health disparities among Black women at large. Upon reviewing and synthesizing the articles included in the collection, the Strong Black Woman trope emerged as a key barrier to health and health care. The essentialist approach to Black women’s strength leaves them prioritizing care for others over care for self, subject to perceptions of them as intimidating and able to take on exorbitant workloads, and boxed in emotionally which manifests stress, anxiety, and other chronic illnesses. The way forward for Black women comes with reimaging strength. Specifically, it should include health-related autonomy, collective accountability, and the creation of inclusive spaces.

Introduction

A widely suggested solution to improving health outcomes for Black women is increasing the number of Black women in health and health care.^1,2 Black women healthcare workers provide a level of care that makes Black female patients feel seen and heard, thus improving adherence to care and retention in medical settings.^3–5 While Black women are the heart of entry-level health careers, dominating as aids and technicians, they remain scarce in positions of power such as physicians, surgeons, and tenured professors.^6–8 This means it is important to understand the experiences of Black women in health and health care to promote greater inclusion and retention at all levels. Understanding Black women’s experiences starts with the question, who cares for Black women in health and health care? Here, contributors across disciplines explored this question from various lenses. A review of all the studies included in the collection led to a consistent conclusion, which is that the Strong Black Woman (SBW) trope has devastating consequences for Black women as both laborers in health and health care, and as recipients of care. The intended takeaway from this work is a call to action for Black women and other stakeholders in their care.

Strong Black woman

The SBW trope emerged in Black feminist literature as the social construction of Black womanhood. The SBW trope carries the connotation that Black women are uncommonly, and naturally strong. They are strong enough to endure physical pain, strong enough to work without ceasing, strong enough to prioritize care for others over care for self, and strong enough to endure turmoil without emotional strain. ⁹ The trope is both forcefully bestowed upon Black women by those who marginalize them ¹⁰ and reclaimed by Black women themselves as a badge of honor. ¹¹ In fact, Hill ¹² (p. 6) highlighted how Black families prepare their daughters for this role by raising them to be both a “lady” and a “warrior” by “fighting everyday of her life for the respect of Black people.” Below, I highlight the ways in which this trope impacts Black women’s health and experiences with the system of health care.

Predictors and consequences of strength

Black women come to adopt the SBW trope via role modeling and parental socialization, ¹² as well as experiences with trauma and microaggressions which take place in diverse settings, including within their own families. ¹¹ Findings from Moolla et al. ¹³ and Modeste-James et al. ¹⁴ added to existing literature on that framing, showing that, in many cases, Black women would rather live with untreated HIV or mental illness, than seek health-related services and face their families’ opinions and ridicule.

The SBW trope also works as a self-fulfilling prophecy and socially constructed phenomena. Johnson et al. ¹⁵ found that the trope limits Black women’s willingness to ask for help as well as medical providers’ perception that they may need it. This sentiment was further supported in Kasal and colleagues’ study where a white provider claimed it is “challenging for me . . .approaching Black cisgender women is just like, how to approach the topic, like how to bring it up. . . as a white provider it can be intimidating to have these conversations.” ¹⁶ (p. 5). Here we see how strong sometimes leads to self-inflicted barriers to care and other times leads to the limited care via mechanisms that are beyond their control.

Black women are also subject to stereotypical treatment linked to other aspects of their identities. This aligns with Black feminist perspectives on intersectionality. ¹⁷ Intersectional research is that which “references the critical insight that race, class, gender, sexuality, ethnicity, nation, ability and age, operate not as unitary, mutually exclusive entities, but as reciprocally constructing phenomena that in turn shape complex social inequalities.” ¹⁷ (p2). For one, Pratt et al. ¹⁸ reported that clinicians struggled with offering Black women sexual health care due to them living in the south and being Baptist, thus making them *presumably* conservative and uncomfortable with the topic. For two, Omowale et al. ¹⁹ found evidence of age exacerbating Black women’s reports of stress and workplace experiences during the perinatal period.

Finally for three, the studies outlined below found that whether in academia, healthcare, or community work, Black women’s labor is often treated like an infinite resource rather than a human contribution with limits. This means being employed is another aspect of their identity that impacts Black women’s health. Omowale et al. ¹⁹ showed that Black women labor (carry babies) and labor (join the workforce) and that both are laborious (due to gendered racism). Thorpe et al. ²⁰ explored burnout among pelvic floor therapists. Their findings showed that work is detrimental to Black women’s health via (1) unsupportive environments that do not allow for work/life balance, (2) experiences of microaggressions from colleagues, (3) race and gender pay gaps, and (4) other universal sources of burnout being compounded with misogynoir, or a disdain for Black women. Across studies, these findings underscore the impact of intersecting factors that perpetually impact Black women’s health.

Another theme that emerged was the fact that Black women academics are a unique laboring class with specific needs.^21–23 Campbell and Stockman ²² detailed concerns facing Black women HIV scholars, which included hostile work environments, experiences of tokensim and self-preservation, challenges hiring experts with lived experiences, and barriers around recruiting and retaining research participants. Malone and colleagues’ ²³ work on Black women scholars of substance abuse echoed many of these barriers by adding an additional challenge around vicarious or secondhand burnout, whereby Black women scholars experience stress over other, overworked Black women scholars.

Caring role

A specific tenet of the SBW trope that jeopardizes Black women’s health is the expectation that they prioritize care for others over care for self. ⁹ Here we see Modeste-James et al. ¹⁴ and Johnson et al. ¹⁵ report that the Black women missed sexual and mental health care due to conflicting obligations to others. Additionally, Omowale et al. ¹⁹ reported that perinatal Black women faced role strain due to demands at work coupled with mothering, community obligations, and a necessity to provide for their families. Lastly, Erving et al. ²⁴ found that this obligation extends to older adulthood as the aging Black women in their sample, who reported greater family demands, also reported higher depression scores.

Collins ¹¹ argued that the caring role for Black women extends beyond the family into the workplace as well. This too is supported in work featured in this special collection. Specifically, the pelvic floor therapists in Thorpe and colleagues’ study felt the burden of patient-provider concordance on Black women healthcare workers. One respondent asserted, “we have to function as the patient’s physical therapist, counselor, even primary care providers as the patients. . .often tell us stuff they don’t even tell their MDs.” ²⁰ (p. 6). A similar sentiment arose in Malone and colleagues’ work on substance abuse scholars; a Black woman on her research team reported, “helping people who look like you can be rewarding and challenging. . .Black women’s painful experiences frequently resembled mine.” ²³ (p. 7). These studies show that, while beneficial to the Black women being served, concordance can put Black women workers into a space of caring for others to the detriment of their own health.

Emotion control

Another tenet of the SBW trope that emerged across the studies as a concern was the idea of emotion control and an obligation to mask feelings of distress. ⁹ Hall et al. ²⁵ found that Black women who identified with the SBW trope, were most likely to engage in identity shifting at work: A practice that requires them to understate their feelings to avoid supporting stereotypes around strength and anger. Additionally, Johnson et al. ¹⁵ found that stereotypical depictions of Black women as “too masculine” or overly aggressive are often on Black women’s minds during health-related decision-making. This thought process was described by a respondent in the work by Modeste-James et al. on mental health care seeking who claimed, “before I say it (a sentiment of disappointment) aloud, I have to make sure it sounds as non-threatening as possible. That’s why it sounds so well-spoken, as they like to say.” ¹⁴ (p. 6).

Omowale et al. ¹⁹ touched on pressures to mask emotions as well, highlighting how perinatal Black women in their study felt obligated to appear emotionally tough in the workplace, against all odds. This process of emotion masking presents a unique health risk among SBW. Malone et al. ²³ and Erving et al. ²⁴ provided perspectives on the cost of emotion control in their work on burnout in academia and mental health in aging populations. The former found that Black women academics who experienced burnout often engaged in emotion control while interviewing marginalized populations, and the later found that older Black women who reported anger suppression also had greater depression scores. Although the findings appear grim for SBW, there are also suggestions incorporated throughout the studies featured in this collection on ways to promote Black women’s well-being.

Reimagining the SBW

Perhaps the most powerful contribution of this compilation of work on Black women’s health is its guidance on reimaging the toxic nature of the SBW trope. Articles included provided recommendations for healthy futures for Black women via several approaches to health and well-being. Below are several key shifts in the SBW trope that may work to promote health equity among Black women.

Health-related autonomy and concordant care

The first key to improving health for SBW is by increasing health-related autonomy and making concordant care widely available. Moolla et al. ¹³ highlighted the cost of poor patient-provider interactions for Black women in South Africa living with HIV, specifically, “people who are sick. . .prefer to die with their sickness just because the nurses don’t treat us well.” ¹³ (p. 6). This sentiment is echoed in US samples as well. In fact, Modeste-James et al. ¹⁴ found that 13/15 of the women they interviewed wanted care from a BW therapist to avoid misunderstandings from therapists with discordant demographics, and women interviewed by Johnson et al. ¹⁵ added that fear of poor experiences with discordant providers leaves them with no choice but to avoid needed vaccinations.

Having more providers who understand the lived experiences of Black women is an essential step toward health equity. Not only do Black women need to see other Black women, but they also need to see Black women who are familiar with stigma, poverty, ageism, and the daunting nature of Black women’s labor. Additionally, given the testimonies of white providers in the work by Kasal et al., ¹⁶ training is needed around culturally relevant care. As vital as concordant care is, it is not always possible to attain in a diverse society. That means policy shifts and curriculum changes are needed to ensure all healthcare workers are educated in ways to communicate across race, class, gender, and other intersectional identities.

Collective accountability and sisterhood

The second key to improving health for SBW is through collective accountability and sisterhood. This differs from care for others over care for self, because it involves Black women using their sociocultural drive to connect and care, but while caring for their sister, their sister also cares for them. Wade’s ²¹ conceptual framework on recruiting and retaining Black women health professors called for cluster hiring to promote the creation of sister circles and onsite affinity groups in academia. These groups allow Black women to connect, vent, and engage in collective accountability. Similarly, in their work on Black women academics, Malone et al. ²³ call for a form of collective accountability and self-care whereby Black women researchers work as teammates to ensure each person is taking needed breaks, engaging in self-care, and emoting as needed. Finally, Campbell and Stockman ²² called for more cohesion among Black women HIV scholars to share resources, build research infrastructure, and support each other as they navigate misogynoir in academia.

Creating inclusive spaces for Black Women

The third key to improving health for SBW is through transforming spaces to make them more inclusive. Diverse spaces emerged in the articles featured here, the first being digital spaces. Johnson et al. ¹⁵ argued that digital spaces should include tailored, non-stereotypical health information, to better engage Black women. Second space that emerged was healthcare spaces, where Kasal et al. ¹⁶ reported that providers requested scripts to use in appointments with Black women, and incentive pay to entice them to undergo further training. This creates an opportunity for the pharmacy industry, who could and should provide cultural competence training to ensure their products are being disseminated with both quantity and quality at the forefront. This also speaks to a third space that needs to be transformed, which is academic spaces. If medical and health students received education in the areas of sociology, psychology, and communication during their training, they would graduate as competent providers who would be less likely to feel intimidated or challenged when attempting to connect with Black women.

Academic spaces also need reimagining to promote the recruitment and retention of Black women scholars. For instance, Wade ²¹ argued for intersectional pipeline programs, financial incentives to pursue various areas of medicine, tailored support in graduate and professional programs, bias, and bystander training. Additionally, Malone et al. ²³ and Campbell and Stockman ²² called for more flexibility in hiring so individuals with lived experiences could join research teams to aid in culturally tailored and community-based approaches to research. The final space that emerged was the workspace. Several articles highlighted the ways in which workspaces exacerbate Black women’s stress and anxiety via experiences with microaggressions. Future research is needed to uncover ways to navigate workspaces and how to reimagine the SBW trope at work.

Self-expression and vulnerability

The fourth and final key to improving health for SBW is the promotion of self-expression and vulnerability. This special collection documented the crippling nature of shifting and managing anger among Black women. Promoting vulnerability in the workplace comes with promoting spaces for Black women to express themselves via organically formed sister circles^21,23 and with the promotion of self-care. Black women need to be educated on the benefits of work life balance, ²⁰ time in nature and prioritizing nutrition, ²³ setting boundaries ²⁵ as well as “coping breaks” where they step away, not to smoke as many workers do, but to get fresh air and regroup Campbell and Stockman. ²² Finally, Black women do not have to completely dismantle the SBW trope; they just need to take on the prosocial qualities and let go of the anti-social ones. One aspect of the SBW trope, personal control, and independence, measured as mastery in the work by Erving et al., ²⁴ had a positive relationship with mental health, leading to lower risk of experiencing depression among Black women. Black women need to own their own emotional well-being the way they own other aspects of their lives.

Conclusions

In closing, this analysis has shown the ways the SBW trope is an outcome of socialization into Black womanhood, an influence on care-seeking behavior, a frame used by providers interacting with Black women, and a persistent source of burnout among professionals. As such we—scholars, practitioners, and Black women as a whole—must work to reimagine it to promote better health and well-being. Malone et al. ²³ spoke to the compassion fatigue experienced by scholars of Black women’s health, which made me tap into my own compassion fatigue as guest editor of this collection on Black women’s health and place in health care. Analyzing story after story revealed the same painful truth: healthcare systems and workplaces routinely fail Black women. The SBW trope, while born from survival, is now weaponized against us, demanding our labor and silence while neglecting our humanity. Caring for Black women means dismantling the systems and stereotypes that keep us overextended and undervalued. It means reimagining the myth of the SBW with a reality where Black women are free to be healthy, vulnerable, and whole. To end on a hopeful note, I draw from the work of Campbell and Stockman, “Black women, as you wade through daily oppressions at the intersection of your sex and gender and racial and ethnic identity, remember your why. Self-reflection is key! Ask yourself, why do you do this work. . .Above all, remember to take care of yourselves and one another.” ²² (p. 6).