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Psychiatrists have been interested in the cross-cultural dimensions of psychosis ever since Emil Kraepelin (1856-1926) sailed to Java in 1904 and published his pivotal 

 [Comparative Psychiatry]. Kraepelin provided the first known comparison of psychotic symptoms across populations: “The early stages of a depression were rarely seen, and violent excitement was also uncommon, but at the same time the very severe forms of 

, so common in our own mental hospitals and found among the Europeans in Java as well, seem rarely to develop among the indigenous population.”

Today’s psychiatrists in North America and Europe do not need to go abroad to encounter individuals from different races and ethnicities. Affordable travel and developments in information technology have led to large-scale population migrations such that more physicians and patients identify as Black, Indigenous, or People of Color (BIPOC).

 Recognizing the increased likelihood of cross-cultural patient-clinician interactions, all medical students, psychiatry residents, fellows, faculty at academic medical institutions, and even psychiatrists in independent practice from certain American states must now develop skills in cultural competence

 to avoid perpetuating disparities in health outcomes for BIPOC individuals with serious mental illnesses.

 This raises a fundamental question of how to understand terms like 

. DSM-5-TR defines culture in the following way

“Culture refers to systems of knowledge, concepts, values, norms, and practices that are learned and transmitted across generations. Culture includes language, religion and spirituality, family structures, life-cycle stages, ceremonial rituals, customs, and ways of understanding health and illness, as well as moral, political, economic, and legal systems. Cultures are open, dynamic systems that undergo continuous change over time; in the contemporary world, most individuals and groups are exposed to multiple cultural contexts, which they use to fashion their own identities and make sense of experience.”

The Centers for Medicare and Medicaid Services—the largest funder of mental health services in the United States—defines 

 as “the capacity to identify, respect, and understand differences in cultural beliefs, behaviors, and needs of consumers.”

 Decades before cultural competence became mandatory for clinicians, cultural psychiatrists pointed out that psychiatrists have their own professional cultures with biomedical knowledge, concepts, values, norms, and practices that introduce barriers to care.

 This article synthesizes research on how culture can impact 

 across the mental health services pathway. It offers suggestions for providing culturally competent care and ways to overcome potential challenges.

Cultural Considerations Affect the Entire Pathway of Mental Health Care

The health services pathway can be divided into 4 discrete phases: help-seeking through the first contact with a mental health clinician, receiving the diagnosis of a psychotic disorder, initiating treatment such as 

 or pharmacotherapy, and adhering to treatment.

 Cultural differences among patients and clinicians affect each of these steps.

. Compared with those who are from majority ethno-racial populations in high-income North American and European countries, BIPOC individuals may make sense of their initial psychotic symptoms through shame and stigma,

 and are more likely to distrust psychiatrists based on personal experiences of 

, which delays their initial contact with mental health clinicians.

: “Mrs Williams” is a Black American woman who contacts her son’s pediatrician out of concerns related to behavioral changes. Her son’s teachers report that he stopped participating in his classes. At first, Mrs Williams thought his behaviors were part of normal adolescent development, but when he started to say that the government wants to kill all Black people, she became concerned. Her pediatrician makes a referral to a child and adolescent psychiatrist who asks how long her son had been experiencing paranoid delusions, and she says, “about 9 months.” He asks why she did not seek care sooner, and she informs him that with so many instances in the news of Black males with mental illnesses experiencing violence from law enforcement officials, she did not want him to be labeled. He evaluates her son, counsels her about first-episode psychosis, and gains her trust by guiding her through the special educational services process with the Department of Education for him to receive medical accommodations.

. Psychiatrists are more likely to diagnose BIPOC individuals with a psychotic disorder rather than a 

 based on misinterpretations of symptoms.

 Studies across countries show that individuals from minoritized ethno-racial backgrounds have 1.35 higher odds compared to majority populations of reporting hallucinations or delusions that are clinically subthreshold and do not meet full criteria for a psychotic disorder, perhaps due to greater acculturative stresses.

 Psychiatrists who are unfamiliar with the cultural backgrounds of patients or exhibit biases are more likely to exacerbate misdiagnoses.

: “Mr Delgado” is an agricultural worker in his 40s who comes to the United States on a seasonal H-2 visa every year to harvest oranges. His mother passed away 5 months ago. He presents for an initial evaluation at an outpatient clinic run by residents and fellows. Although he is sad and tearful, he describes himself as interacting more with colleagues at work and better able to focus than right after his mother died. “Dr Xi,” a Chinese-American physician, asks him if he can hear or see things other people cannot. Mr Delgado replies that he sometimes hears his mother’s voice and sees her image in the form of a guardian angel. Because of his interests in cross-cultural care, Dr Xi asks if these experiences are common in Mr Delgado’s community. Mr Delgado says yes. Dr Xi asks if Mr Delgado wants to try a medication to help treat the visions or only to treat his poor mood, anhedonia, and poor motivation. Mr Delgado says he finds the visions comforting. Both agree to initial treatment with an 

. Mr Delgado comes back 3 months later, before he is to return to Mexico, and thanks Dr Xi for acknowledging his treatment preferences. He no longer describes extrasensory hallucinations.

. Psychiatrists are less likely to offer BIPOC individuals with psychosis a second-generation oral antipsychotic and are more likely to offer long-acting injectable agents.

 BIPOC individuals are also less likely to receive clozapine

. Although patients from all ethno-racial groups exhibit negative attitudes toward pharmacotherapy to treat psychotic disorders, BIPOC individuals are more likely to discontinue these medications due to concerns about adverse effects.

 Due to implicit biases, psychiatrists are less likely to monitor metabolic parameters for BIPOC patients with psychotic disorders who take antipsychotics.

Fortunately, clinical research is increasingly showing how psychiatrists can develop cultural competence skills to improve patient care.

The Cultural Formulation Approach May Improve Clinician Cultural Competence

Studies show that the cultural formulation approach can elicit the knowledge, concepts, values, norms, and practices that individuals with psychosis employ to make sense of their experiences. Researchers on McGill University’s Cultural Consultation Service have used an expanded version of the DSM-IV-TR Outline for Cultural Formulation to assess for cultural issues related to diagnosis, treatment planning, and treatment adherence. Clinicians collaborating with cultural and linguistic brokers and presenting cases in a multidisciplinary conference were able to rediagnose 34 out of 70 cases (49%) from a referral diagnosis of a psychotic disorder to a nonpsychotic disorder, and rediagnose 12 out of 253 (5%) cases from a referral diagnosis of a nonpsychotic disorder to a psychotic disorder.

 Although changes in diagnoses occurred across all ethno-racial groups, immigrants and refugees were misdiagnosed more with an initial psychotic disorder, showing that cultural information related to how individuals make sense of their experiences can impact diagnostic assessment and treatment selection.

Many psychiatrists may not have access to a cultural consultation service or find that cultural issues exist even with patients who share their ethnic, racial, and religious backgrounds. DSM-5 and DSM-5-TR include a series of semi-structured interviews known collectively as the Cultural Formulation Interview, which the American Psychiatric Association (APA) has disseminated free of cost. The 16-question version for use with patients can be found 

. A 17-item for use with informants can be found 

Clinical studies show mixed results in individuals with psychosis. The interview can require more reflection on personal identity and treatment planning than can be tolerated in patients with florid hallucinations or paranoid delusions.

 However, stable outpatients with chronic illnesses felt that clinicians using the CFI validated their experiences and presented new avenues for recovery.

 Practicing clinicians may find the CFI helpful upon resolution of acute symptoms. Cultural competence is a lifelong pursuit, and tools like the CFI can help clinicians take that first step.

is an assistant professor of clinical psychiatry at Columbia University, and a research psychiatrist at New York State Psychiatric Institute in New York, New York.

Cultural psychiatry in a creolizing world: questions for a new research agenda.

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https://marketplace.cms.gov/technical-assistance-resources/training-materials/cultural-competence-language-assistance.pdf

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Structural racism and inequities in incidence, course of illness, and treatment of psychotic disorders among Black Americans.

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Ethnic inequalities in the incidence of diagnosis of severe mental illness in England: a systematic review and new meta-analyses for non-affective and affective psychoses.

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Racial differences in antipsychotic use: claims database analysis of Medicaid-insured patients with schizophrenia.

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Systematic review of racial disparities in clozapine prescribing.

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Comparing medication attitudes and reasons for medication nonadherence among three disparate groups of individuals with serious mental illness.

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Racial/ethnic disparities in monitoring metabolic parameters for patients with schizophrenia receiving antipsychotic medications.

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Using the cultural formulation to resolve uncertainty in diagnoses of psychosis among ethnoculturally diverse patients.

Clinician perceptions of implementing the Cultural Formulation Interview on a mixed forensic unit.

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“I got to voice what’s in my heart”: participation in the Cultural Formulation Interview—perspectives of consumers with psychotic disorders.

All mental health clinicians must now develop skills in cultural competence to avoid perpetuating disparities in health outcomes for BIPOC individuals with serious mental illnesses.

Cultural Issues in Diagnosing and Treating Psychotic Disorders

The lifetime prevalence of schizophrenia and related psychotic disorders is approximately 1% of the population.

 These disorders have clear genetic and biological underpinnings

 and generally respond favorably to antipsychotic medication, particularly in reducing the hallmark positive symptoms (eg, delusions, hallucinations).

 However, even with medication, some positive symptoms persist. Furthermore, negative symptoms (eg, asociality, amotivation), which have an even greater detrimental impact on quality of life, are less impacted by medication,

 underscoring a need for additional therapeutic interventions for individuals with 

. Sociocultural factors have been shown to impact both the presentation and course of schizophrenia/psychosis. In this article, we use 3 case vignettes to illustrate how cultural factors can be considered in treatment planning and for a more holistic understanding of how to improve outcomes for individuals with schizophrenia/psychosis (

“Mr Williams” is a 40-year-old single Black man with a history of schizophrenia, although he notes, “I have been told I have everything: schizophrenia, 

, paranoia, you name it.” Mr Williams states he came in at his sister’s request because she noted he was sleeping less and talking to himself more than usual. Mr Williams explains he has been more anxious about the police in his neighborhood. This coincided with a shooting approximately 1 month ago, when a close acquaintance was shot and killed by police about 3 blocks from his home. Mr Williams says he believes the police have bugged his house and he feels energized to solve the issue. “I have been installing a new security system and filling in all the gaps in my house so no radio waves can get through.” He has also been talking more to his grandmother, who died a decade prior. He hears her voice more frequently when he is distressed, and he likes hearing from her.

Mr Williams’ statement about his many diagnoses reflects an unfortunate reality for Black men with experiences of psychosis. It has been shown that Black men tend to to be overdiagnosed with schizophrenia and underdiagnosed with bipolar disorder.

 Notably, schizophrenia tends to be more stigmatized than 

. This discrepancy in diagnosis has contributed to poorer quality of care, because these 2 diagnoses have key differences in first-line treatment.

Although Mr Williams seems to relay his experiences of disparate diagnoses to his provider as humorous, it should act as a clue to the provider that his existing diagnosis may not be accurate and that Mr Williams may not completely trust the insights of his providers. Potential follow-up questions may be: “What do you think about your diagnosis? Is there a label you prefer that reflects your difficulties with mental health?” Direct questioning about symptomology would also be needed to clarify diagnosis, but these initial questions can help create a shared language between provider and client that prioritizes the client’s understanding of the symptoms. Providers may also reflect this experience back to the client: “That might be frustrating—to be told all these different diagnoses over the years.” Acknowledgements like this can help establish a sense of trust, letting your patients know it is appropriate to acknowledge their challenges with the health care system to their providers.

Mr Williams endorses a belief that the police are recording him inside his house and has acted in response to this delusion. Providers are often told not to reinforce delusions or give them too much airtime beyond what it takes for diagnosis and assessment of severity. Unfortunately, this guidance may be overused such that providers avoid better understanding or seeing the greater context of delusions/hallucinatory symptoms. The presentation and expression of symptoms differs across ethnic groups, often due to differential experiences and environments.

In the case of Mr Williams, although the police may not be explicitly recording him in his home (although further questioning is warranted), his delusion seems triggered by real-life experiences. Black Americans are proportionally more impacted by police brutality and 

 and consequently demonstrate greater levels of suspiciousness in general.

 With this cultural consideration in mind, providers need to be especially cautious of rating something as abnormal or delusional when it is a reality for Black individuals (eg, being followed/watched in stores, being targeted for harassment at work, feeling unsafe at home, being wary of police intentions).

In addition, increased experiences of discrimination are linked to increased 

 and psychotic experiences in ethnic minorities.

 For Mr Williams, it would be helpful to acknowledge and reinforce the realities of his experience (“I am so sorry to hear about your friend. I understand why this would make you fearful of the police.”) while guiding him toward relevant solutions (“Have you talked to anyone, like your sister, about what happened? How are the other individuals in your neighborhood coping with this?”). Further conversation may help Mr Williams consider how to get familial/community support and assist him in finding spaces that feel welcoming and safe (eg, support groups, volunteering, reaching out to friends). For some patients in which the delusion is seemingly unconnected to the environment, clinicians may reinforce the patient’s experience (“What I am hearing is that you have been feeling fearful lately.”) and point to emotion-focused coping strategies instead.

In a similar vein, Mr Williams also acknowledged hearing the voice of his late grandmother, but notes that he likes hearing from her. Although hallucinations/voices can be extremely distressing, they are not always so, with some cultures or groups having higher rates of positive or benign experiences.

 In fact, there is a growing movement among those with experiences of hallucinatory voices to integrate them into daily life rather than trying to avoid them completely (ie, Hearing Voices Network), with some evidence of success.

 Providing quality care therefore involves balancing many considerations (eg, existing symptoms, adverse effects, barriers to adherence), and the distress of current symptoms should not be assumed. Follow-up questions should aim to be neutral (“What is it like to hear your grandmother’s voice? How often does this happen? Are you able to shift your focus when other things need to be done?”) to get a better sense of how it impacts Mr Williams.

“Ms Khan” is a 55-year-old divorced Sunni Muslim Pakistani woman on disability, diagnosed with 

. Outside of 3 relapses triggered by big life changes, Ms Khan mostly struggles with negative symptoms (eg, asociality, low motivation). Ms Khan scheduled a mental health appointment because she has been struggling to get out of bed. She explains, “What is keeping me in bed is a jinn holding me down. It stops me from doing my prayers and makes me lazy. I should do my wudhu and pray, but once I get out of practice, I feel guilty and avoid it.”

Ms Khan endorses a belief that the reason she is struggling to leave bed is the influence of a jinn (ie, a supernatural spirit/demon). A provider unfamiliar with Islam may automatically view this as a sign of pathology. To assess this, however, a clinician should attempt to clarify how common this type of belief is to those who are part of the community. Clinicians may do this by asking questions directly (“I am unfamiliar with jinn. Is this a common experience for other individuals you know?”) but may also need to seek consultation from the patient’s community. In this case, research suggests that many Muslims do indeed believe that physical and mental ailments (eg, sleep paralysis, depression, fever) are caused by jinn

 and subsequently endorse religious-based solutions such as wudhu (ie, ablution), prayer, and consulting an imam. However, Muslims and other religious groups tend to endorse multiple models of mental illness, often endorsing biological factors in addition to others (eg, jinn, engaging in sin, God’s will, environmental factors).

In developing suggestions, clinicians may gain more traction by acknowledging the patient’s perspective. Clinicians should still provide recommendations within their purview (eg, medication changes, therapy recommendations), while also supporting cultural practice and assisting in problem- solving (“Are there other Muslims you know to whom you can reach out for support?”).

In addition, Ms Khan would likely benefit from greater religious coping, because she indicates that being less engaged with her religious practice leads to more distress. In fact, in the United States, the majority of the general public and individuals with schizophrenia in particular endorse engaging in religious and spiritual practices and report finding these practices highly important to them.

 Religious practice is also broadly associated with better mental health.

 In the case of Ms Khan, if clinicians consider behavioral activation—for example, an emphasis on increased religious practice (eg, prayer and wudhu) and engagement with religious community (eg, going to mosque, finding Quran study groups)—this may be especially beneficial, because it already aligns with the patient’s belief system and desires.

Clinicians should be wary of 2 potential issues. First, not all religious coping is created equal, with some strategies consistently leading to less distress (eg, prayer, belief that God is supportive) and others leading to more distress (eg, believing one’s difficulties are a punishment from God, using religion to avoid problems).

 Second, emphasis on religion may not be useful if the patient endorses significant religious delusions. In these cases, focusing on other strategies (eg, light exercise, relaxation techniques) and support networks (eg, family, book club) tends to be more beneficial.

“Mr Baker” is a 60-year-old White retired male veteran who received a diagnosis of schizophrenia and lives with his long-term girlfriend. Over the past year, he has struggled to keep up with chores and relies on his girlfriend to make most of his meals. This has led to fights that escalate into his girlfriend threatening to leave him due to his “laziness, lack of caring, and craziness.” Mr Baker feels like a burden on his girlfriend and is also afraid to tell others how much he struggles with his mental health. “I always prided myself, especially with my veterans group, that I was dependable and logical. If I admit to them that I have heard voices and had to go to the hospital, I will have to admit I am a screwed-up person.”

Mr Baker has internalized the idea that mental illness is shameful, which is more common among men.

 Unfortunately, self-stigma is linked to marked increases in distress and to greater risk of suicide.

 His noted feelings of burdensomeness, therefore, could warrant a suicide risk assessment. Although psychoeducation can reduce 

, engaging with individuals openly about their experience with mental illness tends to be most effective.

 Mr Baker would likely benefit from a referral to support groups of other veterans with serious mental illness. Providers may begin suggesting these referrals by highlighting the effectiveness of therapy for others, because focusing directly on Mr Baker’s need for support may lead to defensiveness or denial: “I find a lot of veterans in your situation have really enjoyed this outpatient group we have.” Keeping it low stakes may also prove helpful: “Hey, this is a good way to get out of the house and meet some new individuals.”

There is also a high level of criticism and hostility (ie, expressed emotion) in Mr Baker’s household, which research indicates is related to higher rates of relapse for individuals with serious mental illness.

 Hostility and criticism occur in some ethnic groups at higher rates (eg, White families) than others (eg, Latinos).

 Mr Baker and his girlfriend may benefit from psychoeducation such that they can recognize that many of Mr Baker’s symptoms are related to a mental illness. This could help reduce some of the girlfriend’s frustration by shifting the blame away from her partner. This couple might also benefit from developing strategies to meet their household needs and demands in tandem with each other. Culturally informed therapy for schizophrenia (CIT-S) is a family intervention that emphasizes the family unit’s shared values, engages in psychoeducation with culture in mind, reinforces positive religious coping, and guides the family unit through communication and problem-solving techniques.

 Rather than solely focusing on Mr Baker, it equally acknowledges the needs of his girlfriend and guides both individuals through their shared difficulties.

Practices like CIT-S also highlight an important message across all 3 cases. Clinicians often see the individual (identified patient) arriving at a session as the sole therapy target. However, there is an untapped but extremely important social support network integral to the lives and well-being of individuals with schizophrenia/psychosis. It may be a family member who suggested they visit a doctor (case 1), a larger religious community that provides meaning (case 2), or a partner who provides resources (case 3). In addition to employing the aforementioned strategies and being mindful of cultural distinctions, providers benefit from relying on these social structures (eg, consultation) and encouraging their patients to be more engaged in these social supports, which ultimately could be an invaluable resource in improving the lives of patients with schizophrenia/psychosis.

is a predoctoral psychology trainee at the University of Miami in Florida.

is a professor of psychology at the University of Miami.

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Sociocultural factors have been shown to impact both the presentation and course of schizophrenia/psychosis. Learn more here. 

Cultural Issues in Caring for Patients With Psychosis

As a psychotherapist and mental health practitioner in Washington, DC and Maryland, I have spent the past 2 decades working closely with dozens of high-profile clients, including politicians, foreign diplomats, lobbyists, CEOs, 

, and reality TV stars. Along the way, I have learned that high-profile clients face many of the same challenges that we face in our day-to-day lives—however, because of their power and influence, they often require an extra degree of accommodation that few therapists are prepared for.

To help give therapists a better understanding about what it is like to work with high-profile clients, I put together a list of some of the unique challenges I face and strategies to overcome them.

Before you begin working with a high-profile client, it is important to recognize that you will be working with a unique population of individuals who are often extremely wealthy, hold influential jobs or positions, and are constantly in the public’s eye. As a result, it is important to understand that their lifestyle is very different from your average Joe and will therefore require an extra degree of accommodation to protect their privacy and their busy schedule.

For example, many of the patients I work with do not work regular hours from Monday to Friday and often spend half of the year traveling for business. This can have a major impact on their family life and put pressure on their professional life. Other clients I work with have close 

 with some of Washington’s most powerful political families. This can impact who they invite into their social circle and limit what they can talk about. This can be a very isolating experience for many families, particularly if the family or individual they have a relationship with was only recently elected.

Before you begin working with a high-profile client, make sure you actually know the person you are working with. It is easy to believe you know the issues your client faces by reading about them in the news; however, it is important to remember that most news stories are designed for entertainment purposes only. Knowing how to discern fact from fiction is critical to building trust between you and your client, and it will demonstrate that you care about who they are as a person, rather than who they are reported to be.

As part of your research, you should also have a good understanding of the world they live in. For example, if your client is a politician, it is important to understand their political background and how the electoral process works. If your client is a celebrity, you should know which movies they have appeared in so you understand references they make. It is also important to understand any of the black marks in your client’s life. For example, have they gone through a turbulent media frenzy before? If so, what was the issue and how did it impact them on both a professional and a personal level? Doing your research will help you develop a strong rapport with your client and ensure you understand the unique circumstances of their high-profile life.

Just like with any relationship in life, it is important to set boundaries. With high-profile clients, it is extremely important to have a sufficient nondisclosure agreement in place and have someone look over it because it needs to be ironclad. It is also important to have someone you can consult with outside of your practice. Whether it is another colleague with similar experiences or even an 

, it is important to be able to consult with someone you can trust because working with high-profile clients can be extremely isolating. With that said, it is critical that whoever you consult with is legally obligated to protect your private conversations.

Treat Them as a Human—Not as a Celebrity

In order to establish a strong relationship with a high-profile client, it is important to treat them as an equal rather than someone of stature or influence. The best way to do this is to be honest with them. For example, they may ask you what you think of an article that was recently written about them. In response, you should be honest about how it made you feel, but also reassure them that you know it is not based on fact and it does not change your opinion of them. Being honest with them and sharing your opinion will show that you are being truly genuine with them, which can help establish a strong relationship built on trust.

A lot of amateur therapists working with individuals of celebrity status want to rescue their clients. In many cases, they will rush to try and fix all their client’s problems at once so they themselves can be their client’s hero. Unfortunately, it does not work that way. If anything, by pursuing this course of action, you will actually do a disservice to the therapeutic process because, regardless of your client’s stature or profile, it takes time, commitment, and willingness to do the hard work to help them overcome their challenges.

Be Prepared for a Thorough Screening Process

Before you begin working for a high-profile client, you will likely have to go through a thorough screening process by a representative for your client or their executive assistant. This usually involves a plethora of questions for you to answer before you can talk to the individual. Most clients will not actually have you sign a nondisclosure agreement because the agreement with your medical practice should be sufficient.

As a general rule, any time you are working with a high-profile client, assume the media is following them. With this in mind, one of the best ways to inhibit that potential exposure is to avoid doing your sessions in VIP suites and be careful with going to their home. Instead, try your best to conduct your sessions in your office at secluded times where the individual will feel their privacy is protected. It is also important to schedule a large buffer between patients so they can come and go in privacy.

Despite the added challenges, working with high-profile clients can be extremely rewarding if you are prepared for it. Taking the time to understand your client’s lifestyle and how this impacts them will help you provide them with the best possible care and help you become an even better therapist.

 is a psychotherapist and mental health practitioner in Washington DC and Maryland with almost 20 years of experience in the field of clinical psychology and human behavior. He equips high-powered professionals, prominent couples, and families committed to healthy interpersonal relationships with personalized support, tailored treatment, and necessary steps to regain a balanced self that positively impacts all areas of life.

Individuals empowered by his proprietary approaches to psychotherapy and counseling include NBA stars, foreign diplomats, reality TV stars, managing partners and founders, lobbyists and Capitol Hill political influencers, and CEOs and CFOs from the top Fortune 500 companies. His specialties include schema therapy, psychological assessment, personality and human behavior, and addiction and substance use, all of which are rooted in comprehensive psychotherapy and mental health training from leading institutions nationwide, including McDaniel College, the Chicago School of Professional Psychology, Towson University, Drexel University, the Center for Cognitive & Behavioral Therapy of New Jersey, and the New Jersey Schema Therapy Institute.

A look at the unique challenges of working with powerful and influential clients and strategies for success.

Working With High-Profile Clients

As we entered the final week of Black History Month 2022, Black women received a very public and painful reminder of the ways in which their bodies have been historically both fetishized and dehumanized. Renowned psychiatrist, Jeffrey Lieberman, MD, a former president of the American Psychiatric Association, and a gatekeeping leader of both psychiatric education and publications, referred to a Black model as both “a beautiful sight” and “a freak of nature” in response to a post about her dark skin.

Though it may seem complimentary, or perhaps trivial, racial fetishization perpetuates stereotypes. For Black people, its roots date back to colonial times when Europeans invaded African countries, and both eroticized and hypersexualized Black people’s bodies. For example, in the 1800s, a South African woman, Sara “Saartijie” Baartman, was made into an exhibition and tourist attraction in Europe because of the size of her buttocks. This dehumanization of Black people made it easier to justify the enslavement and abuse to which they were subjected,

 much as it allows for the disrespect, disregard, and maltreatment of Black women today.

The weaponization of European beauty standards against Black females, such as this, does not in the least spare Black female athletes. Studies have shown that 24.2% of NCAA Division I female athletes and 30.7% of Division III female athletes were either very dissatisfied or mostly dissatisfied with their overall appearance

; more than 60% of elite athletes reported pressure from coaches concerning body shape

; and since 2001, female athletes have become increasingly sexually objectified in media.

Sociocultural beauty ideals have shifted to emphasize appearing both athletic and thin.

 One explanation is acculturation in minority groups. Westernization negatively impacts body image, weight perception, and body image dissatisfaction, all of which are risk factors for eating disorders.

, Oracene Price, mother of the tennis superstars, recalls being deliberate in her daughters wearing braids with beads: “I wanted them to be women of color and be proud of who they are, and not let anyone make them ashamed of it; and that was the main purpose of the beads, ‘cause it shows their heritage and where they come from.”

In 2018, a cartoonist tweeted his racist caricature of Serena Williams and Naomi Osaka at the US Open.

 Williams was drawn with exaggerated masculinized features, much larger in scale, stomping on a racket in an apparent tantrum with a baby’s pacifier at her feet. Osaka was drawn as delicate, her skin tone faded beyond recognition, with straight blonde hair, erasing all signs of her actual features, not to mention Hattian and Japanese heritage… as if to make her appear a more “sympathetic victim” in this dramatization of events.

In “The Policing and Punishment of Black Girl Magic In Sports,” Latisha Engracia Cardoso Brown, PhD, states, “We live in a world that asks Black femmes, girls, and women to shrink, alter, and bend themselves in order to be given a modicum of support. Athletes such as Michael Phelps are lauded for a body that has been said to give him a ‘competitive edge.’ But Serena’s muscular physique remains an issue in the media’s lens.”

Sumiko Wilson interviewed Black female athletes about how sports weaponized racist beauty standards against them. Tennis player Sasha Exeter recalled, “I was told I looked manly or overdeveloped and over-muscular, and didn’t feel feminine.” Coaches asked her, “Can you do something with your hair post-match before interview? Because it looks kind of crazy right now.” Exeter admitted that these interactions affected her self-confidence. You cannot out-perform your own self-image, so how much more confident and successful could she have been, were it not for these aggressions?

Such experiences also impact opportunities to build wealth through endorsements and sponsorship. Another of Wilson’s interviewees, 2-time Olympian Crystal Emmanuel, found that she was not getting the attention of sponsors. Her coach’s answer: her hair. In Emmanuel’s experience, “It’s like, if you’re not wearing weave or if your hair is not straight, then there’s something wrong. But that shouldn’t be something I need to change in myself in order for someone to look at me or think I’m worthy of wearing their brand.”

With the CROWN (“Creating a Respectful and Open World for Natural Hair”) Act,

How the fetishization of Black bodies and the weaponization of European beauty standards are used against Black women in sport.

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