Dark Skin Tones May Be Underrepresented in Medical Textbooks

MedicalResearch.com Interview with:

Patricia Louie, MA PhD Student, Department of Sociology University of Toronto Toronto, ON, Canada

Patricia Louie

Patricia Louie, MA
PhD Student, Department of Sociology
University of Toronto
Toronto, ON, Canada 

MedicalResearch.com: What is the background for this study?


Response: While most physicians believe that they treat patients equally, research shows that racial inequality pervades the U.S. health care system (Feagin and Bennefield 2014; Williams 2012). Because these inequities persist even after demographic and other socio-economic differences are taken into consideration scholars have started to look at the representation of race in the medical curriculum. The idea is that medical curriculum creates both implicit and explicit connections between race and disease. We build on this body of work by investigating the representation of race (White, Black and Person of Color) and skin tone (light, medium and dark) in the images of four preclinical anatomy textbooks – Atlas of Human AnatomyBates’ Guide to Physical Examination & History Taking, Clinically Oriented Anatomy, and Gray’s Anatomy for Students.  Skin tone is important.

The majority of medical imagery consists of decontextualized images of body parts where skin tone, which may be related to disease presentation, is the only phenotypical marker. If doctors associate light skin tones with White patients, this may also influence how doctors think about who is a “typical” patient, particularly for the type of disease that is shown in that image.

MedicalResearch.com: What are the main findings? 

The main findings are that:

1)    Textbooks do approximate the racial distribution of the U.S. population – 62.5% White, 20.4% Black, and 17.0% People of Color.

2)    The skin tones represented overrepresent light skin tone and underrepresent dark skin tone – 74.5% light, 21% medium, and 4.5% dark.

3)    There is underrepresentation of race and skin tone for some topics. For example, over three quarters of the images related to six cancers depict White patients (77.7%) and 93.3% of images depict light skin tone. 

MedicalResearch.com: What should readers take away from your report? 

Response: We want our report to open up a conversation about how visibility in medical materials might matter. In a context where White is the most represented and de facto “typical” racial group, it seems likely that images of light and even medium skin tone are more likely to also be read as White. There are numerous chapters where Black people, People of Color and images of dark skin tones are completely absent.

The absence of dark skin tones is particularly important in instances such as skin cancer and other diseases where physicians are required to “recognize varied presentations of diseases in patients with different skin tones” (Xakellis et al. 2004:140). But it might also matter in other cases. If doctors associate particular groups with particular diseases (even if subconsciously) then patients who present with the same symptoms might be given different treatments (Roberts 2011). 

MedicalResearch.com: What recommendations do you have for future research as a result of this work?

Response: Future research should investigate race and skin tone in other kinds of medical materials such as the posters and informational pamphlets found in doctors’ offices and health care centers. These materials send messages to the general public about who is at “risk” for disease. In the case of the general public if, for example, informational pamphlets present skin cancer as a “light-skinned”, “White”, or “European” disease, then dark-skinned and/or racial minorities may underestimate their own risk and this may be a reason for late-stage diagnosis.  Therefore, research is needed on the wider body of medical materials available not just to health care providers but also to the general public.

MedicalResearch.com: Is there anything else you would like to add?

Response: Diversity and equity in the representation of different groups in the health care curriculum is one piece rather than a panacea for racial inequities in health care delivery. Messaging about race is endemic to U.S. society so our work should be read as part of a larger conversation on race, racism, and colorism.


Feagin, Joe and Zinobia Bennefield. 2014. “Systemic Racism and U.S. Health Care.” Social Science & Medicine 103:7–14.

Roberts, Dorothy, 2011. Fatal invention: How Science, Politics and Big Business Re-Create Race in the Twenty-first Century. The New Press.

Williams, David R. 2012. “Miles to Go before We Sleep.” Journal of Health and Social Behavior 53(3):279–95.

Xakellis, George et al. 2004. “Curricular Framework: Core Competencies in Multicultural Geriatric Care.” Journal of the American Geriatrics Society 52(1):137–42.


Representations of race and skin tone in medical textbook imagery
Social Science & Medicine
Volume 202, April 2018, Pages 38-42


[wysija_form id=”3″] 

The information on MedicalResearch.com is provided for educational purposes only, and is in no way intended to diagnose, cure, or treat any medical or other condition. Always seek the advice of your physician or other qualified health and ask your doctor any questions you may have regarding a medical condition. In addition to all other limitations and disclaimers in this agreement, service provider and its third party providers disclaim any liability or loss in connection with the content provided on this website.


Last Updated on March 7, 2018 by Marie Benz MD FAAD