Hello. And welcome to this author interview from the JAMA Network. This is Dr. Ade Adamson, the web editor for JAMA Dermatology. Hair has played a longstanding role in race relations in the United States and is particularly relevant as current US legislation addresses discrimination on the basis of hair. In a viewpoint in JAMA Dermatology, authors provide a review of hair in US White-Black race relations, informed by historical, texts and offers suggestions to improve delivery of culturally sensitive care.
Dr. Loren Krueger is an assistant professor in the Department of Dermatology at Emory University School of Medicine. She is accompanied by Mr. Tosen Nwadei a PhD candidate at Goizueta Business School at Emory University. They are both here to discuss their article entitled Getting to the Root, A Historical Review of Hair in US White-Black Race Relations and the Importance for Dermatologists. Welcome to the podcast, Mr. Nwadei and Dr. Krueger.
Mr. Tosen Nwadei (01:13):
Dr. Loren Krueger (01:15):
Yes, thank you so much for having us. It's really my pleasure.
I'm excited that both of you decided to come on this podcast to talk about this really important paper that discusses not only history, but currently what dermatologists should know about hair and specifically hair and people that identify as Black. Before we jump into the discussion, I want to first ask Dr. Krueger, what is your role at Emory?
Yes. So I'm based out of Emory University in Atlanta, Georgia. I really enjoy the patient population there. I see a lot of general dermatology, but my primary focus is skin of color, so pigmentary disorders as well as hair and scalp disorders. I also work with the residency program as the associate program director for the residency. And I serve as the departmental diversity, equity, and inclusion lead
And Tosen, what about you? You're not a dermatologist.
What is your PhD that you're working towards? What are you studying?
I'm a behavioral scientist. And I've spent the last couple of years focused on what I've been calling and describing as cultural self-expression. So these are small and large things that we do every day that might signal or suggest on some level our membership in some minority group. Through that, I've taken interest in number of things, including, but not limited to hair texture and hair styling. I've also taken some level of interest in creative self-expression. I've also taken some interest in political self-consciousness. But I'm really interested in how people express themselves in various settings, schools, workplaces, etc.
How did you two meet, besides being at the same university?
I come from a family of physicians. I'm kind of the outlier in that I am not in medicine. My older sister actually is a dermatopathologist. I didn't realize this, but we actually were both very much interested in hair. I more so from the social science perspective, and she was obviously studying it from more of like a derm-path perspective, because that's her specialty. And my interest in hair was twofold. It's kind of a racialized aspect of physical appearance. Race is a social construct that influences physical appearance or manifests in the form of physical appearance. And chiefly, when people think about race, they almost universally focus on the color of people's skin, their skin tone or their skin complexion. When in actuality, there are many different facets that influence how we racially categorize or racially perceive different individuals, including but not limited to hair texture. And in fact, the existing work that we have in the field says that hair is second only to skin tone in signaling or communicating or being leveraged by perceivers in terms of how we ascertain or make judgements to the racial group that someone belongs to.
TN (03:48):
And so I was thinking about what that means in the context of race relations, thinking about what that means in the context of schools and workplaces that obviously have really strong norms pertaining to what people were supposed to do regarding to their appearance, concerning their dress, whether it be in the case of looking professional or looking presentable or not being distracting. And all the while thinking about this, I was also kind of talking with my sister about some of the downstream health consequences pertaining to decisions that we made concerning hair styling, whether that be ponytails that we use or whether it means we're using locks or natural hairstyles. All these things can have the implications of influencing various downstream health outcomes.
TN (04:30):
And so we started talking about this, and we kind of put together this team of people that would be able to try and tackle this in the form of a paper. We were working on this in the midst of COVID. And so there were all kinds of things transpiring and unfolding in the world. People were getting sick. Some people were grieving loved ones. And it was actually fairly difficult for our authorship team. Even after I submitted the initial paper that I was working on with my sister, my sister also kind of had some emergencies come up and she wasn't able to proceed on the paper. So now I was kind of in this situation in which I was invited to potentially resubmit the paper to JAMA Dermatology, but I didn't necessarily have the dermatological expertise to craft and design a compelling manuscript for the journal.
TN (05:12):
One name that came up was Dr. Loren Krueger, who was actually at my institution. And so we reached out and we connected via email, and over a couple of months, we were able to write a paper that I think we both feel really, really excited about.
And so Loren, what is your interest in hair? Does it come from somewhere, patients, yourself?
That's a great question. Just to reiterate what Tosen mentioned, so I feel very lucky to be a part of this. I think it's definitely something that's needed in our literature, as well as provides such an important context when we're making these decisions on hair and scalp disorders and counseling our patients. I think hair is such an incredibly personal thing. I've enjoyed taking care of hair patients who are struggling. I think it can be quite challenging, but also quite rewarding. Caring for this population, especially skin of color patients with hair loss, really requires a high degree of cultural sensitivity and humility. And I find that intriguing and I really enjoy it.
So both of you two got together and you had a mutual interest and you decided to write this viewpoint through the prism of history. So Tosen, would you mind giving us some highlights related to hair within the context of Black-White relations in the United States context?
America isn't a particularly old nation compared to other nations in the world, but throughout our very short history and Black people's history in this country, hair has served as a recurring theme in White-Black race relations. Even during the era of American slavery, this was kind of used to ridicule and mock and derive slaves, even to the extent of dehumanization. That's something that's consistently presented in text by historians. Enslaved persons were ridiculed by people who own slaves because of their hair texture, and their hair was likened to that of livestock. And that was during the 1700s and during the 1800s, even after American slavery was abolished. Obviously there's racial progress that's being made. But now there's this expectation where in order for Black and White Americans to coexist peacefully in this period of the 1800s, Black Americans now need to assimilate to a more American way of life, to more of a modern way of life.
And that's where you have expectations pertaining to straightening hair. And obviously throughout history, that's taken many different forms. But that widespread practice within the context of racial and ethnic relations really started in the US in the 1800s. During the early 1900s, this practice became so widespread that now we see this pattern wherein individuals were making judgements of people, their class background, their educational background, their occupational status, based on their physical appearance. And in fact, if you wanted to achieve some level of social mobility in America, if you wanted to achieve and ascend this class hierarchy, you had to alter your physical appearance, or you were strongly encouraged or expected to alter your physical appearance. That took the form of bleaching skin. It also took the form of hair straightening.
Now, later in the 20th century, the 1940s, the 1950s, now we see people inclined to express themselves in slightly different ways and even kind of taking a little bit of a political interest in doing so. In the 1950s, there were models, Black models, and these were people that were always on the cutting edge of fashion. And so they were taking interest in styles like Afros. And at the time, it wasn't even necessarily political. They were just trying to be fashionistas, if you will. But as that permeated parts of Harlem, as it permeated parts of New York, it actually extended to Black poets, Black writers, Black musicians. And these are artists. These are people who take an interest in being authentic and being true to themselves and engaging in this broader goal of shaping culture. And in their case, in their writings and in their music and in their poetry, they're engaging with elements of Black expression and the Black experience. And this obviously permeated also to their choice of physical appearance.
That's really when things like the Afro and locks started to take on a little bit more of a political position because there was Black liberation across Africa. This was in the 1950s, in the early 1960s. By the mid 1960s, you have the civil rights movement. You also have the Black power movement. And things progressed in that way. And so thinking about all this in 2020, 2021, 2022, understanding the racial climate is different, but the battles that we're facing today are similar in some respects to the plight that Black Americans have been facing throughout America's history. And it's this kind of central question of what do people need to do in order to be successful? What do people need to do in order to be respectable? What do people need to do in order to get access to the American dream? And that's where this interest in things like hair styling and physical appearance and expression comes to bear.
And so following the civil rights movement, the Black power movements, the Black liberation movements of the '60s, the '70s, these hairstyles started to take on a little bit of a different meaning because the social climate, the political climate concerning these hairstyles was very, very different. And so these hairstyles are maybe even more popular, at least just as popular as they were back then, but they're not politicized in the same way and certainly not to the same degree. They very much mean different things to different people. And we note that and make that reference in the paper as well.
And so Loren, we're talking about hair and hair presentation. In dermatology, many dermatologists may not know this historical context in which some of their black patients are in or their family are in. Why do you think it's important for the ones that may not be aware for them to know about this history?
Choosing how one styles his or her hair is incredibly personal, and it has financial implications, it has societal implications as Tosen mentioned, and occupational implications. So we, as dermatologists, are uniquely positioned. We know this is one of the top reasons why Black patients seek dermatologic care. We have to be aware of these things in counseling our patients and in understanding why it has such an impact on quality of life.
Because some of the hairstyles that Black people choose do have implications on some disorders that end up resulting.
Yeah, absolutely. And I think that this is an area that's ripe for more research. For example, the literature on central centrifugal sacrificial cicatricial alopecia, or CCCA, actually is quite mixed. So even though that was called hot comb alopecia, and it's very understandable that perhaps it's carried forward that this is a type of alopecia that happens in response to hair styling, there's mixed data actually. So we cannot conclusively say that hair loss in CCCA is linked to hair styling. And in fact, some of the larger studies suggest that it's not associated with hot comb use or chemical relaxer use, and instead may be more associated with higher tension styling. However, we do know hair loss disorders or hair disorders such as acquired trichorrhexis nodosa and traction alopecia have been more definitively tied to hair styling practices.
So when we're counseling patients, it's important to first understand where we have literature and where our literature is lacking. But then second to know, when we make these asks of our patient, we're doing the right thing, we want to inform on multiple levels as to how to address a health concern such as these hair loss disorders. We have to be mindful of the many implications that come with that, however. It may not be reasonable or easy for that patient to transition out of a relaxer. That patient may feel as if they had financial implications with switching to natural hairstyles. There may be particular view of society that they feel the pressure of in changing their hairstyle. So all of our counseling really needs to be joint decision making, and we should be informed of the many ways this impacts our patients.
Your hair is more than just keratin growing out of your scalp. It has meaning for your position in society. How your hair is styled is a reflection of a mix of cultural and societal norms and sometimes based on what you can afford financially or through the investment of time to maintain. And some hairstyles, such as corn rows in Black men, have been deemed by the larger society as associated with criminality.
Black communities are more aware of how hair health may play a role and how certain hair styling practices, such as relaxing, heat, dye are playing a role in hair health. So whereas in the past more so there were implications financially, implications societally that played a role in making those decisions, now, communities are more aware of the implications of certain hair styling on hair health and are choosing to do things such as go naturally, or, and even more recent in the past year or so, feel empowered to make the decision about how to style their hair that's best for them. And for some, that may be natural hair styling. Whereas for others, that may be using things like heat or chemical relaxers.
Could you tell us a little bit about the CROWN Act, which is legislation that is currently occurring both at the state and federal levels, and why this may be important for dermatologists or anybody in the United States to be aware of?
So the CROWN Act is Creating A Respectful and Open World for Natural Hair Act. It has been passed in, I believe, 12 states, the first of which was California in July 2019, and most recently in Oregon in June of 2021. It recently went to the House as of March 18th, 2022, and passed in the House where currently the House is controlled by Democrats. It now has to pass in the Senate. So essentially this is an act that would ban discrimination based on hair and hair styling.
I think the legal aspects of this, without getting into the nuances, are really complicated, because we know that in 1964, we have the Civil Rights Act, which explicitly prohibited discrimination against protected identities and protected categories. And so many people would say, "Well, obviously here discrimination is illegal because we have the Civil Rights Act." But what's really tricky about that is law is open and subject to interpretation. And of course the courts ends up setting a precedent with how they make rulings concerning these cases. And so I'll just cite two, just to kind of give you a sense of the landscape. So we have the Civil Rights Act in 1964. 1976, just about a decade later, we have this very large court case pertaining to hair discrimination. We have Jenkins versus Blue Cross Mutual Hospital, in which case the woman in question was denied a promotion because her supervisor told her, "You can never represent the company with your Afro."
And so she took the company to court, and the US Court of Appeals agreed, like, "Hey, you can't do that because of the Civil Rights Act. It's in Title VII." Just a couple of years later in 1981, we have Rogers versus American Airlines. So this flight attendant was wearing corn rows and the company insisted she needs to pull her hair back in a bun. If you can't do that, you're going to be terminated. And so the courts ruled in support of American Airlines. And their logic was your decision to wear corn rows, corn rows are a mutable trait, whereas, having an Afro, the way your hair grows out of your scalp, that is an immutable trait. And so having an Afro is protected, but the moment you start making decisions pertaining to your hair, things like locks, things like corn rows, things like braids, the moment you start making decisions pertaining to your hairstyles, those are all mutable traits and it's legal for a school or for a company to exclude or discriminate against you in these settings based on these hairstyles. And so what the CROWN Act is intended to do, and obviously states kind of differ their interpretation of that a little bit, but what the CROWN Act is intended to do is to put a law on the book that explicitly prohibits this form of discrimination that we have evidence disproportionately affects Black women and girls.
Black men and their hairstyles were largely left out of today's conversation. While the CROWN Act will likely help more than just Black women, this group bears a disproportionate impact of hair-based discrimination, and therefore may likely derive the most benefit. The viewpoint, which was the basis of this discussion, focused on Black people. So discussions of all other people of color was beyond this podcast episode. Before we close, I want to ask Loren to give us dermatologists some words of advice. What are some actionable things we can do for our patients that identify as Black, especially for those of us that really care about these issues? What can we do?
I think first I have to say, thank you. Thank you for tuning in to the podcast. And thank you for getting a sense of the history, because that's important. Educating ourselves on these things is so important. And thank you for caring for patients with that lens of cultural humility. We all cannot know everything, and that's okay. All we can do is continue to learn, be open-minded, and educate ourselves. So that would be my first point. Second, we need to strive to have better evidence-based medicine as it relates to hair and hair styling and implications for different types of alopecia or hair disorders. Support that research. If you're interested, get involved in that research. And also learn what exists, so when we're counseling patients, we can do it in a confident, yet sensitive way. We should be able to provide counseling to our patients on these issues. So, read the literature that exists on disorders such as CCCA, acquired trichorrhexis nodosa, traction alopecia. Although it's limited, there is great evidence out there and it is open for the reading and learning.
Next, I would say instill in your learners, so whoever's learning from you, whether it's your staff, whether it's your colleagues, whether it's residents or medical students, instill in your learners the importance of cultural sensitivity and humility and that thirst for more knowledge. Although you don't necessarily have to know history to be a dermatologist, imagine the difference knowing history makes in your sensitivity in your approach to patients. So always have that thirst and drive to learn more, which I know that most dermatologists do. Lastly, support legislation for patients, such as the CROWN Act. This is important to ensure our patients feel empowered and are able to make the right decisions for their hair care.
I really want to thank you, Dr. Krueger and Mr. Nwadei. This is a truly important discussion. This is a podcast that's a little different than others, but I think it's critical to highlight this area from an advocacy perspective, a historical perspective, and from a communication and education perspective, which you all did marvelously. This is Dr. Ade Adamson, web editor for JAMA Dermatology. This episode was produced by Shelly Stephens and Daniel Morrow of the JAMA Network. The audio team here at JAMA also includes Jesse McQuarters, Lisa Hardin, Audrey Forman, and Mary Lynn Ferkaluk. Extra guidance was provided by Emily Ling and Lisa Hardin. Dr. Robert Golub is the JAMA executive deputy editor. To follow this and other JAMA Network podcasts, please visit us at jamanetworkaudio.com. Catch you on the next episode of the JAMA Dermatology podcast.