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Ethnicity & Health
ISSN: 1355-7858 (Print) 1465-3419 (Online) Journal homepage: http://www.tandfonline.com/loi/ceth20
Racism, racial discrimination, and trauma: a
systematic review of the social science literature
Katherine Kirkinis, Alex L. Pieterse, Christina Martin, Alex Agiliga & Amanda
Brownell
To cite this article: Katherine Kirkinis, Alex L. Pieterse, Christina Martin, Alex Agiliga & Amanda
Brownell (2018): Racism, racial discrimination, and trauma: a systematic review of the social
science literature, Ethnicity & Health, DOI: 10.1080/13557858.2018.1514453
To link to this article: https://doi.org/10.1080/13557858.2018.1514453
Published online: 30 Aug 2018.
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Racism, racial discrimination, and trauma: a systematic review
of the social science literature
Katherine Kirkinis, Alex L. Pieterse, Christina Martin, Alex Agiliga and
Amanda Brownell
The University at Albany –State University of New York, Albany, NY, USA
ABSTRACT
Objective: The aim of this paper is to provide a systematic review of
studies that examine relationships between racial discrimination
and trauma in order to further understand the relationship
between racial oppression and psychological functioning.
Design: In this review, we describe the characteristics of 28 studies,
identified by a comprehensive search strategy, including
measurements of racial discrimination and trauma, as well as the
nature of the reported associations.
Results: Half of studies included in this review were published in the
last 6 years. The majority of studies used cross-sectional designs and
were conducted in the United States with adults ≥18 years old.
African American, White, Latinx, and Asian populations were most
frequently included in these studies. Of the 44 associations
examined in these studies, 70% of the trauma symptomology
outcomes were statistically significantly associated with racial
discrimination. Significant positive associations ranged in strength,
with the strongest relationships between racial discrimination and
trauma occurring in studies examining veteran populations and
moderate relationships among these variables in non-veteran,
student populations.
Conclusions: Our findings reveal that current research on race-
based trauma seems to be limited by a lack of measures that
capture the stress/intensity associated with race-related events, an
inability to account for vicarious/collective/intergenerational
experiences of trauma, and failure to control for non-race-based
trauma.
ARTICLE HISTORY
Received 8 January 2018
Accepted 16 August 2018
KEYWORDS
Racism; racial discrimination;
trauma; race-based traumatic
stress; systematic review
Race refers to the social construct and practice of categorizing humans based on their skin
tone, physical features (e.g. eye and/or nose shape, hair texture, etc.), and/or language
(Carter and Pieterse 2005). This grouping practice, particularly prevalent in North
America, includes the grouping of all people: Whites, people of Color (Blacks, Asians,
Latinx, Native Americans), refugees, immigrants, and biracial people. The terms race,
culture, and ethnicity are often confused or used interchangeably. Within the United
States (U.S.), racial groups have been socially and legally separated for centuries. As
such, racial groups have retained distinct cultural patterns which make race and
culture, in many cases, seem to be one in the same (Marger 2014). Culture, however, is
© 2018 Informa UK Limited, trading as Taylor & Francis Group
CONTACT Katherine Kirkinis kkirkinis@albany.edu
ETHNICITY & HEALTH
https://doi.org/10.1080/13557858.2018.1514453
distinct from race: While race refers to the social practice of categorizing people based on
physical features and/or language (Carter and Pieterse 2005), culture is the system of
values, norms, behaviors, language, and history passed on from one generation to the
next through socialization (Carter 2007). Ethnicity, although also conflated with these con-
cepts, differs still –it is a person’s perceived group membership based on nationality and/
or ancestry (Murry, Smith, and Hill 2001). The constructs of race, ethnicity, and culture
and their intersections have been the basis of vastly different historical experiences of
oppression in the U.S. Historically disenfranchised racial-cultural groups in the U.S.
include Black/African, Latinx, Asian/Pacific Islanders, and Native–Indigenous (Carter
2007). More recent groups to experience discrimination and oppression include individ-
uals from Middle Eastern backgrounds (Jamal, Naber, and Naber 2008). For the purposes
of this paper, the term, people of Color, will be used to refer to historically disenfranchised
American racial-cultural groups.
In the United States, people fall into a racial social hierarchy with Whites at the top as
the dominant group, and people of Color at the bottom (Marger 2014; Smedley and
Smedley 2005). Feagin (2006,2014) describes an enduring system of oppression in the
U.S. where people of Color have been the targets of a wide range of racism, including
social and economic oppression (e.g. slavery, Jim Crow laws, Japanese internment
camps, police brutality, mass incarceration, etc.), the negative depictions of people of
Color in television, film and other media controlled mostly by Whites (Cortese 2010;
Morris 2007; Stanfield 1993; Vera and Gordon 2003) and the everyday acts of invalidation
and dismissal people of Color experience in a White-dominant society (i.e. racial micro-
aggressions; Pierce 1995; Solorzano, Ceja, and Yosso 2000).
The behavioral manifestation of racism, racial discrimination, is at the intersection of
power and prejudice. Racial discrimination is understood to be a combination of the ideol-
ogy of racial superiority (racism) and the social structures and interpersonal behaviors
associated with dominance and oppression (Pieterse and Powell 2016). As such, racial dis-
crimination manifests in people of Color being denied access to resources, opportunities
and the power to define reality (Neville and Pieterse 2009), the normalization of which is
known as structural racism (Lawrence and Keleher 1995). Individuals, institutions, and the
dominant culture express racism and racial discrimination in different ways, with racism
occurring at the interpersonal, institutional, and cultural levels (cf. Jones and Carter 1996).
Carter, Johnson, Muchow et al. (2016)categorize racial discrimination (occurring at the
individual, institutional, or cultural level) into three types: avoidance wherein people are
rejected or ignored because of their race; hostility wherein verbal and non-verbal acts
are directed at people to demean, intimidate, or communicate inferior status to them
based on their race; and aversive-hostility, wherein one encounters barriers in the form
of lack of opportunity or a hostile environment.
A wealth of research indicates that racial discrimination is a stressor for its targets (e.g.
Brondolo et al. 2009; Carter 2007; Clark et al. 1999; Pieterse and Carter 2007; Williams and
Mohammed 2009,2013). There is mounting evidence pointing to the connection between
racial discrimination and a variety of negative physical and mental health outcomes (e.g.
Britt-Spells et al. 2018; Lee and Ahn 2011,2012,2013; Paradies et al. 2015; Pascoe and
Smart Richman 2009; Pieterse et al. 2012; Schmitt et al. 2014; Smedley 2012; Triana, Jaya-
singer, and Pieper 2015). This body of work rests on the conceptualization of stress as a
phenomenon in which an individual perceives their resources to be insufficient to meet
2K. KIRKINIS ET AL.
the demand of their environment, creating a stress reaction due to an inability to cope
(Lazarus and Folkman 1984). Harrell (2000) has applied this concept to the effects of
racism defining racism-related stress as race-related interactions between individuals/
groups and the environment that are “perceived to tax or exceed existing individual
and collective resources or threaten well-being”(p. 44). Race-related stress, however,
differs still from trauma.
Trauma is related to stress in that psychologists understand it to be a more acute form of
stress resulting from a particular event or series of events that overwhelm a person’s typical
coping mechanisms (Pearlman and Saakvitne 1995; Van der Kolk 1998). In fact, the etymol-
ogy of the word trauma, comes from the Greek word, τραῦμα, which is literally translated to
“wound”(“Wound”1989). Thus, the connection between stress and trauma is that some
stressful life events have the ability to result in psychological wounds or injuries to the
self (Carter 2007). Due to individual differences and the subjective nature of such experi-
ences, two people experiencing the same event or condition may react differently,
wherein one may experience stress (with the ability to cope), and the other may experience
trauma (overwhelmed by the experience and unable to cope; cf. Carter et al. 2017).
Distressing psychological responses to traumatic experiences have been conceptualized
in the field of psychiatry and psychology as a specific disorder –Post-Traumatic Stress
Disorder (PTSD; American Psychiatric Association 2013). The hallmark of PTSD has
been exposure to a traumatic event (e.g. violent or accidental death/threatened death,
actual/threatened serious injury, or actual/threatened sexual violence) with accompanying
reactions including feelings of helplessness and fear. It should be noted, however, that
the definition and criteria of PTSD has come under criticism for its lack of attention to
stressful events associated with racial discrimination and the experience of racism
(Butts 2002; Carter 2007). As such, the relationship between racism-related stress and
psychological symptoms has become an increasing area of inquiry. Research has been
driven by various scholars’argument that our current conceptualization of trauma
needs to be expanded to account for non-life-threatening experiences that do represent
a psychological threat and result in emotional pain (Carlson 1997; Helms, Nicolas, and
Green 2010).
The race-trauma connection
In research that has examined the prevalence of trauma (in accordance with the PTSD
model), researchers have found higher rates of traumatic stress in response to significant
life stressors among people of Color as compared to the general population (Breslau et al.
1998). For example, Pieterse et al. (2010) found that racial discrimination was a stronger
predictor of trauma-related symptoms than general life stress in a sample of Black college
students. Similarly, for Asian students, campus racial climate contributed to a significant
amount of variance in trauma symptoms, again more so than general life stress (Pieterse
et al. 2010). In a sample of veterans, Loo, Fairbank, and Chemtob (2005), found that the
experience of race-related stressors was associated with more severe PTSD outcomes when
compared with veterans with no or few race-related stressors. Echoing these findings,
Roberts et al. (2011) found Blacks to have significantly higher rates of PTSD (8.7%)
than Whites (7.4%), even after controlling for the number of reported traumatic events
over the lifespan.
ETHNICITY & HEALTH 3
There is also evidence of differential exposure to stressful life events with Whites tending
to report less stress associated with life events than people of Color (Norris 1992;Poleetal.
2005). While findings in this area are too few to draw conclusions, the disparity in impact of
stressful life events between people of Color and Whites remains unexplained by covariates
that theoretically might serve as buffers such as level of acculturation (Marshall and
Orlando 2002), socioeconomic status, education, and mental health (Roberts et al. 2011),
and frequency of stressful life events (Pole, Gone, and Kukarni 2008).
An important development in the field of race and trauma has been Carter’s(2007)
theory of race-based traumatic stress which posits race-based traumatic stress is a
unique type of trauma. Carter’s(2007)workbuildsonCarlson’s(1997)theoryoftraumatic
stress, a form of stress arising out of emotional pain, rather than a violent or life-threatening
event, making a connection between racial discrimination and traumatic stress. Carter and
Forsyth (2010) found that people of Color who experienced racism were also reported
higher levels of anxiety, guilt/shame, avoidance/numbing, and hypervigilance, suggesting
that race-based traumatic stress may share some symptoms with the experience of
PTSD. Additionally, researchers have documented that interpersonal trauma (i.e. person-
to-person trauma) tends to produce more severe emotional reactions than experiences of
impersonal trauma (i.e. natural disasters, automobile accidents, etc.; Courtois 2004),
which is particularly important given the prevalence of interpersonal race-based stressors.
Given the body of work highlighting the connection between exposure to racism and
increased levels of stress in people of Color (e.g. Williams and Mohammed 2009,2013),
higher rates of trauma reactions in people of Color (e.g. Frueh et al. 2002; Frueh,
Brady, and de Arellano 1998; Norris et al. 2002; Perilla, Norris, and Lavizzo 2002; Ruef,
Litz, and Schlenger 2000), and the adverse physical and mental health effects associated
with the experience of racial discrimination (e.g. Britt-Spells et al. 2018; Lee and Ahn
2013; Paradies et al. 2015; Pascoe and Smart Richman 2009; Pieterse et al. 2012;
Schmitt et al. 2014; Smedley 2012; Triana, Jayasinger, and Pieper 2015), it seems that
an important and necessary next step is to examine the existing literature on racial dis-
crimination as a potential factor contributing to trauma (Bryant-Davis and Ocampo
2005; Carter 2007; Harrell 2000).
Current review
The current review examined the existing literature on the relationship between racism
and trauma. The primary focus was to examine associations between racial discrimination
and trauma symptoms, with a secondary focus of assessing current approaches to measur-
ing and assessing race-based trauma in the extant literature. Based on our search of the
literature, no systematic reviews of the racial discrimination and trauma link were
found, therefore the current work marks the first systematic review of empirical studies
examining racial discrimination and trauma in adult populations in the United States.
This review aims to describe: (1) the nature of associations found between racial discrimi-
nation and trauma for adults in the United States; (2) measurement of reported racial dis-
crimination used in this research, including timeframes, settings, and impact of exposure;
and (3) other characteristics of this body of research racial discrimination and trauma. In
line with theory, we anticipated that moderate relationships would emerge between racial
discrimination and traditional PTSD trauma symptoms (e.g. dissociation, intrusive
4K. KIRKINIS ET AL.
thoughts, etc.). We did however anticipate that the effect sizes would be small given the
theoretical inability of the PTSD frame to capture the full spectrum of race-based trau-
matic stress (Carter 2007). Due to the heterogeneity observed in measurement approaches
to both racism discrimination and trauma, we concluded that a meta-analytic investi-
gation was not appropriate at this stage. As such, we report our findings as a systematic
narrative review of the racial discrimination and trauma literature as it currently stands.
Method
Literature search and study selection
A systematic narrative review was conducted to review the existing empirical outlining the
relationship between racial discrimination and trauma. Using systematic and explicit
methods, this study sought to identify, select, and assess relevant primary research on
the relationship between racial discrimination and trauma (Wright et al. 2007). The sys-
temic review strategy was guided by Moher et al.’s(2015) PRISMA-P checklist which
includes suggested data collection items for a systematic review protocol. As per Moher
et al. (2015), we recorded administrative data for each article (title, registration,
authors, amendments, support); introduction data (rationale, objectives), and defined
our methodology (defined eligibility criteria, search strategy, information sources, data
items, outcomes, data collection process, and plans for data synthesis).
Eligibility criteria
The literature search was conducted to identify studies that met the following inclusion
criteria:
(1) Empirical studies using quantitative methods including (i.e. experimental, retrospec-
tive / prospective cohort, longitudinal, and cross-sectional designs).
(2) Published in peer-reviewed journals or unpublished dissertations/ theses, manuscripts
from the earliest time available to December 2017 were considered.
(3) Studies included both a specific measure of racial discrimination (i.e. self-report
measure of discrimination based on racial-ethnic backgrounds) and trauma (e.g.
PTSD symptomology, trauma symptom checklist, or other self-report measure of
experience with trauma) and/or a combined racial discrimination-trauma measure.
(4) Participants were adults (ages ≥18; studies that utilized college student populations and
included some participants under age18 were not excluded)and studies were conducted
in the United States (immigrants, refugees, foreign-born participants were included as
long as the study was conducted in the U.S.). This search was limited to adults in the
U.S. given the unique history and system of racism in the U.S. (cf. Feagin 2006,2014).
Information sources & search strategy
In terms of methodology, the search began with an extensive review of the literature using
various combinations of the following search terms: race based trauma, race based stress,
racial stress, racial trauma, racial discrimination, racism, perceived racism/discrimination,
racial oppression, ethnic discrimination. We explored several databases, including
ETHNICITY & HEALTH 5
PsychINFO, PsychARTICLES, Medline, EbscoHost, CINAHL, Google Scholar, PubMed, and
ProQuest (for dissertation/theses). Reference lists of articles selected for inclusion were mined
by hand for additional relevant studies. In addition, Google searches with the same search
terms were conducted to search for unpublished articles in PDF form notincluded in database
searches, and experts in the field were contacted requesting unpublished manuscripts and/or
manuscripts under review that might meet criteria. A Google Scholar alert with the samekey
words was also set up to e-mail the primary investigator of any newly added publications
during the period of the search (from September-December 2017). All searches were con-
ducted in English. The initial search yielded 94 titles: 64 journal articles, 14 dissertations, 9
book chapters, and 7 unpublished manuscripts that were screened for inclusion.
A detailed screening was conducted to ensure that the studies met the study criteria
which reduced the total number of articles and papers (elimination of 69 studies) to 28
studies (5 dissertations, 18 articles, and 5 unpublished manuscripts) that met all of the
inclusion criteria and was comprised in the final data set. All study details were recorded
in an Excel document.
Data & outcome Items
Variables for which data was sought included any measures and/or items related to racial
and/or ethnic-based discrimination (e.g. measures of discrimination frequency and/or
stress) and any measures and/or items related to trauma (e.g. PTSD diagnostic measures,
items measuring single trauma symptoms such as dissociation and/or flashbacks).
Data collection & coding process
Data was collected by hand by a team of four doctoral-level psychology graduate students.
Data was then coded by hand, splitting the team of researchers into two teams of two. Inter-
rater reliability was calculated following Huberman and Miles (1994), where a reliability rate
of 85% or greater is viewed as statistically acceptable. Agreements were defined as any
instance in which the coders pulled the same piece of data from a given codable objective
(e.g. title, author, variable). Disagreements were defined as instances in which the coders
pulled different pieces of data to the same codable objective. The percent of inter-rater
reliability was calculated utilizing Huberman and Miles (1994) formula: (Reliability = Agree-
ment/ Agreement + Disagreement). The overall inter-rater reliability rate for this study
equaled 87.2%. Once it was determined that the coding teams were reliable (two consecutive
passes of coding where the coders met or exceeded the 85% minimum level of reliability), the
remaining articles were coded and data was recorded in an electronic spreadsheet.
Data synthesis
There were no plans for data synthesis beyond descriptive data analysis due to the small
sample size and heterogeneity of the data. In terms of descriptive findings, we examined
descriptive analyses of the full sample of studies included, as well as subgroup analyses of
the quality and characteristics of measures of trauma and racial-ethnic discrimination
exposure. Lastly, we examined the nature of associations between racial-ethnic discrimi-
nation and trauma.
6K. KIRKINIS ET AL.
Results
From the 94 titles generated by the search, 28 studies met the inclusion criteria. Of the 28
papers, 18 were published journal articles and reports and 5 were unpublished articles, and
5 were theses/dissertations. The primary reasons for exclusion were: samples being out of
age range, samples not being conducted with participants in the U.S., or studies lacking a
measure of trauma and/or racism. A number of studies were also excluded because they
utilized measures of general discrimination that did not specify discrimination due to
racial, ethnic, or cultural background. Findings were screened to ensure that they were
not published from the same study and/or utilizing the same sample.
Description of the studies
Table 1 provides details of the key characteristics of included studies. Half of
studies included in this review were published in the past six years (50% n= 14). Most
of the studies used a cross-sectional study design (93% n= 26), with two studies utilizing
longitudinal designs. All of the studies in this review employed convenience (i.e. non-
representative) samples, with a majority of studies including samples of >200 participants
(75% n= 21). The most common ethnic/ racial groups represented in the studies
were Black (70% n= 20), White (57% n= 16), and Asian (50% n= 14), followed by
Latinx (46% n= 13), Biracial (30%, n= 8), Middle Eastern (10% n= 3), and Native Amer-
ican (10% n= 2). Combined, the total number of participants included in this review is
11,775.
Measures of racial discrimination exposure
Almost all racial discrimination exposure measures included some form of frequency (see
Table 1), with the majority of studies utilizing Likert-scales (e.g. ranging from never to very
often or almost all of the time (n= 12) with two studies measuring frequency asking par-
ticipants to indicate “yes”or “no”to whether they experienced any events due to their race
or ethnicity, and one study asking participants to record the number of times they experi-
enced a race-based event. Other studies used a forced-choice scale that measured percep-
tion of discrimination rather than frequency, with a Likert-scale ranging from strongly
agree to strongly disagree (n= 4) and two studies used a combined frequency-intensity
Likert-scale from 0 this event never happened to me to 4 this event happened and I was
extremely upset. A handful of studies were unique in that researchers utilized the Race
Based Traumatic Stress Symptom Scale (Carter et al. 2013), a combined measure of
race and trauma (n= 7).
In terms of timeframe, the majority of studies examined lifetime exposure to racism
(n= 14), followed by studies that examined racism exposure in a specified timeframe
(e.g. as an international student, in their current workplace, during time the military,
after 9/11; n= 7). The remainder of studies utilized the Race Based Traumatic Stress
Symptom Scale (n= 7), examining a single memorable event of racial discrimination.
In terms of setting and experience, most studies examined racial discrimination in a
specified setting (e.g. school, healthcare, workplace; n= 10), with the remainder of
studies leaving setting unspecified (n= 18) in their examination. Almost all of the
ETHNICITY & HEALTH 7
studies examined direct experiences of racial discrimination (n= 24), with only four
studies including measurement of experiences of intergenerational or vicarious racial
discrimination. Of the studies that reported reliability for racial discrimination scales
Table 1. Characteristics of 28 empirical studies of racial discrimination and trauma.
Year of publication Number of studies % of total studies
2000–2005 4 14
2006–2010 10 36
2011–2017 14 50
Study Design I
Observational 28 104
Experimental 0 0
Study Design II
Cross Sectional 26 93
Longitudinal 2 7
Sampling Procedure
Convenience 28 104
Population / Representative 0 0
Sample Size
n< 100 2 7
100 n< 200 5 18
200 n<1000 16 57
n> 1000 5 18
Region of Study
United States 28 100
Study Population Characteristics
Age
≥18 26 93
College-age including some participants <18 2 7
Racial-Ethnic Group
Black 20 71
Latinx 13 46
White 16 57
Asian 14 50
Biracial 8 29
Middle Eastern 3 11
Native American 2 7
Other 2 7
Racial Discrimination Measures
Conceptualization of Racial Discrimination
Measure of Frequency 21 75
Measure Race Based Traumatic Stress Symptoms 7 25
Exposure Timeframe
None 7 25
Specified Timeframe 9 32
Lifetime 12 43
Type of Discrimination
Direct 24 86
Vicarious 4 14
Intensity
Measure of Intensity of Experience 2 7
Setting
Specified setting 10 36
Unspecified 18 64
Dataset
National Dataset 3 11
Other 25 89
Trauma Measures
PTSD-model 20 71
Dissociation 4 14
Other 4 14
8K. KIRKINIS ET AL.
(n= 20), reliability ranged from .67-.98 for racial discrimination scales, with the majority
of scales (n= 16; 84%) reporting reliability above .86 (see Table 2 for reliability infor-
mation of racial discrimination measures).
Table 2. Reliability of measures included in the study.
Racial discrimination measures α
Spencer Discrimination Scale 0.86
Race-Related Events Scale (RES) 0.86
Schedule of Racist Events (SRE)
Work Environment Inventory (WEI) 0.65
Race-Related Stress Scale: Racial Prejudice & Stigmatization subscale 0.97
Race-Related Stress Scale: Bicultural Identification & Conflict subscale 0.93
Race-Related Stress Scale: Racist Environment 0.93
Race-Related Stress Scale: Total Score 0.97
Impact of Race-Related Events (IRE)
Perceived Ethnic Discrimination Questionnaire (PEDQ) .74–.84
Acculturative Stress Scale for International Students (ASSIS) 0.92
Race-Related Events Scale (RRES)
Perceived Racial/Ethnic Discrimination Stress Scale
Index of Race Related Stress: Cultural Racism subscale 0.91
Index of Race Related Stress: Institutional Racism subscale 0.95
Index of Race Related Stress: Collective Racism subscale 0.93
Index of Race Related Stress: Individual Racism subscale 0.93
Index of Race Related Stress: Total Score 0.98
Racial Vigilance 0.86
Experiences of Discrimination Scale (EOD) .67–.74
Everyday Racial Discrimination 0.90
The Oppression Questionnaire (OQ) 0.98
The Brief Perceived Racism in the Workplace Scale (BPR) 0.90
Trauma Measures
Childhood Trauma Questionnaire 0.90
Dissociative Experiences Scale (DES) 0.95
Life Stressors Checklist–Revised
Mississippi Scale for Combat-Related Posttraumatic Stress Disorder-Civilian Version (M-PTSD-C) .64–.87
Mississippi Scale for Combat-Related Posttraumatic Stress Disorder (M-PTSD) 0.61–0.90
Peritraumatic Dissociative Experiences Questionnaire (PDEQ) 0.83
Posttraumatic Stress Disorder Checklist-Civilian Version (PCL-C) 0.93
Posttraumatic Stress Disorder Checklist-Specific (PCL-S-6) 0.89
Posttraumatic Stress Disorder Checklist-Specific (PCL-S) 0.95
PTSD Symptoms Scale –SR 0.87
Trauma Symptom Checklist-40 (TSC-40) 0.73
Stress Response Questionnaire for Disorders of Extreme Stress (SRQ-DES) 0.78
Posttraumatic Symptom Scale–Self-Report (PSS-SR) 0.91
Alcohol Use Disorder and Associated Disability Interview Schedule (AUDADIS-IV) 0.69
World Mental Health Composite International Diagnostic Interview
Trauma and Attachment Belief Scale (TABS) Full Scale 0.93
TABS: Self Safety 0.77
TABS: Other Safety 0.66
TABS: Self-trust 0.77
TABS: Other-Trust 0.83
TABS: Self-Esteem 0.76
TABS: Other-Esteem 0.73
TABS: Self-Intimacy 0.58
TABS: Other Intimacy 0.73
TABS: Self Control 0.70
TABS: Other Control 0.73
The Life Events Checklist (LEC) 0.63
The Dissociative Symptom Scale (DSS) 0.89
Amount of Exposure to Client Trauma Material
Intensity of Exposure to Client Trauma Material
Notes: blanks signify that reliability information was not reported.
ETHNICITY & HEALTH 9
Measures of trauma
The bulk of the studies in this review specifically examined PTSD conceptualizations of
trauma (n= 13), with other studies examining dissociate experiences associated with
trauma (n= 3), and other measures of trauma (n= 5). The remaining studies used the
Race-Based Traumatic Stress Symptom Scale (n= 7), a combined measure capturing
symptomology specific to race-based-trauma. The most common measures were versions
of the Mississippi Scale for Combat-Related Posttraumatic Stress Disorder (M-PTSD;
Keane, Caddell, and Taylor 1988) and the Posttraumatic Stress Disorder Checklist
(PCL; Weathers et al. 1993). Of the studies that reported reliability for trauma measures
(n= 15), reliability ranged from .61-.95, with the majority of scales (n= 14; 54%) reporting
reliability above .75 (see Table 2 for reliability information of trauma measures).
Associations between racial discrimination and trauma
In the studies that examined racial discrimination and trauma, we found consistent
patterns of associations, with 70% of associations (n= 31) as positively significant (see
Table 3). Significant positive associations ranged from r= .10-.68, with 37% of associations
above .45 and 17% of the associations above .50.
The strongest associations were between the PTSD-specific measure, the Mississippi
Scale for Combat-Related Posttraumatic Stress Disorder (M-PTSD) with the Race-
Related Stress Scale’s (RSS; two correlations) and the Impact of Race-Related Events
(IRE; one correlation), both with Asian-American veteran populations (r= .61, .68, .61,
respectively). Moderate associations were found between the Schedule of Racist Events
(SRE) with the Life Stressors Checklist–Revised (r= .55), the Oppression Questionnaire
with the Trauma and Attachment Belief Self Safety subscale (TABS; r= .46), the Accul-
turative Stress Scale for International Students (ASSIS) with the Post-Traumatic Stress
Disorder Checklist (PCL-S-6; r= .46), both conducted with student populations, and
one study screening out any participants with a previous PTSD diagnosis or a report of
any PTSD-qualifying traumatic experiences. Further moderate correlations were found
between the Work Environment Inventory (WEI) with the Peritraumatic Dissociative
Experiences Questionnaire (PEDQ; r= .48), among urban police officers, and again
between the Mississippi Scale for Combat-Related Posttraumatic Stress Disorder
(M-PTSD) with the Race-Related Stress Scale’s (RSS; r= .53, .48) and the Vietnam
Racial Stressor Scale (VRSS; r= .49, .48), again with veteran populations of Color.
Discussion
Scholars have discussed racism and trauma at length (e.g. Bryant-Davis and Ocampo 2005;
Carter 2007; Clark et al. 1999; Carter and Forsyth 2009; Carter, Forsyth, Mazzula, et al.
2005; Harrell 2000; Comaz-Diaz and Jacobsen 2001; Helms, Nicolas, and Green 2010),
yet a clear demonstration of the association between racial discrimination and trauma
has yet to be determined through empirical review. The aim of this review was to
examine racial discrimination as a potential factor contributing to trauma and to
provide the first systematic review of empirical studies on reported racial discrimination
and trauma for adult populations in the United States. Our goals were: (1) to describe the
10 K. KIRKINIS ET AL.
Table 3. Findings of 18 empirical quantitative studies of reported racial discrimination and various measures of trauma.
Trauma measure Racial discrimination measure Positive Unrelated Negative Publication Sample N
Posttraumatic Symptom Scale–
Self-Report (PSS-SR)
Everyday Racial Discrimination 0.33 * Bowleg et al. (2014)
a
Black male adults 526
Stress Response Questionnaire for
Disorders of Extreme Stress (SRQ-
DES)
Index of Race Related Stress: Cultural
Racism subscale
0.21 Douglas (2004) Multiracial university students 330
Index of Race Related Stress: Institutional
Racism subscale
0.25
Index of Race Related Stress: Collective
Racism subscale
0.14
Index of Race Related Stress: Individual
Racism subscale
0.31 *
Index of Race Related Stress: Total Score 0.16
Racial Vigilance 0.26 **
PTSD Checklist-Specific (PCL-S)
††
Race-Related Events Scale (RES) 0.35 ** Flores et al. (2010) Mexican-American youth and
adults
110
Amount of Exposure to Client
Trauma Material
The Brief Perceived Racism in the
Workplace Scale (BPR)
−0.07 Hahn (2010) Doctoral-level psychology
interns
234
Intensity of Exposure to Client
Trauma Material
The Brief Perceived Racism in the
Workplace Scale (BPR)
−0.14 *
Childhood Trauma Questionnaire Schedule of Racist Events (SRE) 0.04 Harrington et al. (2006) Black and White female
university students
231
Life Stressors Checklist–Revised 0.55 **
Trauma Symptom Checklist-40
(TSC-40)
Spencer Discrimination Scale 0.10 * Kang and Burton (2014) Incarcerated African-American
youth
189
PTSD Symptoms Scale –SR Perceived Racial/Ethnic Discrimination
Stress Scale
0.35 ** Khaylis, Waelde, and Bruce
(2007)
Multiracial university students 91
Mississippi Scale for Combat-Related
Posttraumatic Stress Disorder (M-
PTSD)
Impact of Race-Related Events (IRE) 0.61 ** Loo, Fairbank, and
Chemtob (2005)
Asian-American Vietnam
veterans
300
Mississippi Scale for Combat-Related
Posttraumatic Stress Disorder (M-
PTSD)
Vietnam Racial Stressor Scale (VRSS):
Racial Prejudice and Stigmatization
subscale
0.49 ** Loo et al. (2001) Asisn-American Vietnam
veterans
300
VRSS: Bicultural Identification & Conflict
subscale
0.33 **
VRSS: Racist Environment subscale 0.41 **
VRSS: Total Score 0.48 **
Posttraumatic Stress Disorder Checklist-
Civilian Version (PCL-C)
Perceived Ethnic Discrimination
Questionnaire
0.16 * Pieterse et al. (2010)
a
Multiracial university students 289
(Continued)
ETHNICITY & HEALTH 11
Table 3. Continued.
Trauma measure Racial discrimination measure Positive Unrelated Negative Publication Sample N
Impact of Events Scale (IES) General Ethnic Discrimination Scale
(GEDS)
0.30 * Polanco-Roman (2017) Multiracial university students 1541
The Life Events Checklist (LEC) The Experiences of Discrimination scale
(EOD)
0.21 * Polanco-Roman, Danies,
and Anglin (2016)
a
Multiracial university students 743
The Dissociative Symptom Scale (DSS) The Experiences of Discrimination scale
(EOD)
0.18 *
Peritraumatic Dissociative Experiences
Questionnaire (PDEQ)
Work Environment Inventory (WEI) 0.48 ** Pole et al. (2005) Multiracial urban police officers 668
Mississippi Scale for Combat-Related
Posttraumatic Stress Disorder-Civilian
Version (M-PTSD-C)
0.28 **
World Mental Health Composite
International Diagnostic Interview
Perceived Race-Based Discrimination
Experiences Scale
0.17 ** Rodriguez-Seijas et al.
(2015)
Non-instutionalized Black
American adults
5191
Trauma and Attachment Belief Scale
(TABS) Full Scale
The Oppression Questionnaire (OQ) 0.30 * Swift (2010) Non-vertan, non-traumatized
Black American adults
146
TABS: Self Safety 0.46 **
TABS: Other Safety 0.37 **
TABS: Self-Trust 0.13
TABS: Other-Trust 0.31 *
TABS: Self-Esteem 0.01
TABS: Other-Esteem 0.26
TABS: Self-Intimacy 0.12
TABS: Other Intimacy 0.29 *
TABS: Self Control 0.04
TABS: Other Control 0.16
Dissociative Experiences Scale (DES) Race-Related Events Scale (RES) 0.12 ** Waelde, Pennington,
Mahan et al. (2010)
Multiracial university students 408
Posttraumatic Stress Disorder Checklist-
Specific (PCL-S)
††
0.22 **
Posttraumatic Stress Disorder Checklist-
Specific (PCL-S-6)
†
Acculturative Stress Scale for
International Students (ASSIS)
0.46 ** Wei et al. (2012) Chinese international university
students in the U.S.
383
Mississippi Scale for Combat-Related
Posttraumatic Stress Disorder-Civilian
Version (M-PTSD-C)
Race-Related Stressor Scale (RRSS): Racial
Prejudice and Stigmatization subscale
0.67 ** Zamon Williams (2007) African-American Vietnam
veterans
95
RRSS: Bicultural Identification & Conflict
subscale
0.53 **
RRSS: Racist Environment subscale 0.48 **
RRSS: Total Score 0.68 **
Notes: K = 28, although only 17 studies provided usable correlations.
†the specific version with six items (PCL-S-6) was used, where specific events were classified as racial discrimination experiences.
‡self-report measure covering the 17 DSM-IV-R symptoms of PTSD.
a
Correlations unpublished in manuscript, provided by authors through personal communication.
b
This measure examines trauma history, not symptoms (i.e. a checklist of 30 traumatic events such as natural disaster, car accident, or physical abuse).
12 K. KIRKINIS ET AL.
nature and characteristics of this body of research racial discrimination and trauma; (2) to
present details of measurement of reported racial discrimination being used in the field,
including timeframes, settings, and impact of exposure; and (3) to report the associations
found between racial discrimination and trauma as a proxy for evaluating the efficacy of
PTSD-specific measures in capturing race-specific forms of trauma.
At first glance, we found moderate to strong, positive associations between racial dis-
crimination and trauma, providing support for the idea that racial discrimination and
trauma are likely related (Bryant-Davis and Ocampo 2005; Loo et al. 2001). The
findings were stronger than we had expected. A comparison between Carter et al.’s
(2013) measure of race-based traumatic stress (Carter et al. 2013) and the DSM-V (Amer-
ican Psychological Association 2013) criteria for PTSD reveals that several symptoms of
race-based traumatic stress (e.g. hypervigilance, avoidance, intrusive thoughts, depression,
physical symptoms; Carter et al. 2013; Carter and Sant-Barket 2015) overlap with symp-
toms of PTSD. Given that race-based traumatic stress may share some symptoms with the
experience of PTSD, the moderate to strong correlations are not wholly surprising.
A closer look at the strongest findings revealed that the largest positive correlations
were found in samples entirely composed of veterans who may also have experienced
combat-related trauma, in addition to race-based trauma, thus potentially creating artifi-
cially high correlations between measures of racial discrimination and PTSD-defined
trauma. It is important to note that Loo et al. (2001) and Zamon Williams (2007), two
of the studies reporting the strongest correlations, made adaptations to the Race-
Related Stressor Scale (for Asian-American veterans) and the Vietnam Racial Stressor
Scale (for African-American veterans) in effort separate the associations between race-
related stressors and trauma symptoms from those of combat exposure, military rank, psy-
chiatric distress, and PTSD symptoms. In examining race-based trauma, controlling for
other types of trauma is highly important and both Loo et al.’s(2001) and Zamon Wil-
liams (2007) works have attended to this issue. Other researchers (e.g. Swift 2010)
made efforts to control for “other”types of trauma that may have the potential to
inflate the strength of associations by excluding participants who report that they have
previously experienced a traumatic event or who have been previously diagnosed with
PTSD. There is little evidence, however, that other researchers in the field have attempted
to control for “other”types of trauma when attempting to examine race-based trauma (i.e.
they have not asked participants to identify if they have experienced non race-based trau-
matic events or if they had previously been diagnosed with PTSD). This finding highlights
the importance of control in future research abound race-based trauma.
A closer look at Swift’s(2010) study with a non-veteran population reveals other
sources of trauma were indeed well-controlled for and this study reveals moderate to
strong correlations between oppression and the Trauma Attachment and Beliefs (TABS)
subscales of self-safety and other-safety, highlighting the connection between race-based
experiences with safety concerns. The use of the TABS is particularly noteworthy as it
is designed to assess cognitive schemas easily impacted by trauma (e.g. safety, trust,
esteem, intimacy, and control; Pearlman 2003). The finding of safety being the only cog-
nitive trauma schema related to oppression in the study echoes Carter’s(2007) theory that
race-based traumatic stress may be a unique form of stress.
Similarly, several other studies with non-veteran populations (e.g. Flores et al. 2010;
Khaylis, Waelde, and Bruce 2007; Wei et al. 2012) found moderate correlations
ETHNICITY & HEALTH 13
between PTSD symptoms and racial discrimination. Given that overall, correlations
between non-veteran populations and trauma were moderate at best, it is possible that
PTSD conceptualizations of trauma may not be capturing the full experience of race-
based trauma. In line with this finding, future research should also work to examine theor-
etically unique aspects of race-based trauma that differ from PTSD such as low self-esteem
and anger, as identified by Carter (2007). The strength of associations of low self-esteem
and anger with racial discrimination should also be tested.
Measures of racial discrimination
In terms of measures of racial discrimination, the majority of measures focused only on
the frequency of racial discrimination experiences. It was surprising that only one
measure in our review, The Schedule of Racist Events (SRE; Landrine and Klonoff
1996), examined intensity of the experience, utilizing a combined frequency-intensity
Likert-scale from 0 this event never happened to me to 4 this event happened and I was
extremely upset. Given the breadth of previous research on the stressfulness of racial dis-
crimination, it was surprising that so few studies incorporated measures that examine
intensity of stress associated with the experience of racial discrimination. In our view,
the more advanced measures of racial discrimination are those that go beyond frequency
and account for both frequency and level of stress.
Furthermore, in examining racial trauma, an advancement in racial discrimination
measurement is the examination of symptoms related to specific incidents: all of the
instruments included in this study apart from the Race-Based Traumatic Stress
Symptom Scale (Carter et al. 2013), focused on cumulative experiences of racial discrimi-
nation rather than specific race-based events. In line with the diagnostic criteria of PTSD,
it makes sense for racial discrimination (and potential trauma related to racial discrimi-
nation) to be examined within the context of a specific event. Therefore, in order to
gain an accurate measure of race-based trauma, researchers may want to refrain from
cumulative measures and engage in event-specific inquiries.
Lastly, few studies examined vicarious or generational experiences of racial discrimi-
nation, with the majority of studies focusing only on direct experiences. Researchers
have indicated that vicarious trauma may be particularly important for people of Color:
Helms, Nicolas, and Green (2010) have noted the plausibility that people of Color
“might experience acts against their personhood as stressful or even traumatic”(p. 68).
For example, Dassouri and Silva (1998) describe a Latino American client experiencing
PTSD-like symptoms after witnessing border patrol beatings of Mexican immigrants on
television. Furthermore, given the unique history of racism in the United States (cf.
Feagin 2006), and the wide body of work establishing a potential for intergenerational
transmission of PTSD (Crenshaw and Hardy 2005; Kellermann 2001)asan“invisible”
form of trauma (Franklin, Boyd-Franklin, and Kelly 2006). It is also surprising that
racial discrimination measures typically do not examine intergenerational experiences
of racism and racial discrimination (i.e. experiences of grandparents, parents, friends
passed down to younger generations). Additionally, given the prevalence of and access
to smartphones with video recording capabilities and the growing importance of social
media, it seems crucial to examine vicarious experiences racial discrimination (i.e. the
vicarious experience of trauma via video footage on internet; cf. Bor et al. 2018).
14 K. KIRKINIS ET AL.
The challenge, of course, is that for people of Color, racist events are experienced mul-
tiple times over one’s lifetime (Landrine and Klonoff1996). Therefore, the most compre-
hensive conceptualizations of race-based trauma will need to consider the impact of
specific racist events, cumulative race-based incidents, and the existence of any inter-gen-
erational transmission of trauma, all of which combined could result in a more accurate
measure of race-based trauma. That is to say, race-based trauma may be a more
complex form traumatic stress (Ford 2008) and therefore, more complex measures may
be needed to capture the experience of racial trauma.
Limitations of current literature
While more research is needed to elucidate how race-based traumatic stress differs from
other forms of psychological trauma, the findings from this study shed light on the poten-
tial unique nature of race-based trauma, pointing to the need to expand the notion of
trauma as conceptualized by the DSM-V to include a wider array of experiences that
may be considered traumatic. The current criteria and definition of trauma remains pro-
blematic in that it limits the ability for people with other types of traumatic experiences
(e.g. race-based trauma) to access appropriate diagnosis, medical care, and insurance
reimbursement. Our findings also raise questions about if PTSD symptomology is an ade-
quate measure of race-based trauma due to the weak to moderate correlations between
racial discrimination and PTSD in non-veteran samples. Furthermore, the current
definition of trauma in the DSM-V may be problematic in that it could also contribute
to pathologizing misdiagnoses, especially among people of Color (e.g. clients being diag-
nosed with paranoid personality disorder when they are really experiencing a race-based
traumatic stress reaction). Thus, it remains important for researchers and clinicians to
keep in mind those traumatic events that fall outside the DSM criteria when treating
clients and making differential diagnoses.
A further limitation relates to the current assessment of racism and racial discrimi-
nation. As previously outlined, racism within the U.S. is conceptualized as occurring at
both individual/interpersonal and institutional/structural levels (Jones 2000). However,
as outlined in the current review, most of the assessment of racial discrimination or experi-
ence of racism focus primarily in individual level experiences. The impact of structural
racism, vicarious racism, or intergenerational aspects of racism is difficult to capture in
measures that rely solely on self-report and typically only capture individual experiences
of racial discrimination. As such, there exists the possibility the current findings, though
compelling, remain an underestimate of the relationship between racism, racial discrimi-
nation and trauma-related symptoms (cf. Bryant-Davis, Adams et al. 2017).
Conclusion
The current review as focused on the empirical findings associated with experiences of
racism, racial discrimination and trauma symptoms. The review may serve as an introduc-
tion to the ways that researchers and health professionals can begin to respond, to and
consider the relationship between racial discrimination and trauma. While this review
is based only on studies in the U.S., the findings may serve as a foundation for understand-
ing the negative impact of racial discrimination across nations. The U.S. has a unique
ETHNICITY & HEALTH 15
history and system of racism, yet the experiences of the groups represented in this study
might also be reflective of the experience of other marginalized racial groups outside the
U.S., given research that has examined the impact of racism from a global perspective
(Paradies et al. 2015). The review also serves to highlight the continued need for health
care professionals to be attentive social factors that have a direct bearing on health and
well-being.
Disclosure statement
No potential conflict of interest was reported by the authors.
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