Skip to main content

An Exploration of Implicit Racial Bias as a Source of Diagnostic Error


Recent events led this author to realize that an error made during the Vietnam War by him and others had been due to focusing too narrowly on predisposing factors for PTSD while failing to consciously acknowledge acute systemic stressors. In not accepting that along with the stress of combat, Black troops daily experienced acute pervasive systemic racism, he failed to understand correctly their disproportionately higher levels of PTSD when compared to white troops. Motivating factors to examine this error included a recent movie by Spike Lee. Oral histories of Black veterans were then used to research the experience of Blacks in the military in two world wars and the Vietnam War. Little change in the treatment of Black service members was evident across the time frame which included WWI, WWII and the Vietnam War. An understanding of Shay’s concept of moral injury was found very valuable in understanding the consequences of PTSD.

This is a preview of subscription content, access via your institution.


  • American Psychiatric Association. (1980). Diagnostic and Statistical Manual of Mental Disorders (DSM-3) (3rd ed.). Washington: American Psychiatric Association.

    Google Scholar 

  • American Psychiatric Association. (2017). Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (5th ed.). Washington: American Psychiatric Association.

    Google Scholar 

  • Antonelli, M. (2017). Moral injury. American Journal of Psychoanalysis, 77(4), 406–416.

    Article  Google Scholar 

  • Atkinson, D. (Director). Atkinson, D., Hunt, R., & Williams, B. (Writers). (2012). In their own words: The Tuskegee Airmen. [DVD Video]. Augusta, GA: Bryton Entertainment.

  • Coleman, J. A. (2016). Racial differences in posttraumatic stress disorder in military personnel: Intergenerational transmission of trauma as a theoretical lens. Journal of Aggression, Maltreatment & Trauma, 25(6), 561–579.

    Article  Google Scholar 

  • Dohrenwend, B. P., Turner, J. B., Turse, N. A., Lewis-Fernandez, R., & Yager, T. J. (2008). War-related posttraumatic stress disorder in Black, Hispanic, and majority white Vietnam veterans: The roles of exposure and vulnerability. Journal of Traumatic Stress, 21(2), 133–141.

    Article  Google Scholar 

  • Egendorf, A. (1982). The postwar healing of Vietnam veterans: Recent research. Journal of Hospital and Counselling Psychiatry, 33(11), 901–912.

    Google Scholar 

  • Emery, V. O., Emery, P. E., Shama, D. K., Quiana, N. A., & Jassani, A. K. (1991). Predisposing variables in PTSD patients. Journal of Traumatic Stress, 4(3), 325–343.

    Article  Google Scholar 

  • Guglielmo, T. A. (2010). “Red Cross, double cross:” Race and America’s WW II era blood donor service. Journal of American History, 97(1), 63–90.

    Article  Google Scholar 

  • Hemingway, A. (Director) and Lucas, G. (Producer). (2012). Red Tails. [Motion Picture]. San Francisco, CA: Lucasfilm.

  • Lee, S. (Director & Producer). (2020). Da 5 Bloods. [Motion Picture]. Brooklyn, NY: 40 Acres & a Mule Filmworks.

  • Lepre, G. (2011). Fragging: Why U.S. Soldiers assaulted their officers in Vietnam. Lubbock, Texas: Texas Tech University Press.

  • Levin, E. C. (2020). In my opinion: Shatan should be celebrated for his successes: “Happiness is a warm gun” was not one of them. Studies in Gender and Sexuality, 21, 205–212.

    Article  Google Scholar 

  • Levin, E. C., & Parry, P. I. (2011). Conflict of interest as a possible factor in the rise of pediatric bipolar disorder. Adolescent Psychiatry, 1(1), 61–66.

    Article  Google Scholar 

  • Loo, C. M. (2019). PTSD among ethnic minority veterans. Washington, DC: U.S. Department of Veteran Affairs.

  • Luke, S. (Director) & Bloxom, D. (Producer). (2019). The great war. [Motion Picture]. Santa Monica, CA: Schuetzle Company Productions.

  • Markowitz, R. (Director) & Petrucelli, J. (Producer). (2012). Double Victory: The Tuskegee airmen at war. [Online video]. San Francisco, CA: Lucasfilm Documentaries.

  • Markowitz, R. (Director) & Price, F. (Producer). (1995). The Tuskegee airmen. [Motion Picture]. New York: Home Box Office & Time Warner Productions.

  • Maslin Nir, S. & Fondren, P. (2021). Buffalo soldiers, the famed Black Cavalry, get a statue at West Point. New York Times, September 12th, 2021.

  • Motley, M. P. (1975). The invisible soldier: The experience of the Black soldier, WW II. Detroit, MI: Wayne State University Press.

    Google Scholar 

  • Nichols, D. A. (2007). A matter of justice: Eisenhower and the beginning of the Civil Rights revolution. New York, NY: Simon & Schuster.

    Google Scholar 

  • Parson, E. R. (1985). Ethnicity and traumatic stress: The intersecting point in psychotherapy. In C. R. Figley (Ed.), Trauma and its wake. Volume I: The study and treatment of post-traumatic stress disorder. (pp. 314–337).

  • Rendon, M. (2020). The morality of evolution and a return of subjectivity. American Journal of Psychoanalysis, 80(1), 1–15.

    Article  Google Scholar 

  • Renner, J. A. (1973). The changing pattern of psychiatric problems in Vietnam. Comprehensive Psychiatry, 14(2), 169–181.

    Article  Google Scholar 

  • Shay, J. (1991). Learning about combat stress from Homer’s Iliad. Journal of Traumatic Stress., 4(4), 561–579.

  • Shay, J. (1994). Achilles in Vietnam: Combat trauma and the undoing of character. New York, NY: Scribner.

    Google Scholar 

  • Smith, W. H., Ternes, E., & Wright, J. J. (Writers). (2000). The invisible soldiers: Unheard voices. (Stories of Black Soldiers in WW II). [DVD Video.] Sudbury, MA: WHS Media Productions. Black Filmmakers Hall of Fame. 2004.

  • Steenkamp, M. M., Schlenger, W. E., Corry, N., Henn-Hasse, C., Qlan, M., Li, M., Horesh, D., Karstoft, K.-I., Williams, C., Ho, C.-L., Shalev, A., Kulka, R., & Marmar, C. (2017). Predictors of PTSD 40 years after combat: Findings from the National Vietnam Veterans longitudinal study. Depression and Anxiety, 34(8), 711–722.

    Article  PubMed  Google Scholar 

  • Terry, W. (1984). Bloods: Black veterans of the Vietnam War: An oral history. New York, NY: Ballantine Books.

    Google Scholar 

Download references

Author information

Authors and Affiliations


Corresponding author

Correspondence to Edmund C. Levin.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Edmund C. Levin, M.D., was an active staff member at the Alta Bates Medical Center from 1976 to 2001 and an affiliate staff member, since 2001. He is Chair of the ABMC Psychiatric Grand Rounds Committee, Department of Psychiatry.

Address correspondence to: Edmund C. Levin, M.D., 38 Seagull Drive, Richmond, CA 94804, USA. E-mail:

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Levin, E.C. An Exploration of Implicit Racial Bias as a Source of Diagnostic Error. Am J Psychoanal 81, 496–510 (2021).

Download citation

  • Published:

  • Issue Date:

  • DOI:


  • Vietnam
  • military
  • PTSD
  • moral injury
  • systemic racism
  • Black Lives Matter
  • pseudospeciation vs. cultural differences