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REVIEW ARTICLE
Dis Manage Health Outcomes 2003; 11 (4): 233-248
1173-8790/03/0004-0233/$30.00/0
 Adis Data Information BV 2003. All rights reserved.
Importance of Cultural Sensitivity in
Therapeutic Transactions
Considerations for Healthcare Providers
Oyedeji Ayonrinde
Maudsley Hospital, Denmark Hill, London, UK
Contents
Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
1. Culture and Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
1.1 Health and Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
1.2 Therapeutic Transactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
1.3 Stereotyping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
2. Culture and Care Pathways . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
2.1 Culture, Assessment and Diagnostic Bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
2.2 Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
2.3 Hospitalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
2.4 Prognosis and Treatment Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
3. Cultural Aspects of Sociodemographic Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
3.1 Migration and Acculturation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
3.2 Social Structures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
3.3 Religion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
3.4 Children and Child-Rearing Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
3.5 The Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
3.6 Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
3.7 The Family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
3.8 Lifestyle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
4. Symptom Presentation: Somatization and Pain Across Cultures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
5. Physician–Patient Communication and Culture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
5.1 Principles of Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
5.1.1 The Interpersonal Relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
5.1.2 Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
5.1.3 Non-Verbal Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
5.1.4 Decision Making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
5.1.5 Psychological Privacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
5.1.6 Social Privacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
5.1.7 Physical Privacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
5.2 Language in the Cross-Cultural Clinical Encounter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
5.3 Translating Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
5.4 The Interpreter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
5.5 The Therapist in the Cross-Cultural Dyad . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
5.6 ‘Color Blindness’ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
6. Culture, Ethnicity and Pharmacotherapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
7. Organizational Sensitivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
8. Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
9. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246
234
Ayonrinde
Abstract
Culture influences all spheres of human life. It defines health, illness, and the search for relief from disease or
distress. With increased mobilization of people across geographical and national borders, multicultural trends are
emerging in many countries. This is reflected in the cultural diversity presenting to clinicians in their daily
practice. With these presentations, patients bring their own world views, expectations, norms and taboos to the
clinical transaction. Cross-cultural transactions occur when two or more of the participants are culturally
different.
Although it is impossible to be conversant with all cultures, clinicians should be sensitive to the role culture
plays in their practice without stereotyping patients. Culture influences help-seeking or care pathways, and may
bias the process of assessment and choice of management. The interplay of patient culture, clinical setting and
clinician culture can pose significant challenges experienced against a backdrop of other factors such as age,
gender, religion, and acculturation.
Language, even when shared, does not ensure skillful clinician–patient communications as there are different
culture codes for interpersonal relationships, disclosure, privacy, and non-verbal communication. Linguistic
difficulties can be partially overcome with the use of an interpreter, a triangular relationship with its own
dynamics requiring skill and sensitivity.
The cultural matching of patient and therapist is complex and may be complicated by the emergence of other
differences that may be equally challenging. However, awareness of this should serve to reduce the number of
differences.
Cultural sensitivity in patient care is associated with a number of positive health outcomes, including
improved patient satisfaction.
1. Culture and Illness
Culture can be defined as the symbolic and learned nonbiological aspect of human society, including language, custom
and convention, by which human behavior can be distinguished. It
guides how people live, what they generally believe and value,
how they communicate, their habits, customs and tastes. It also
organizes our cognitions, emotions and behaviors in both subtle
and obvious ways that may be beyond awareness.[1,2] Culture is a
non-static heterogeneous phenomenon with complex and fluid
boundaries. With these characteristics, culture unavoidably impacts on the ways in which people interpret and perceive health
and illness, and their choices in seeking and providing care (table
I).
The relationship between culture and illness is a close yet
complexly interwoven one. This relationship impacts on all levels
of illness presentation and treatment and can be summarized as
follows:
• defining ‘normality’ and ‘abnormality’
• etiological role in some disorders
• influencing clinical presentation and its interpretation
• influencing rates and distribution of illness
• determining the recognition, labeling, and explanatory models
of disorders
• determining treatment options and care pathways within a
society
 Adis Data Information BV 2003. All rights reserved.
•
influencing the outcome of treatment interventions.
1.1 Health and Disease
Definitions of ‘normality’ and ‘health’ vary globally within and
across national, geographical, cultural and subcultural boundaries,
influencing societal perception of the appropriateness of social
behavior, health, illness and disease. Disease is the malfunctioning
of biological, psychological, or physiological mechanisms. Illness,
however, represents personal, interpersonal, and sociocultural explanations of, and reactions to, diseases and their consequences.[2]
In most cultures, society recognizes that there are certain situations
when ‘abnormal’ behavior is permissible (usually conforming to
recognized codes). For instance, during fancy dress parties, traditional festivals and carnivals, people may dress as animals or
cross-dress.
Occasionally, an apparently circumscribed behavior may be
viewed differently within the same society. For example, diverse
groups may see alcohol consumption as normal, taboo, immoral, a
symptom of psychological disorder, or even a vital part of rituals
or religious occasions.[4]
Recognition of illness or disease is often followed by a quest for
treatment or alleviation of distress.
1.2 Therapeutic Transactions
Therapeutic transactions occur during all forms of interaction
between health professionals and their patients. This process may
Dis Manage Health Outcomes 2003; 11 (4)
Cultural Sensitivity in Therapeutic Transactions
Table I. The cultural formulation (adapted from the Diagnostic and Statistical Manual of Mental Disorders [4th edition], text revision[3])
Cultural identity
Ethnic/cultural reference group(s)
Degree of involvement with both culture of origin and host culture
Language (abilities, use, preference, multilinguistic)
Cultural explanation of the individual’s illness
Predominant idiom(s) of distress
Meaning of symptoms
Perceived severity of symptoms in relation to cultural norms
Perceived causes or explanatory models of illness
Past experiences of care
Current preferences
Cultural factors related to psychosocial environment and levels of
functioning
Interpretation of social stressors
Availability of social support
Level of functioning/disability
Cultural elements of relationship between individual and clinician
Differences in cultural and social status
Problems associated with these differences
communication
elicitation of symptoms
cultural significance
negotiating relationship
Overview of cultural assessment and impact on diagnosis and care
be conscious, partially conscious or even unconscious to both
parties (figure 1).
The transactions involve:[5] (i) a ‘healing agent’/‘healer’ (not
necessarily a professional); (ii) a ‘sufferer’ seeking relief from the
‘healer’; and (iii) a healing relationship between sufferer and
healer.
Culture may influence any of the above variables.
A cross-cultural therapeutic alliance is any therapeutic relationship in which two or more of the participants are culturally
different. This intercultural interaction involves users of health
services who bring their specific values, beliefs and expectations
about health, illness and appropriate healthcare to the health
system.[6]
Global migration and demographic shifts have led to the multiculturalization of many countries, such as the US, UK, Australia,
and Canada, with increasing diversity of ethnicity, customs, languages, and identities in all walks of life.
This diversity is also reflected in the patient lists of family
physicians and primary care practitioners, and inevitably poses
challenges to healthcare providers, particularly in gateway cities,
 Adis Data Information BV 2003. All rights reserved.
235
points of debarkation, urban communities, and rural communities
with migrant workers.[7]
A study of 12 000 family therapists in California observed that,
although 94% of the therapists were White, 66% of clients were
from other racial and ethnic groups.[8] Rates and distribution of
cross-cultural clinical transactions are invariably influenced by
epidemiological trends, manpower, help-seeking behaviors, and
health service structure.
Practically speaking, it is impossible to be familiar with the
cultural norms of all ethnic and social groups. Neither will all
cultural issues presented be relevant. The challenge for the health
professional is to effectively screen clinical and cultural information for their significance in patient management. How does
culture influence the patient, therapist, and therapeutic process?
How should the therapist deal with cultural differences?
Literature on the influence of culture on therapeutic processes
has focussed on issues such as group characteristics, values,
norms, taboos, needs, strengths, and weaknesses of cultural
groups.[1,2,6-8] Culture-bound syndromes have also been of interest.[9] Although the general consensus is that there is a need for
awareness of cultural differences, there are differing opinions on
the significance of this awareness and its therapeutic benefits.
Some authors[10] stress that ethnicity is just one of a number of
influences in therapeutic transactions, and a strong focus on
ethnicity may overestimate other differences between therapist
and client. Other authors[7,8] emphasize that a lack of awareness of
cultural or ethnic issues may compromise the therapeutic process.
Another view is that there is a need for therapist awareness of
their own ethnicity, and the impact or limitations of this on their
relationship with clients[11] as other variables come to play within
and across cultures. Some clinicians contend though that ethnicity
is not as important as therapeutic skill in understanding clients.
The view held by some health professionals that if each patient
is treated with respect cultural problems will be averted[12] is
fraught with problems, although well meant. Others advocate a
posture of ‘cultural naiveté’ and ‘respectful curiosity’ as being as
important as acquiring skills about specific cultural groups.[13]
1.3 Stereotyping
A danger of emphasizing cultural differences in clinical practice and research is that of stereotyping people or reinforcing racial
views. Stereotyping is the ascription to an individual of characteristics associated with a group of people, or extending to a group
characteristics attributed to a single individual.[14] Both the professional and patient may find themselves drawing on stereotypes in
unfamiliar or challenging situations, regardless of their culture.[15]
However, one must caution that ethnoracial group labels may
Dis Manage Health Outcomes 2003; 11 (4)
236
Ayonrinde
Patient
Clinician
1. Assumptions about
illness
2. Expectations of
clinician role
3. Preferences for
treatments
4. Expresses symptoms
in culturally
determined way
5. Communicates
construct of disorder
to clinician
6. Accepts/rejects
proposed treatment
7. Appraises outcome
against cultural
constructs
1. Assumptions about
nature and control
of illness
2. Expectations of
patient role
3. Preferences for
treatment modalities
4. Examines for
signs/symptoms of
illness
5. Communicates
decisions to patient
6. Implements
treatment
7. Appraises outcome
against medical
constructs
Individual variables
1. Age
2. Gender
3. Sexuality
4. Ethnicity
5. Identity
6. Social class
7. Religion
8. Health system
9. National and local policy
Fig. 1. The patient–clinician cultural interface.
erroneously suggest attributes that may therefore be clinically
2. Culture and Care Pathways
misleading.
•
An Asian patient checks his watch during a routine medical
consultation with a locum practitioner. Noticing this, the locum
asks if he needs to return to the ‘family business’. The patient
replies ‘I am a doctor too and running late for my clinic’.
Selective perception can perpetuate stereotypes in clinical
transactions. Unlike stereotypes, generalizations may be a useful
framework in some situations.[12] So while stereotypes are ending
points (such as conclusions about persons and their background or
way of life), generalizations serve as a starting point about common trends within a group (with recognition that further information would be required as applies to the individual).[12] Although
these processes are inherent to medical training, further sensitivities are required across cultures. This review aims at providing
principles while cautioning against the clinical and therapeutic
risks of generalizing. Table II provides a glossary of terminology
used.
 Adis Data Information BV 2003. All rights reserved.
Definition and expression of disease, illness and distress vary
across cultures.[2] Culture influences help-seeking behaviors and
ultimately affects care pathways.[16]
Numerous descriptions of pathways to care have been reported
in the scientific literature for different ethnic groups, for instance
the Turkish in the UK,[17] African Caribbeans in the UK,[18]
Russians in the US,[19] Asians in the US,[20] Bedouin Arabs,[21] and
Vietnamese in Australia;[22] these studies consistently demonstrate
differences between majority and minority groups.
Researchers in the US[23] observed ethnic and cultural differences in the use of alternative therapies among women with breast
cancer. Chinese women preferred herbal remedies (22%), Latino
women used dietary therapies (30%) and spiritual healing (26%),
Black women preferred spiritual healing (36%) and White women
preferred dietary (35%) and physical (21%) methods. Treatment
delay in some groups, e.g. Asian Americans, may be associated
with conceptualization of distress as a manifestation of underlying
medical problems amenable to indigenous, alternative, or home
remedies.[24] Past experience of discrimination or prejudice may
Dis Manage Health Outcomes 2003; 11 (4)
Cultural Sensitivity in Therapeutic Transactions
237
Table II. Glossary of terminology
Term
Definition
Culture
The symbolic and learned non-biological aspect of human society, including language, custom and convention by
which human behavior can be distinguished. It guides how people live, what they generally believe and value, how
they communicate and their habits, customs, and tastes
Race
The phenotypic features of a group that distinguish it from others, e.g. skin color, eyes
Ethnicity
The cultural practices and outlooks of a given community of people that sets them apart from others. Different
characteristics such as language, history, ancestry (actual or perceived), religion, and nationality may serve to
distinguish these groups. Ethnic differences are wholly learned with individual awareness of group membership
Cultural identity
The extent to which an individual endorses and manifests the cultural traditions and practices of a particular group
White
In the broadest sense, members of a light-skinned race. Loosely used to refer to people of European ancestry
Black
In the broadest sense, members of a dark-skinned race. Loosely used to refer to people of African descent. Individuals
of Black African origin have been described as colored, Negro, Black and African American in the US, while in the UK
persons of similar ethnic heritage have been described as Black, Afro-Caribbean, African Caribbean and Black British
Asian
Used differently in American, British and Australian literature. For example, Asian American (Japanese, Chinese,
Philippine, Korean), South East Asian (Vietnamese, Cambodian), and Asian Pacific Islanders (Hawaiian, Samoan). On
the whole, ‘Asian’ in the UK refers to the Indian subcontinent (India, Pakistan, Bangladesh)
Hispanic
Represents language (Spanish speaking), family name (Spanish surname), ancestry (Hispanic American), Latino
(country of origin). Being Hispanic does not necessarily mean the individual speaks Spanish
People of color
Persons whose ostensible ancestry is at least in part African, Asian, or indigenous, and/or combinations of these
groups and/or White or European ancestry
Transference
The patient’s thoughts and emotional response to the therapist
Countertransference
The therapist’s thoughts and emotional response to the patient (this may impede clinician objectivity or enhance the
transaction)
result in suspiciousness, mistrust and avoidance of health services.[25] Physician awareness, stigma, and availability of other
treatment modalities also play a role. Ethnic and cultural differences may also influence referral patterns to specialist services.[26,27]
The majority of patients and their caregivers select from a wide
array of therapeutic options available to them, of which medical
services are only one.
2.1 Culture, Assessment and Diagnostic Bias
Studies (for example, Cooper et al.[28]) have described varying
rates of diseases and disorders across ethnic and cultural groups in
community, primary care, and hospital populations.[29-31] Although
some disorders, e.g. cystic fibrosis and sickle cell disease,[32] show
higher prevalence rates in ethnic groups with a genetic predisposition, racialization of these disorders may neglect persons lacking
overt phenotypical features. Interethnic variation has been reported in the interpretation and expression of pain.[33]
In the US and the UK, overdiagnosis of schizophrenia and
underdiagnosis of affective disorders has been observed among
African American and African Caribbean populations, and Asian
Americans with mood disorders are more likely to be misdiagnosed with schizophrenia.[29] It is crucial for accurate detection
 Adis Data Information BV 2003. All rights reserved.
and monitoring of disorders that when rating scales are used for
cross-cultural assessments they should be standardized, validated,
reliable, specific, and sensitive to the culture. Literacy can also
influence assessment outcomes.
2.2 Expectations
Expectations about treatment influence help seeking, discontinuation of therapy, compliance with medication and its effectiveness.[30,31,34] Both clinician and patient have their own expectations
of the consultation (figure 1). Cultural differences, prejudicial or
stereotyped expectations may create therapeutic misalliance.[35]
2.3 Hospitalization
Regardless of culture, the experience of hospitalization may be
stressful. The culturally different individual, already anxious, experiences a new community, loss of liberty, privacy and a change
in daily routine, e.g. waking, meal, medication and visitor times.
The hospital, like other subcultures, has its own codes and encourages conformity. Hence, the patient may feel doubly alien. In
hospital, patients are occasionally exposed to patients or
caregivers of different backgrounds who may be ignorant, repugnant, or perplexed about their differences.[32,34] Alienation serves
to hinder therapeutic response with variable outcomes.
Dis Manage Health Outcomes 2003; 11 (4)
238
•
Ayonrinde
A female Somali refugee from a rural farming background was
admitted to a maternity unit shortly after arrival in the UK. She
found fetal monitoring and examination by the male physician a
terrifying experience. Unable to share her anxieties with staff,
she kept to herself. She found the food unfamiliar and was
stared at by other patients with discriminatory curiosity. Her
previous successful pregnancy had been under the skillful
supervision of her elderly aunt, a joyous experience.
2.4 Prognosis and Treatment Outcome
Although the patients’ right to know should be respected, in
some cultures the norm is for the patient’s family to be initially
informed of a poor prognosis, after which decisions are made on
how to notify the patient.[12] Relatives may perceive the physicians
breaking difficult news to the patient as insensitive and even
hastening death. Clinicians face the risk of unwittingly colluding
with family members against the wish of their patients, and
ultimately need to be guided by the ethics of confidentiality.
3. Cultural Aspects of Sociodemographic Issues
3.1 Migration and Acculturation
Psychological and physical morbidity have been widely reported in immigrant groups.[36,37] Migration is associated with disequilibria of social networks, family, community, and physical
environment[37] which are all major contributors to individual
identity. There are four stages of migration trauma: (i) pre-migration; (ii) transit; (iii) asylum seeking/resettlement; and (iv) substandard living and minority persecution.[37] Clinicians must not
ignore the effects of post-traumatic stress disorder resulting from
war, torture, or witnessing conflict. Presentation may differ during
stages of acculturation (the process by which a new culture is
acquired), even within the same ethnic group.[37,38] Patients of
uncertain immigration status may find medical interviews probing,
intrusive and may be cautious or withhold information for fear of
adverse outcomes.
3.2 Social Structures
Different social structures and hierarchies exist within and
between cultures. Across these structures, social class, caste, and
educational differences may emerge between the clinician and
patient. For instance, a traditional African chief may face status
contradiction when addressed by first name by a clinic receptionist. Many immigrants experience a conflict of, or decline in, status
during the period of acculturation. Patient communication and
behavior may also show deference towards the authority figure of
the clinician.
 Adis Data Information BV 2003. All rights reserved.
3.3 Religion
Religion is an integral part of culture in many societies. In fact,
some cultures are defined by their religious practices such as diet,
prayer routine, sacred days, prohibitions, rites, dress codes, and
even attitudes. Religion may lead to disagreement over value
systems, power brokering, denial or even collusion between therapist and patient.[34,39] A lack of awareness or sensitivity about the
patients’ religion may be perceived as offensive. For instance, a
Sikh person may feel insulted being referred to as Hindu,[39] as
would an Irish Protestant referred to as Catholic. On a similar vein,
a seemingly innocuous question such as ‘what is your Christian
name?’ may be perceived as insensitive if asked of a Muslim
patient.
The pitfalls of pathologizing normal religious experience cannot be underestimated.
• A member of a Black Pentecostal church presents to his family
practitioner reporting that he had heard ‘the voice of God’
directing him to seek help for his distress. The practitioner
remembers discretely observing him several weeks earlier
speaking incoherently with head shaking and swaying motions
while visiting his sick child. He promptly requested a psychiatric opinion. In Pentecostal faith it is not uncommon to ‘hear
God’ and to ‘speak in tongues’[40] as opposed to the experience
of auditory hallucinations with abnormal stereotyped movements. ‘Stereotype-looking’ behavior may also be observed in
other forms of worship.
Religious awareness without sensitivity could undermine therapeutic relationships as well.
• A devout Sikh man was offered chemotherapy/radiotherapy for
the treatment of cancer. The attending oncologist painstakingly
explained possible adverse effects and their relative risks. He
also cautioned that the patient would have global alopecia from
the treatment. One of the founding tenets of Sikhism is that
males must not cut their hair. Although the physician had
explained the procedure in detail, the patient was left in a
quandary: faith with cancer, or diminished adherence to his
faith and treatment. Although the oncologist was aware that
hair loss would be difficult for the patient, he was insensitive to
the emotional impact.
In close-knit communities, stigmatization of illness may lead
people to seek care from other cultural or religious groups, in
order, for example, to avoid jeopardizing opportunities for marriage.[34]
As a religious safeguard against improper sexual behavior, two
people of opposite sex are not permitted to be alone in a potentially
intimate situation in Orthodox Jewish and some other Middle
Eastern faiths. Similarly, casual touching or handshaking (taken
Dis Manage Health Outcomes 2003; 11 (4)
Cultural Sensitivity in Therapeutic Transactions
for granted in some cultures) is prohibited between men and
women in other cultures.[34] In such interactions, interpersonal
distance should be respected and may require for doors to be kept
unlocked or ajar in some situations and immodest dress avoided.
3.4 Children and Child-Rearing Practice
Child-rearing practices not only differ between families but
across cultures. Children imbibe family values and their parents’
culture as well as that in which they live. Health service usage by
children is greatly influenced by decision-making adults in the
household.[28] Adolescence, a period of physical and psychological
change, is characterized by a need to identify with the peer group.
This may be challenging for ethnic minority children who experience ‘identity confusion’ and requires sensitive attention.[39,41]
Children may be treated using cultural remedies before presentation, e.g. the Asian practice of ‘coining’, in which a coin, heated
or oiled, is rubbed on the patient’s back to extract illness; the
ensuing welts are evidence of a successful procedure.[12] Such
traditional remedies may be mistaken for physical abuse and may
lead to the initiation of child protection proceedings.[42]
3.5 The Elderly
The roles of the elderly are dictated by tradition and strong
cultural beliefs[43] that also influence attitudes toward aging. Elderly migrant persons are more likely to seek help in primary care
than through specialist services.[19] They also have greater physical
morbidity than younger persons. Unique issues of the older migrant include acculturation difficulties, e.g. dietary changes, financial limitations (less likely to be able to compete in the job market)
and narrow social networks.
Cross-cultural impact on symptom presentation, behaviors and
caregiving style have been described among the elderly, e.g.
different rates of Alzheimer’s disease between African American
and African groups.[44] The clinician should not be surprised if
families from some groups express reluctance to relinquish support for their elderly to ‘outsiders’, as this contravenes traditional
care values.[12,38]
3.6 Gender
Gender roles and their significance vary across cultures. In
many less industrialized cultures men have a traditional provider
role while women are responsible for child rearing. Gender role
reversals in therapeutic encounters could pose problems for some
patients. Transgenerational cultural deference to men is encouraged in some Asian (and African) societies; from daughters to
fathers, wives to husbands and in old age, mothers to sons.[45]
 Adis Data Information BV 2003. All rights reserved.
239
Cultural variables influence various spheres of female service
utilization. In the UK, investigators found that spoken English and
social class influenced patterns and quality of maternity services,
with reduced satisfaction amongst ethnic minority groups.[46] In
The Netherlands, immigrant women (Surinamese, Antillean,
Turkish and Moroccan) were heavier users of social work facilities
and crisis centers than were local counterparts.[47]
Multicultural contraceptive service provision is complex.[48]
Muslim opinion with regard to contraception ranges from prohibition to acceptance.[49] This is reflected by the different rates (5% to
over 50%) of contraceptive use in some Muslim countries.[49]
Clinicians should clarify individual opinion and knowledge about
contraception in such services. The practice in some rural West
African cultures of prolonged breastfeeding also serves a contraceptive role, as does adults sharing sleeping quarters with children
in some Asian societies.
Menstruation exempts Muslim women from important religious rites, and may explain reluctance in some quarters to seek
help for gynecological symptoms, cervical smears or intrauterine
devices for fear of bleeding. Women unaware that traumatic
bleeding is distinct from menstrual bleeding may unknowingly
impose religious restrictions.[49] Cultural sequelae of menstruation
have also been described in Jewish populations. [50]
3.7 The Family
In many non-Western cultures, identity is entrenched in interpersonal family relationships[39,49] with family obligations overriding personal ambition. If successfully negotiated, this brings pride
to the family – otherwise, shame.[51,52] Culture interacts with the
family life cycle at all stages, defining roles,[53] transitions, tasks
and rites of passage appropriate to each stage.
In some groups, the head of the family is crucial to help-seeking
decisions and is consulted (sometimes in the country of origin) in
matters of distress.[39] Immigrant families may initially be of lower
socioeconomic status or educational achievement than the general
population; hence, health needs are prioritized against other requirements.
It is suggested that family therapy may be more acceptable than
previously thought to those from family-oriented countries.[54]
Treatment approaches emphasizing family and community have
been effective in Western cultures by encouraging sociocentric
family practices as therapeutic tools. Alternatively, treatment strategies may be doomed to failure if they are viewed by family
members as threatening to family integrity.[55]
Where families present with a ‘spokesperson’ this may compromise presentation of sensitive issues, e.g. sexual abuse.[56] One
should caution that cultural sensitivity to the extent of collusion
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240
Ayonrinde
with families or against medical ethics could be counterproductive, if not damaging. The decision to exclude ‘significant others’
should also be given careful consideration.
• A Somali couple present with their young daughter requesting
advice on local services for female circumcision. The female
practitioner finds this request abhorrent and attempts to counsel
them on the hazards and implication of such a procedure. The
girls’ father explains ‘It is our culture! It has been the practice
of our mothers, wives and daughters over generations.’ The
practitioner replies ‘I must also warn that it is illegal.’ Although
culturally sanctioned, this practice is not condoned in many
countries.[57-59]
Marriage between partners of different ethnic groups, religious
communities or castes (e.g. Muslim-Christian, Hindu-Sikh, African-Chinese) presents families with the task of redefining their
identity.[38] Presentation of such couples or their offspring would
require sensitivity to their transitions or renewed identity.
3.8 Lifestyle
Lifestyle is diverse within and across culture, and includes diet,
clothing, sexual mores, education, recreation, and spirituality.
Hence, health information leaflets with pictures of golfers or
graduates in academic gowns may alienate some patients. Advice
on diet and exercise should also be alert to diversity, e.g. halal and
vegetarian.[60] Many relished traditional dishes and ingredients do
not have translatable English equivalents. The unemployed migrant looking to provide for his family may find medical advice to
register with a gymnasium impracticable or not a priority.
There is clear evidence that with acculturation lifestyle trends
such as patterns of alcohol use change in migrant groups.[61]
Lifestyle changes can increase the risk of other health problems.
4. Symptom Presentation: Somatization and Pain
Across Cultures
At all levels of care, physicians see patients presenting with
somatic symptoms such as headache, weakness, and pain. The
perception of pain and psychological distress varies from culture
to culture.[60] Presentation of somatic symptoms is widespread
among patients with depression.[62-64] Earlier reports depicted somatic symptoms as an alternative idiom of distress, prevalent in
cultures where illness carried great stigma[65] and that this was
more common in patients from non-Western countries.[66,67] Other
authors[17] proposed that in cultures where the body-mind dichotomy is not as salient as in Western societies, it would be natural to
express distressing emotions through bodily complaints. Interestingly though, these views were not supported by a 14-country
international study.[68] Researchers argue that the concept of soma Adis Data Information BV 2003. All rights reserved.
tization rests on the culturally determined assumption about the
secondary nature of somatic symptoms.[68] Idiomatic expressions
of somatic complaints vary across cultures,[17] e.g. ‘heat in the
head’ in some African cultures,[69] and ‘heartbroken’ in Western
societies.
Current evidence demonstrates the term ‘somatization’ refers to
a variety of phenomena,[68,70] with different research and clinical
definitions[65,71-73] as follows: (i) patients who report only somatic
symptoms as the reason for visiting the physician;[71] (ii) reporting
of medically unexplained somatic symptoms as a presentation of
depression;[72] and (iii) denial of psychological symptoms of depression on direct questioning. Rates were inconsistent and not
associated with technological development. Only 4% of patients
met all three definitions, therefore raising doubts on some research
in this area.
Somatic complaints may not reflect reluctance or an inability to
acknowledge psychological distress.[68] In some cultures, the reporting of somatic symptoms may seem a more appropriate route
for seeking help from the primary care therapist. This ‘facultative
somatization’ thus provides a ‘ticket of admission’ to the primary
care service.[71]
Given the frequency of somatic complaints during cross-cultural consultations, the clinicians’ challenge lies in unraveling what is
being communicated by the patient[74] as presentation of a ‘headache’ may also bring fear, anger, worries, and frustrations.[17] Or,
in the case of traditional Chinese medicine, an association between
internal organs and individual emotional states, e.g. happiness in
the heart, anger in the liver, worry in the lung, fear in the kidney,
and desire in the spleen.[75]
5. Physician–Patient Communication and Culture
5.1 Principles of Communication
Communication between physicians and patients is one of the
most complex interpersonal relationships. The principle is the use
of communication as a tool in the identification of health problems
with a view to achieving a health solution. It involves individuals
in non-equal positions, often non-voluntary, concerns issues of
vital importance, is emotionally laden and requires close cooperation,[76] and is all the more complex when across a cultural
gradient. Intercultural communication occurs whenever a message
produced in one culture has to be processed in another culture.
Clinical communication influences patient satisfaction, treatment
adherence, understanding of medical information, well-being, and
quality of life.[77] The following sections consider key elements in
physician–patient communication.
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Cultural Sensitivity in Therapeutic Transactions
241
5.1.1 The Interpersonal Relationship
approaches[78]
Advocates of patient- or client-centered
stress
the importance of empathy, respect, genuineness, unconditional
acceptance, and warmth. Others[79] suggest an amalgamation of
both ‘patient-centered’ and ‘physician-centered’ approaches
whereby the patient is the expert regarding their symptoms, preferences and concerns and the physician in diagnosis and treatment.
Both techniques are applicable in cross-cultural transactions.
5.1.2 Information
Information is the key to diagnosis and to the formulation and
implementation of a treatment strategy. Regardless of culture, all
patients want to feel understood, as do clinicians. This may present
a number of challenges, particularly across linguistic barriers (see
section 5.4 on language and interpreters). To engage the patient the
therapist must explicitly educate him/her about the purpose of
questions[55] Cultural differences occur in clinician attitudes and
communication style, e.g. the word ‘cancer’ may be substituted
with words such as ‘growth’, ‘unclean tissue’ or ‘blood disease’.[80] Patient communication styles also influence the amount
of information clinicians give to patients;[81] particularly, female
patients[82] tend to express more concerns, ask more questions, be
more anxious, and receive more information. Linguistic and socioeconomic factors may compound the ability to acquire medical
information, the amount of which may range from minimal to
overload via the Internet.[83] Different illness models between
patient and therapist can also lead to etiological dispute, e.g. the
belief by a Bangladeshi man that lack of sweating in the UK was a
cause of diabetes mellitus.[84]
5.1.3 Non-Verbal Communication
Non-verbal communication has even greater salience in transactions with limited linguistic ‘bridging’. Although it has been
reported[85] that only 7% of emotional communication during
medical interviews is conveyed verbally, 22% transmitted by tone
of voice and 55% by visual cues (e.g. eye contact or body posture),
little has been done to evaluate this across cultures. Mediterranean
cultures, for instance, are more explicitly physical in everyday
interactions, and body language may say more than verbal communication in some situations.[17] The ready smile of some patients
from African cultures may mask underlying distress.
Culture influences the emotional tone of interpersonal exchange such as tone of voice, gaze, posture, facial expressions,
laughter, touch, gesticulations, and physical distance.[77,86,87] Reduced eye contact in a number of cultures communicates respect or
deference and not ‘shiftiness’. As therapeutic encounters are often
emotionally laden with anxiety or even fear, patients scan for
subtle cues to the seriousness of their illness. Inconsistencies
 Adis Data Information BV 2003. All rights reserved.
between therapists’ verbal and non-verbal communication may
suggest a lack of genuineness to the wary patient.[77]
5.1.4 Decision Making
Decision-making in contemporary medical practice encourages
clinician and patient involvement. The authoritarian, ‘paternalistic’ or controlling physician may be perceived as threatening, yet
authoritative or directive communication is seen as a sign of
competence by others.[38,55] Transactions with traditional healers
are often prescriptive, with clear definition of tasks, and their
competence is evident in their ability to effuse authority.[88]
5.1.5 Psychological Privacy
Psychological privacy[89] includes the right to determine with
whom and under what circumstances thoughts and feelings are
shared. Black and Asian groups may be reserved or even reluctant
to discuss problems outside the family.[39,55] A lack of appreciation
of cultural aspects of self-disclosure may lead to patients being
perceived by therapists as guarded, concealing information, or
even paranoid. Mistrust due to genuine or perceived racial or
discriminatory experiences also influences patient disclosure to
clinicians.[90]
5.1.6 Social Privacy
Social privacy involves the control of social contacts in order to
manage interactions or maintain status divisions. Across cultures,
formality, conversational topics, and language are determined by
social codes. ‘Platica’ – the need to talk informally about irrelevant topics before proceeding to the more serious and relevant –
has been described among Hispanics.[40] Patients may feel uncomfortable being addressed on first name terms.
5.1.7 Physical Privacy
Physical privacy, accessibility to others and the definition of
personal space are influenced by culture, ethnicity, and gender.
The physicians’ ‘caring’ proximity may seem threatening. Some
cultures are ‘touch oriented’, e.g. some Turkish patients have little
faith in physicians who do not touch them,[17] whereas others, e.g.
Islamic and Orthodox Jewish, discourage this, particularly across
genders.
5.2 Language in the Cross-Cultural Clinical Encounter
Unique to all cultures are the denotations, connotations, grammar, accents, dialects, and functionality inherent in their languages. Even when the ‘same language’ is being spoken, educational, class and regional differences emerge.[6]
• A young African-Caribbean boy tells a health worker that his
uncle is ‘wicked’, with flagellating and flicking motions of his
fingers. Concerned that the boy was being physically hurt, child
protection proceedings are initiated. A family crisis follows.
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Ayonrinde
The word ‘wicked’ was used to describe this ‘favorite’ uncle
using street parlance and the hand motions emphasizing how
special he was.
Clinicians should seek to contextualize and clarify narratives
before concluding therapeutic interventions, as misunderstood
communication may have harmful outcomes.
Across the clinical spectrum, there are multilingual persons
who speak no English, to the grammatically correct who speak
with a heavy foreign accent. Clinicians must be aware of the
intrinsic risk of prejudice in these situations.
Essentially, physicians are bilingual in that they speak ‘everyday language’ and ‘medical language’. Patients, on the other hand,
are most conversant and fluent in everyday language.[91] A study
examining knowledge of common health terms by physicians,
nurses and patients found highest correlation between physicians
(70%), and lowest (36%) for patients.[92] The widest discrepancy
was found with respect to psychological terms, e.g. depressed,
paranoid and confused. Greater discrepancies are expected with
non-clinical linguistic differences.
The bilingual patient speaking a second language can experience anxiety or pervasive discomfort during clinical presentation.[37] The monolingual clinician must take care not to misinterpret the pauses, sparse words, and emotional preoccupation of the
struggling bilingual.[37] Linguistic inaccessibility may actually add
to a sense of helplessness in the distressed patient.[93] The clinician’s alertness to non-verbal cues is usually invaluable.
5.3 Translating Language
Table III demonstrates the challenge of translation from languages in which subtle inflections in tone can significantly change
the meaning of words or phrases. As an exercise, readers are
encouraged to substitute each of these meanings in response to the
question ‘What is the problem?’
In Chinese, the pronunciation of the character for the number
‘four’ is similar to that of the character for the word ‘death’.[12]
Table III. Challenge of translating from Yoruba
Yoruba
English
Ógùn
Medicine
Ogún
Twenty
Ògun
War
Ògún
God of iron/war
Ogun
Inheritance
Ōgùn
Name of a river
Ōgun
Sweat
Ogun
The person was stabbed
Ogūn
It is long/(s)he is tall
 Adis Data Information BV 2003. All rights reserved.
Although unintentional, this can be distressing for a Chinese
patient hospitalized in ‘room 4’ and in some communities health
facilities avoid use of this symbol. Arguably, few superstitious
people would opt to undergo high-risk surgery on ‘Friday the 13th’
in some Western cultures.
5.4 The Interpreter
It is impossible to be fluent in all languages. A common
language between clinician and bilingual patient may seem the
logical option,[94] but this may abbreviate or hinder free flow of
communication. The anxious patient can be even less adept when
speaking a second language.[95]
As language of assessment impacts on symptom presentation,
dual assessments in each of the bilingual patient’s languages have
been advocated.[37] However, this may not be practical. Where
either clinician or patient lack adequate proficiency in the language of communication, an interpreter is required.
The triangular relationship between the patient, interpreter and
clinician needs skillful harmonization to maximize verbal and
non-verbal communications. This involves task definition, mutual
dependence and appreciation,[94] therefore requiring the combined
experience of the clinician and the competence of the interpreter
(figure 2). Patients may refuse interpreter services because:[94] (i)
the interpreter may be from a conflicting ethnic group; (ii) the
interpreter may be from the same community as the patient,
causing the patient to be anxious about confidentiality; (iii) the
patient may feel insulted by questioning of their language skills; or
(iv) the patient may want to impress with their ‘command’ of the
language. Furthermore, medical and psychological terms can be
difficult to translate, particularly scientific or unfamiliar concepts.[96]
Translation is the ability to exchange words from one language
to another while retaining the meaning. Additional skills are
required for interpretation, the transmission of connotative as well
as denotative meaning. Working with interpreters is an acquired
clinical skill. The clinician should observe experienced clinicians
with different interpreters, be comfortable with others speaking an
unfamiliar language, empathize with the interpreter, ask translatable questions, seek clarification, educate the patient in translatable terms or contexts, manage mutual dependence in the
clinician–interpreter dyad, and recognize incongruity in verbalnon-verbal cues.
Good interpreter skills are:
• familiarity with general medical and social care systems
• sensitivity
• general awareness of the physician–patient relationship, e.g.
confidentiality
Dis Manage Health Outcomes 2003; 11 (4)
Cultural Sensitivity in Therapeutic Transactions
243
Clinician
spirit, heart nor self are here’ detracts from the implicit meaning ‘I
am homesick’.
In emergencies it may be necessary to use any translator
available. Telephone language services provide translation but
may be limited by their impersonal nature and missed non-verbal
cues. This can be reduced with the use of video conferencing
facilities.
5.5 The Therapist in the Cross-Cultural Dyad
Interpreter
Patient
Verbal and nonverbal communication
Non-verbal and para-verbal communication
Fig. 2. Working with an interpreter (the triangle of communication).
•
•
•
•
ability to work as a team member
reasonable fluency in both languages
literacy in both languages
ability to use different interview techniques e.g. facilitation,
clarification
• awareness of non-verbal communication[97]
• skill in asking about issues not common to ordinary conversation, e.g. sexual problems, finances, suicidal intentions
• an understanding of the task, its purpose and the means of
achieving success.
Potential problems with interpretation include: (i) inaccurate
translation to and from clinician to patient; (ii) the interpreter may
be directive or provide unsolicited editorial input; (iii) the interpreter may lack the corresponding vocabulary in either language;
(iv) non-verbal cues may be missed or misunderstood; (v) transference/counter-transference issues may be present in the dyad and
triad of communication; (vi) the interpreter may collude with the
patient to withhold information, or the patient may withhold taboo
or embarrassing information from the interpreter; and (vii) the
interpreter may be unacceptable to the patient because of gender or
conflicting ethnicity.
Effective interpretation requires didactic, culturally aware, and
on-the-job training.[94] For instance, fluency in classroom Spanish
does not ensure awareness of Hispanic cultural norms or healthrelated behaviors and attitudes. Similarly, a skilled family practice
interpreter may experience difficulties in a specialist oncology
clinic. There is also the risk of over-interpreting symbolic meanings beyond linguistic translation, hence distorting communication.[17] Literal translation of the Yoruba phrase ‘neither my body,
 Adis Data Information BV 2003. All rights reserved.
Cultural difference between patients and professionals is often
inevitable in multicultural societies. Some authors[98] imply that
cross-ethnic dyads pose insoluble problems and may even be
destructive to clients, while others[99] express the opinion that ‘it is
not the race of the clinician but the acknowledgment of race that is
crucial to the therapeutic interaction’. Some ethnic organizations
advocate that their experience cannot be understood unless the
clinician has first-hand experience[100] and some groups argue that
‘if the physician does not share their etiological and pathophysiological model how can he fully understand or relieve the
problem?’[17]
The selection of clinicians for patients on the basis of the degree
of cultural similarity has been advocated as a means of reducing
clinician-patient misalliance and cross-cultural difficulties.[100]
However, health professionals who share the same ethnicity as a
patient may share little with that patient’s culture.[101] Furthermore, the patients may not be ‘typical’ of the cultural norm.[38]
Discussions about the clinician-patient relationship across cultures
often neglect variables such as previous experience of other cultures, contact with less familiar cultures, and socio-economic
status.[100] Other influential factors are the experience and personality of the clinician, their style of information gathering, gender,
race and age.[11]
Across cultures there may be transference and countertransference issues between the patient and health professional associated
with race,[11,102-104] a powerful trigger for the projection of unacceptable impulses.
• An alcohol-dependent man seeing an Arab physician confronts
him by saying ‘how can you understand me when you are not
from a drinking culture?’ Should the therapist’s countertransference feelings match those of the client (‘Do you doubt my
competence because I don’t drink?’), frustration and resentment may impair the therapeutic alliance.[105]
Nafsiyat, an intercultural psychotherapy center in London, UK,
opposed ethnic matching except where issues of language left no
option.[106] Critics[107] are of the opinion that such culturally specific services only distance ethnic minorities from the other less
culturally specific services.
Dis Manage Health Outcomes 2003; 11 (4)
244
Although ethnic pairing is a combination sometimes advocated
on the basis that it allows for freer communication, this is not
always the case. Differences often emerge within ‘homogeneous’
groups,[11] e.g. the observation that although a large number of
Russian refugees to the US are Jewish, they are both ideologically
and culturally different from the American Jewish population.[19]
Patients from ethnic minorities may attribute differences in
quality of care to clinician ethnicity.[108] The matched professional
may also be perceived as distant from the street subculture of the
group. Furthermore, patients who wish to disclose and discuss acts
or events that are taboo within their own culture may refuse to see
a therapist from the same ethnic background and culture.[38,101]
• A British-born Bangladeshi adolescent girl developed a close
alliance with her white therapist, sharing anxieties about traditional gender role issues and her fear of an ‘arranged marriage’.[109]Should the therapist attempt to encourage independence and self-sufficiency in such a patient, this may conflict
with cultural norms and so needs to be managed with great
sensitivity.
A clinician who is of the same ethnic group as the patient may
also strongly identify with the patient and collude with, or go to
great lengths to support, them.[102] On the other hand, the sameculture therapist ignoring or disrespecting sacred ground may face
conflict with patients who might have given ‘diplomatic immunity’ to cross-cultural exchange.[110]
• A Yoruba West African health worker in an ‘African dyad’
with an elderly Shona African patient waits to be offered a
handshake when introduced, in keeping with Yoruba traditional
respect for elders. The older man feels insulted and disrespected by this ‘African’, because in Shona culture the younger
party offers his hand as a show of respect to elders.
In a US study that evaluated the impact of psychoeducation and
culture brokerage across five ethnic communities (African Americans, Bahamians, Cubans, Haitians, and Puerto Ricans), best outcomes were associated with ethnic matching.[111]
Another study of Asian clients matched for ethnicity, language,
and gender observed that common language or ethnic background
between urban clients and therapists increased client sessions with
reduced discontinuation rate. However, it had no beneficial effect
on the eventual outcome.[112] Other research indicates that persons
of color in race-concordant dyads participated more in their
medical care than dissimilar dyads.[113] It has been argued, though,
that it is actually the clinicians’ collaborative style that actually
facilitates Black client satisfaction with treatment.[114] On the other
hand, good outcomes have been reported in other inter-cultural
services.[106] The lack of consistency in research findings highlights the complexity of these transactions,[115,116] further complicated by racial bias in the recommendations of some studies.[99]
 Adis Data Information BV 2003. All rights reserved.
Ayonrinde
Canadian researchers found inhibition and activation of stereotypes depending on the desirability of outcomes. Hence the Black
physician was viewed as ‘a physician’ when the outcome was
positive and ‘Black’ when adverse.[108] Problems of studies of
therapy across cultures[117] include inadequate randomization of
the race/ethnicity of clients and therapists, inadequate appreciation
that treatment seekers may not be representative of the cultural
group and the role of variables such as gender, social class, and
age. Outcome measures may also lack cross-cultural validity.
5.6 ‘Color Blindness’
‘Color blindness’ has been described as the illusion of sameness of cultures.[99] Core problems of such approaches are that: (i)
they disregard the central importance of the client’s ethnicity/
culture; (ii) they ignore the impact of the therapist’s culture on the
patient; and (iii) they abstract the patient from the social realities
of their experiences as a member of the group, e.g. ChineseAmerican. In claiming that all patients are the same, we take away
any special differences they may have. Importantly, these differences are essential for sense of identity and self esteem. As Davids
wrote, “… we are very susceptible to persuasion that ‘differences
don’t matter’ … and have no psychological meaning on our
professional work. We spare ourselves a painful struggle … however, in so doing we undermine our therapeutic efficacy.”[118]
While ethnic matching may enhance some transactions, it may
prove problematic in others. Awareness of these complex issues
enhances sensitivity in same or cross-cultural dyads.
6. Culture, Ethnicity and Pharmacotherapies
Although there are widespread differences in pharmacological
practices across geo-cultural boundaries, the general consensus is
that they are efficacious in patients of diverse ethnic and cultural
backgrounds.
Physical treatments, such as oral and parenteral medication and
surgery, carry different symbolic representations to individuals
based on past experience and culture. Illness models, which include physical causations, may be more amenable to the acceptance of physical treatments to alleviate symptoms. On the contrary, where patient and therapist have different belief systems,[119]
difficulties may be experienced. Allowance should therefore be
made for ‘holistic’ care, with a non-critical stance, particularly if
there is minimal risk of adverse effects (e.g. sacrifices or rituals).[120]
Researchers[121] have reported racial differences in community
patterns and preferences of over-the-counter medications, nutritional supplements, and psychotropic, gastrointestinal, and analgesic medications. In this US study, African Americans were less
Dis Manage Health Outcomes 2003; 11 (4)
Cultural Sensitivity in Therapeutic Transactions
likely to use medication than were Whites. However, the strongest
predictor was health insurance status and use of health services,
with only 6% of the variance associated with race.[121]
Trends in the use of complementary therapies highlight the
growth in popularity of alternative therapies. The wide variety,
availability, and indications for herbal remedies (e.g. St John’s
Wort and ginseng) and their complementary use with other medication is often neglected in clinical practice. However adverse
effects and interactions, such as hypotension and depression
secondary to amine depletion with Rauwolfia serpentina or unfamiliar dietary composition and the use of monoamine oxidase
inhibitors, pose a significant risk. It is good practice to enquire if
other remedies (traditional or over the counter) are being used
concomitantly and caution on the risk of interaction.
Recent advances in pharmacogenetics, pharmacokinetics (determining bioavailability to target organs) and pharmacodynamics
(determining response to agent) have revealed mechanisms that
may explain variations in responses, doses and adverse effect
profiles across ethnic groups.[122-124] This ethnic and genetic diversity probably reflects adaptation to the metabolism of different
substances by different groups. For instance, genetic differences in
the cytochrome P450 isoenzymes CYP2D6 and CYP2C19 are
reflected in the metabolism of hypnosedative, antidepressant and
antipsychotic agents in Asian, African and Caucasian groups[125]
as the distribution of alleles varies substantially. In addition, ethnic
variations in body size and distribution of fat and fluid have been
observed to impact on the conjugation, plasma protein binding,
enzyme induction, and distribution of drugs;[124] for example,
Black Africans have higher red cell/serum lithium ratios than
Caucasians, and hence a greater risk of CNS-related adverse
effects.[125] On the whole, variations in metabolism best explain
differences in response across groups.[126] Cultural differences in
diet and lifestyle also influence metabolism e.g. induction of the
isoenzyme CYP1A2 by eating cabbage, charbroiled beef or smoking tobacco. A high protein diet accelerates the metabolism of
theophylline, whereas a carbohydrate diet reduces this. It is worth
noting that significant dietary changes following migration may
affect therapeutic response to medication.
Although acknowledging the role of pharmacotherapy, it has
been suggested that sociocultural transactions and contextual issues may actually play a more important role than pharmacodynamics and pharmacokinetics in determining medication prescription and compliance.[126]
The accessibility of medication across national and cultural
regions is influenced by availability, cost, licensing, prescribing
practice, marketing, and political factors. Invariably, restricted
treatment options affect health outcomes. Client expectations or
 Adis Data Information BV 2003. All rights reserved.
245
therapist characteristics may result in a placebo effect or even
treatment failure in a number of patients.
Compliance or treatment adherence can be compromised by
differences in illness beliefs, inadequate explanation, or lack of
understanding of the rationale for the treatment. Sometimes treatment interventions are against the patient’s spiritual or cultural
beliefs e.g. blood transfusion to a Jehovah’s Witness.
• A Muslim man with insulin-dependent diabetes mellitus had
been compliant with treatment and monitoring of his blood
sugar over 10 years. On reading the fine print of the drug
information leaflet, a family member realizes it is a pork insulin
preparation. The man stops use of all his medication with
ensuing metabolic derangement. He also describes feeling
poisoned and rendered impure by health professionals. He
became depressed but emphatically refused all forms of formal
medical intervention. In Islamic faith pork is ‘haram’ (forbidden). The implications for a Muslim of daily injections of a pig
extract are significant. The clinician had not been aware of this
and had also not discussed the type of insulin with the patient.
7. Organizational Sensitivity
As with the individual therapist, health services should be
culturally sensitive to the needs of their clients by implementing
appropriate and relevant structures and policies. Organizations
may be subject to governmental, political, care system, policy,
staffing, and financial influences, to mention but a few. This
macro-interplay impacts on the cross-cultural consultation with
marked variability. Ultimately, services should be tailored to
demographic characteristics, epidemiology, and the needs of individual clients. Lessons can be learnt from other service models,
but the cultural relevance of health programs is dependent on their
specificity and not their generalization.[109] Service models should
therefore meet the demographic and epidemiological needs of the
area provided for. This multidimensional and dynamic process
incorporates both objective and subjective assessment of cultural
realities.[109] It is worth noting that health resources exist in individual cultures which, if not preserved, may destabilize some
members of these groups.
8. Outcomes
There are wide cultural differences on what constitutes ‘good
medical care’. At times, patient expectations may be completely
divergent from those of the healthcare provider. This understandably influences subjective and objective perception of health outcomes. Good outcomes from the perspective of cross-cultural
communicative behaviors are patient satisfaction, compliance, and
understanding of information. However, these do not necessarily
Dis Manage Health Outcomes 2003; 11 (4)
246
Ayonrinde
result in improved health or reduction in morbidity. Lifestyle, care
options, and support systems also influence disease risk and health
outcomes. On the whole, there is a dearth of empirical data on the
impact of culture on outcomes relevant to the physician–patient
relationship.[127] It is recognized, though, that positive
physician–patient relationships can have important consequences
for physical health outcomes, whereas patient dissatisfaction is
associated with higher psychological morbidity (depression and
anxiety). Cultural sensitivity reduces this dissonance in therapeutic transactions.
9. Conclusion
Neither physicians nor patients are homogeneous groups. There
is great diversity between patients and physicians within and
across cultures. The interplay of world views, culture, and individual traits influences the physician–patient dyad in the care of
different diseases.
Cross-cultural clinical transactions are commonplace.[128] Cultural sensitivity involves a balanced awareness of both patient and
treatment cultures. Successful negotiation of these interactions
improves patient information, compliance and satisfaction with
services, with significant consequences for physical and psychological health outcomes. The inculcation of cultural awareness,
sensitivity, and competence in the training and practice of clinicians cannot be overemphasized.
Acknowledgements
The author had no sources of funding or conflicts of interest directly
relevant to the content of this review. He would like to acknowledge Dr
Akolawole Ayonrinde for his comments on the original manuscript.
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 Adis Data Information BV 2003. All rights reserved.
About the Author: Dr Ayonrinde is a Consultant Psychiatrist with the
South London and Maudsley National Health Service Trust in the UK. He
has clinical responsibility for an adult psychiatric service as well as a
regional psychosexual clinic. His research and academic affiliation is with
the Cultural Psychiatry Section of the Institute of Psychiatry in London and
his interests are in health services research, cross-cultural aspects of mental
health, migration and mood disorders.
Correspondence and offprints: Dr Oyedeji Ayonrinde, Maudsley Hospital,
London, Denmark Hill, London, SE5 8AZ, UK.
E-mail: [email protected]
Dis Manage Health Outcomes 2003; 11 (4)