Download Ethnicity in the United States - American College Health Association

Cultural and Spiritual
Views on Birth Control and
Pap Smears
Mary Lopes, ARNP
Cathy Locke, CMA
Presenters
Reference
Paul D. Blumenthal, MD, MPH
Ethnicity in the United States
US Census Bureau. Population Projections. Available at:
http://www.census.gov/population/www/projections/popproj.html.
Religious Denominations
in the United States
Evangelical
Protestant
33.6%
Mainline
Protestant
33.6%
Roman
Catholic
21.20%
Black
Protestant
5.0%
Jewish 2.5%
Other 4.9%
Unaffiliated
10.8%
Bader C, et al. American Piety in the 21st Century: New Insights to the Depth and
Complexity of Religion in the US: Selected Findings from the Baylor Religion Survey.
Available at: http://www.baylor.edu/content/services/document.php/33304.pdf.
Religious Beliefs About Contraception:
Roman Catholicism
• The purpose of marriage is procreation
• Artificial contraception is wrong because it:
 Breaks the natural connection between the procreative
and the punitive purposes of sex
 Damages the institution of marriage
• The only permitted form of birth control is natural family
planning (e.g., periodic abstinence)
British Broadcasting Corporation. Religion & Ethics: History of Christian Attitudes to Birth Control.
Available at: http://www.bbc.co.uk/religion/religions/christianity/christianethics/contraception_2.shtml.
Religious Beliefs About Contraception:
Protestantism

Beliefs about birth control are based on different Christian
interpretations of the meaning of marriage, sex, and family

In general, Protestant denominations let believers use birth
control as their consciences dictate

Evangelical churches consider birth control to be controversial
– from opposition to all methods to opposition to any methods
that prevent implantation of fertilized eggs
British Broadcasting Corporation. Religion & Ethics: History of Christian Attitudes to Birth Control.
Available at: http://www.bbc.co.uk/religion/religions/christianity/christianethics/contraception_2.shtml.
Religious Beliefs About Contraception: Judaism

Jewish tradition values childbearing; “be fruitful and multiply”
◦
The obligation is fulfilled with birth of a son and a daughter
◦
The obligation is directed to men; women are the conduit

Many rabbinic authorities permit contraception when pregnancy would
seriously harm the woman

Methods that prevent the “spilling of seed” – condoms, some female barrier
methods, coitus interrupts, male and most female sterilization methods - are not
permitted

Methods that cause bleeding or spotting affect intimacy and quality of marital
life. The woman must verify that there has been no recurrence for the 7 days
following the end of bleeding

Laws and adherence differ for Orthodox, Conservative, and Reform Judaism
Purnell LD, Paulanka BJ. Transcultural Health Care:
A Culturally Competent Approach. 1998.
Religious Beliefs About Contraception: Islam

Marriage is not equated with conception

The Qur’an does not mention contraception
◦
The sayings of the Prophet Mohammed tolerate coitus interruptus
(azl), with the permission of the wife, who is also entitled to full sexual
pleasure
◦
Contraceptive methods that temporarily prevent pregnancy are
analogous to azl and are permissible

In Islam there is a prioritization on the quality of life
◦
Planned birth spacing allows the mother the opportunity to care for
each child

Contraception is supported for economic reasons; to protect the life of the
wife; to preserve the attractiveness of the wife for the enjoyment of the
marriage; and to provide for the needs of the children
Lawrence P, Rozmus C. J Transcult Nurs. 2001;12:228-233.
Basic Values of Major Cultures
in the United States
Values
American
Hispanic
African-American
Control of
Environment
Look out for
your own
interests first
Events happen by
luck, fate, or
powers beyond
one’s control
Determined and
competitive in
situations that threaten
survival
Change
Change equals
progress and
growth
Preservation of
traditions
Change equals progress
and growth; education
is an instrument of
change
Time
Time is of the
essence
Being late is
socially acceptable
Self-help
Achieving goals
on your own
Do what is best for Solutions/advice sought
others
of others
Clutter AW, Nieto RD. Ohio State University Fact Sheet: Understanding the Hispanic Culture. Available
at: http://ohioline.osu.edu/hyg-fact/5000/5237.html; Pew Hispanic Center: Henry J Kaiser Family
Foundation. 2002 National Survey of Latinos: Survey Brief: Assimilation and Language. Available at:
http://www.kff.org/kaiserpolls/upload/Assimilation-and-Language-2002-National-Survey-of-LatinosSurvey-Brief.pdf; Scott HJ. The African American Culture. Available at:
http://appserv.pace.edu/emplibrary/VP-THEAFRICANAMERICANCULTURE_Hugh_J_Scott.pdf.
Basic Values of Major Cultures
in the United States (Continued)
Values
American
Hispanic
African-American
Gender
“All men are Father is head of
created
family; mother is
equal”
responsible for home
Commitment to social
justice and equality
Relationships
The
individual is
unique and
precious
The extended family
– la familia – is the
most important
social unit
“Family” is more than
genetic kinship: parents
depend on “family” to
teach/discipline children
Interactions
Informality,
directness,
honesty
Formality, manners,
honor, respect for
authority and elders
Respect for elders;
maintenance of harmony;
reliance on oral traditions
Tradition important;
church influences
family life
Community and tradition
important; religion woven
into fabric of life
Rituals and
Religion
Clutter AW, Nieto RD. Ohio State University Fact Sheet: Understanding the Hispanic Culture. Available
at: http://ohioline.osu.edu/hyg-fact/5000/5237.html;Pew Hispanic Center: Henry J Kaiser Family
Foundation. 2002 National Survey of Latinos: Survey Brief: Assimilation and Language. Available at:
http://www.kff.org/kaiserpolls/upload/Assimilation-and-Language-2002-National-Survey-of-LatinosSurvey-Brief.pdf; Scott HJ. The African American Culture. Available at:
http://appserv.pace.edu/emplibrary/VP-THEAFRICANAMERICANCULTURE_Hugh_J_Scott.pdf.
Power Imbalances Affect the Use of
Contraceptives in Different Cultures

Power imbalances account for much of the underuse of
contraceptives among women from different cultures
◦
In one study, two-thirds of men surveyed in the United
Arab Emirates objected to the use of contraception by their
wives
◦
Some married Latino women report using birth control
without their husbands’ knowledge, fearing disapproval or
accusations of infidelity
◦
Many Bolivian women avoid contraception because of
disapproval by their husbands
Ghazal-Aswad S. J Fam Plann Reprod Health Care. 2002;28:196-200; Arroyo L, Pinzon LA.
Entre Parejas: An Exploration of Latinos’ Perspectives Regarding Family-Planning and
Contraception. Available at: http://www.nclr.org/content/publications/detail/40994; Schuler
SR, et al. Stud Fam Plann. 1994;25:211-221.
Ethnic Differences in Beliefs
About Condoms and Their Use*
AfricanAmerican
(n=589)
Belief
Hispanic
(n=502)
Mean
SD
Mean
SD
It is embarrassing to put on a condom
4.35
1.12
3.93
1.29
After sex, it is sometimes hard to find a good way
to get rid of the condom
4.34
1.20
3.83
1.41
It is embarrassing to buy condoms
4.13
1.36
3.64
1.52
People only use condoms with people that they
don’t want to be close to
4.04
1.40
3.67
1.50
Condoms are messy
3.58
1.50
3.00
1.50
Condoms often come off in the vagina or anus
2.84
1.47
3.10
1.43
Condoms often break
2.24
1.32
2.60
1.37
*Responses were scored on a 5-point scale: 1= strongly agree; 3 = neither agree nor
disagree; 5 = strongly disagree. Mean responses for African-Americans and Hispanics
were significantly different at P<0.02.
Norris AE, Ford K. Health Educ Q. 1994;21:39-53.
Common Differences Between the
United States and other Cultures
 Excessive deference to authority figures
 Male-female power imbalances
 A sense of fatalism
 Embarrassment regarding reproductive organs and/or
contraceptive use
Counseling African-American Women
About Contraception
• Holistic/spiritual
 Acknowledge the collective wisdom and experience
• Communal
 Use social network – family, church, and community groups –
to support goals
• Awareness
 Build self-confidence; sense of self-control
 Create an awareness of symptoms
 Focus on long-term personal goals
Eiser AR, Ellis G. Acad Med. 2007;82:176-183.
Counseling Hispanics
About Contraception
50
P=0.003 for Hispanics vs. Others
37.8
40
30
20
16.7
12.5
10
0
Whites
Proctor A, et al. J Reprod Med. 2006;51:377-382.
African
Americans
Hispanics
Identifying Cultural Barriers
Among African Americans
 The “conspiracy” theory that contraception is a way
of controlling African-American reproduction
 Adolescent and unplanned pregnancies are more
acceptable
Thorburn S, Bogart LM. Health Educ Behav. 2005;32:474-487;
Horn B. Nurse Pract. 1983;8:35, 39, 74.
Identifying Cultural Barriers Among Hispanics
•
Language barriers

Varying levels of English proficiency

Many dialects of Spanish spoken

Literacy deficiencies
•
Deep-rooted religious beliefs and values

Women should be sexually naïve

Speaking about sexual practices should be avoided

Fatalismo – events are meant to happen
•
Role of male as provider (machismo)

Cooperation and/or approval of the head of the family is required before
health care can be sought

Fear of discussing safe sexual practices so as not to be perceived as
unfaithful or untrusting
–
If economically dependent, fear of domestic violence
•
Distrust of health-care providers
Sangi-Haghpeykar H, et al. Contraception. 2006;74:125-132; Scott CS, et al. Adolescence.
1988;23:667-688; Cuellar I, et al. J Commun Psychol. 1997; 25:535-549; Pew Hispanic Center,
Henry J Kaiser Family Foundation. 2002 National Survey of Latinos: Survey Brief: Assimilation
and Language. Available at: http://www.kff.org/kaiserpolls/upload/Assimilation-and-Language2002-National-Survey-of-Latinos-Survey-Brief.pdf.
Counseling Strategies:
Active Listening
 On average, clinicians interrupt approximately 18 seconds after
patients begin speaking
 Once interrupted, patients rarely attempt to continue expressing
their concerns
 If patients are allowed to speak without being interrupted, it
takes no more than 150 seconds for them to complete their
statement of concerns
 Other studies have shown that failure to ask for a patient's
agenda significantly reduces the clinician’s understanding of the
problem
Beckman HB, Frankel RM. Ann Intern Med. 1984;101:692-696;
Marvel MK, et al. JAMA. 1999;282(10):942-943; Rhoades DR, et al.
Fam Med. 2001;33:528-532; Dyche L, Swiderski D. J Gen Intern
Med. 2005;20:267-270.
Preferred Family Planning in Russia
• Abortion still preferred choice
• Attempting to slow abortion rate
• Rapid decline
• Modern contraception use
• Market as a healthy alternative
Cultural Sensitivity in
Gynecology
The ultimate patient-centered care
Reference:
M. Elson, M.D.
Clin Assoc Prof Ob/Gyn
University of Iowa Carver College of Medicine
 What is the difference between cultural
sensitivity and cultural stereotyping?
 Cultural stereotyping presumes that
individuals within any given community
think and behave the same way.
 Cultural sensitivity respects and responds to
the health beliefs, practices, cultural and
linguistic needs of the individual.
The Iceberg model
Above the Water Line
• Habitus
• Visible impairment
• Posture/coordination
• Mannerisms
• Hygiene
• Dentition
• Skin color/race
• Gender
• Dress/hairstyle
• Fluency in language of interaction
• Piercings
Below the Water Line
• Non-visible impairment/learning disability
• Occupation
• Education
• Religion
• Sexual orientation
• Political persuasion
• Citizenship/national origin
• Income/economic status
• Interests
• Native language
• Family situation
Far more lies beneath the water line
than above--
Medicine as culture?
•Language?
•Customs?
•Beliefs?
•YES!
Medical School’s Hidden CurriculumCultural Insensitivity
• What students come to “know” and “understand”
Scientific rationality
• Emphasis on objectivity
• Value measurements and physiochemical data
• Objectify the patient’s own desire or body part
• Community member or whole person
•
Other Significant Cultural Barriers to Health Care
• Modesty
• Medical decision making authority
 Individual
may not be empowered to make decisions
regarding care
 In some cultures poor prognosis is never shared with
patient
• Lack of understanding of belief system
• Cost, often other barriers to care
Common Across All Cultures
• Nervous in clinical or unfamiliar environments
• Reluctant to question providers
• Language barriers heighten sense of helplessness and
loss of control
“Help Me To Understand”
 When There Seems to be a Barrier- ASK
 Sometimes
there is no way to know what is happening
 The patient and family are looking for respect and
sensitivity—they do not expect miraculous intuition
 Help me to understand why you aren’t taking your ____??
High vs. Low Context Cultures
 High Context
-Meaning of individual
behavior and speech changes
depend on situation
-Non-verbal messages are full
of important meaning
-Interpretation of messages
dependent on relationship of
sender and receiver, time and
site of communication
• China
• Korea
• Japan
• Iran
• Saudi Arabia
• Mexico
• Latin America
High vs. Low context cultures
Low Context
• Intentions are expressed verbally
• Context conveys little or no
information
• Words are shortest route from
here to there
• Individualistic, explicit and
direct
• Independent individuals
• Germany
• USA
• Scandinavia
• Swiss
Low Context Communication
• Nothing filtered
• Mirrored, or a shared experience
Mistranslation
• Introduced in the U.S.
• “Creap” coffee creamer
(Japan)
• “Super Piss” car lock de-icer
(Finland)
• Introduced in Latin America
• The Chevy “Nova”
Avoid Cultural Stereotyping
•Do not presume that individuals within
any given community think and behave
the same way.
•There are more differences between
individuals in a given group than there
are between groups
Not different from them, different like them
CULTURAL BARRIERS TO HEALTH
CARE; ARABS
•Medical care and provider
•Gender
•Privacy
Female Muslim Patients
• Under normal circumstances, a female Muslim patient
is examined by a female Muslim doctor or a female
non-Muslim doctor
• However, if the case of a serious medical problem, it
is permissible for a male doctor to examine and treat
the female Muslim patient, observing her privacy
rights
Dr. Hamed Ghazili, Imam and Supt,
Iman Academy Schools
Islamic American University
Three Privacy Rights for Female
Muslim Patients
• Khalwa-a male doctor may not examine a female
patient without a chaperone.
• Awra- no part of the body is exposed unless there
is a need to do so.
• No physical contact by male medical staff except
as required for medical treatment.
Dr. Hamed Ghazili, Imam and Supt,
Iman Academy Schools
Islamic American University
Exceptions to the Three Conditions
• “Necessities and emergencies make the prohibited
permissible”
• Life is precious and valuable in the sight of God and
should not be endangered
Dr. Hamed Ghazili, Imam and Supt,
Iman Academy Schools
Islamic American University
Muslims
• Muslims are persons who practice the organized religion of Islam. They come from
various countries, vary widely in ethnicity, and speak many different languages. As with
most other groups, individuals vary in beliefs and amounts of assimilation. Muslim
culture is paternalistic, so women might expect to have a male protector sign consent
forms. If necessary, explain US legal requirements, and after meeting HIPAA and other
confidentiality requirements, the male may countersign the consents and forms if the
client desires it. Since the left hand is considered less clean, use your right hand for
palpation as much as possible. Even if you are left handed, use your right hand to give
papers or medications to the client. Muslims especially value modesty and privacy. To
keep as much of the body covered as possible, suggest removing as few clothes as
necessary, or provide a sheet to wrap about the lower body and legs, in addition to a
gown. During the month of Ramadan, religious fasting (includes water, food, smoking,
sex) from before dawn until sunset may prevent adults from taking medications during
daylight hours (have exceptions for pregnancy, illness, etc.). Reversible contraceptives
are permitted, but tubal ligation or vasectomy usually is not. Abortion may be permitted
under some circumstance, and usually before 120 days after fertilization. Muslim women
may be adversely affected by breakthrough bleeding, since it may prevent praying (similar
to menses).[1]
[1]Best,
K; Menstrual Changes Influence Method Use, Network, 19:4–9, 1998.
Buddhism
In Buddhism, there is no established doctrine about contraception. Traditional
Buddhist teaching favors fertility over birth control, so some are reluctant to tamper
with the natural development of life. A Buddhist may accept all contraceptive
methods but with different degrees of hesitation. The worst of all is abortion or
‘killing a human to be.’
Korea
http://depts.washington.edu/pfes/CultureClues.htm
 What are the Korean culture's norms about touch?
 Understanding Norms About Eye Contact and Body Language.
 Do not expect sustained direct eye contact. When you first meet your patient he or she may frequently look at you
when you are not looking to become more comfortable.
 Handshakes are appropriate between men; women do not shake hands. Respect is
shown to authority figures by giving a gentle bow.
 Understanding Personal Space
 Your patient may highly value emotional self-control, appearing stoic. Be aware that your patient may not show pain
or ask for pain medications.
 Instead of asking your patient about pain, ask, "May I get you something for pain?"
 Respect of your patient's desire to keep emotions in control when asked about upsetting matters.

Understanding Norms About Modesty
 Consider the modesty of women and girls when giving a pelvic exam. Many young women are modest about having
an exam and may prefer a female doctor to do it. In some cases, your patient may refuse a gynecologic exam from a
provider of either gender.
 Before you begin a gynecological exam, it is important to ask your patient, "May I
examine you?"
 Ask your patient if she prefers a female doctor, attendant, or interpreter to remain in
the room during the exam.
Vietnam
http://depts.washington.edu/pfes/CultureClues.htm
 What are the Vietnamese culture's norms about touch?
 Understanding Personal Space
 Handshakes are appropriate between men; women do not shake hands.
 Respect is shown to authority figures by giving a gentle bow and avoiding eye contact.
 Your patient may highly value emotional self-control, appearing stoic. Be aware that your patient may not
show pain or ask for pain medications.
 Instead of asking your patient about pain, ask, "May I get you something for pain?“
 Be respectful of your patient's desire to keep emotions in control when asked about upsetting subject matters.
 Some elder or new immigrant patients may consider the head sacred. Avoid touching it unless necessary.
 If an exam or procedure requires head care, let your patient know in advance. Some patients may feel
protected if the opposite side of the head or shoulder is also touched.
 When examining your patient, do a head-to-toe assessment to honor the highest, most important part of the
body first.
 Understanding Norms About Modesty
 Consider the modesty of women and girls when giving a pelvic exam. Many young nulliparous women are
modest about having an exam and may prefer a female doctor to do it. In some cases, your patient may
refuse a gynecologic exam from a provider of either gender.
 Before you begin a gynecological exam, it is important to ask your patient, "May I examine you?“
 Ask your patient if she prefers a female doctor, attendant or interpreter to remain in the room during the
exam.
China
http://depts.washington.edu/pfes/CultureClues.htm
 What are the Chinese culture's norms about touch?
 Understanding Norms About Eye Contact and Body Language
 Respect is shown to authority figures by giving a gentle bow and avoiding eye contact.
 Nonverbal cues are an important part of communication. For example, smiles when appropriate may be one
way to build rapport.
 Your patient may highly value emotional self-control, appearing stoic. Be aware that your patient may not
show pain or ask for pain medications.
 Instead of asking your patient about pain, ask, "May I get you something for pain?“
 Be respectful of your patient's desire to keep emotions in control when asked about upsetting subject matters.
 Understanding Norms About Modesty
 Consider the modesty of women and girls when giving a pelvic exam. Many young women are modest about
having an exam and may prefer a female doctor to do it. In some cases, your patient may refuse a
gynecological exam from a provider of either gender.
 Before you begin a gynecological exam, it is important to ask your patient, "May I examine you?" Ask your
patient if she prefers a female doctor, attendant, or interpreter to remain in the room during the exam.
Vivien Hanson, MD. Reproductive Health,
Clinical Practice Guidelines, Protocols on CDROM, 2008 From: Vivien Hanson
mailto:[email protected] or questions to
[email protected]
Be Sensitive, and Ask:
 What do you call this problem?
 What do you think causes this problem?
 What do your family or friends say about the problem?
 How have you managed it?
 Native Americans and East Asians tend to be stoic about
pain, while many Arabs and Hispanics believe suppressing
or hiding pain makes the problem worse. Many Hispanics
and traditional Chinese believe the blood supply is finite
and some Hispanics believe drawing blood steals the soul
or brings ill health. Chinese women often believe that sex
after delivery will damage the body and that they must
wait 100 days to resume sex.
•Be especially careful to explain what you
are doing during the physical examination
to avoid misunderstanding. Taking blood
pressure or examining the breasts when the
client complains of vaginal discharge may
be confusing to the client. Ask permission,
especially when examining the vagina.
Muslims
 Since the left hand is considered less clean, use your
right hand for palpation as much as possible.
 Value modesty and privacy
 Contraceptives are permitted, but tubal ligation or
vasectomy usually is not.
 Muslim women may be adversely affected by
breakthrough bleeding.
Religions
Catholic, Jewish and Muslim
• Religion also may create cultural barriers or differences, especially around
sexuality and reproductive issues. Members of religious groups have varied
levels of devotion, orthodoxy, and beliefs. Despite pronouncements of the
church, Catholics in the US use contraceptives at the same rate as other groups
and many accept abortions.
• An orthodox Jewish woman must avoid sex during and for seven days after
menses. Her husband may not touch her during this time and she needs to have a
ritual bath before they resume sex. For these women, contraceptive methods or
conditions that cause spotting or irregular bleeding may be of great concern, yet
hormonal contraceptives may be preferred to barrier methods.
Contraception Outrage
 Amy is a 32 year old woman who is 14 days postpartum after an
uncomplicated vaginal birth.
 On the day of her postpartum visit the nurse asked Amy about her
plans for contraception. Amy replies that she doesn’t need any.
 When the provider says she’ll write a prescription for contraception
“Just in case you want to start”, Amy becomes furious and leaves the
appointment.
Contraception Outrage
 Amy and her partner Katie have been in a
committed monogamous relationship for ten years
 Their baby was conceived by donor insemination
 This information was in the prenatal record
•As with all patient contacts, approach
the interview showing empathy, openmindedness, and without rendering
judgment.
• Intake forms should use the term “relationship
status” instead of “marital status” including
options like “partnered”. When asking-on the form
or verbally- about a patient’s significant other, use
terms such as “partner”, in addition to “spouse”
and/or “husband/wife”
•Adding “transgender” option to the
male/female check boxes on your intake
form can help capture better information
about transgender patients, and will be an
immediate sign of acceptance to that person
•Prepare now to treat a transgender patient
someday. Health care providers’ ignorance,
surprise, or discomfort as they treat
transgender people may alienate patients
and result in lower quality or inappropriate
care, as well as deter them from seeking
future medical care.
• When talking with transgender people, ask
questions necessary to asses the issue, but avoid
unrelated probing. Explaining why you need
information can help avoid the perception of
intrusion, for example:” To help asses your health
risks, can you tell me about any history you have
had with hormone use?”
• When talking about sexual or relationship
partners, use gender-neutral language such as
“partner(s)” or “significant other(s).” Ask openended questions, and avoid making assumptions
about the gender of a patient’s partner(s) or about
sexual behavior(s). Use the same language that a
patient does to describe self, sexual partners,
relationships, and identity.
 When assessing the sexual history of
transgender people, there are several special
considerations:
1. Do not make assumptions about their behavior or bodies based on
their presentation;
2. Ask if they have had any gender confirmation surgeries to
understand what risks behaviors might be possible; and
3. Understand that discussion of genitals or sexual acts may be
complicated by a disassociation with their body, and this can make the
conversation particularly sensitive or stressful to the patient.
•Ask the patient to clarify any terms or
behaviors with which you are
unfamiliar, or repeat a patient’s term
with your own understanding of its
meaning, to make sure you have no
miscommunication
•It is important to discuss sexual health
issues openly with your patients. Nonjudgmental questions about sexual practices
and behaviors are more important than
asking about sexual orientation or gender
identity/expression.
 Be aware that sexual behavior of a bisexual person may
not differ significantly from that of heterosexual or
lesbian/gay people. They may be monogamous for long
periods of time and still identify as bisexual; they may be
in multiple relationships with the full knowledge and
consent of their partners. However, they may have been
treated as confused, promiscuous, or even dangerous.
 They may be on guard against health care providers who
assume that they are “sick” simply because they have
sexual relationships with more than one sex. Yet they may
also, in fact, lack comprehensive safer-sex information that
reflects their sexual practices and attitudes, and may
benefit from thorough discussions about sexual safety.
Screenings and Health Concerns
• Provide the age-appropriate screenings to lesbians
and bisexual women that you would offer to any
woman in your practice. Remember to focus on
actual behaviors and practices more than your
patient’s lesbian or bisexual identity when
discussing risk, especially regarding sexually
transmitted diseases (STDs).
Fertility and Pregnancy
•Do not assume that the lesbian in your
office has no plans to bear children, or that
she has never been pregnant.
Papanicolau “pap” Screening
 Pap smears are no less important for lesbians and bisexual
women that they are for heterosexual women. Human
Papilloma virus (HPV) can be transmitted among women
who exclusively have sex with women. Women who
partner with women may also have (past or present) had
sexual contact with men. Unfortunately, many lesbians and
some health care practitioners mistakenly assume that
lesbians are not at risk for HPV, cervical cancer, and that
Pap smears are unnecessary.
STD Screening
 Most sexually transmitted diseases and infections can
be transmitted by lesbians’ sexual practices. In
addition, women who identify as lesbian may have
had male sexual partners (past or present), or have
experienced sexual abuse. Additionally, do not
assume that older lesbians are not sexually active or
that they do not need STD screening or safer sex
information. Women can “come out” or begin sexual
relationships with women at any age.
WSU Demographics in Females
#1 White
#2 Asian American
#3 Hispanic
#4 African American
#5 Native American
Specific Approaches and Subcultures
• Attractive culture
• Other subcultures
• Contraception worries, weight gain, moods, acne and
concerns about chemical interference etc.
“Many women’s
health related
handouts for
selected Asian
populations are
found here”
http://spiral.tufts.
edu/index.html
http://ethnomed.org/
•Culture Specific Pages
Amharic
•Cambodian
•Chinese
•Eritrean
•Ethiopian
•Hispanic
•Hmong
•Karen
•Oromo
•Somali
•Tigrean
•Vietnamese
•Other groups
•Cross Cultural Health Clinical
Topics
•Community HouseCalls
•Cultural Competency
•Immigration
•Patient Education
•Pearls of Cross Cultural Care
•Related Sites
•About Ethnomed EthnoMed
•Copyright
•Contribute
Here is a good website to find health
information in any language:
http://healthlibrary.stanford.edu/reso
urces/foreign/
Suggested Reading
• Special Issues in Women’s Health, ACOG (2005)


Patient Communication
Cultural Competency, Sensitivity, and Awareness in the Delivery of
Health Care
• Racial and Ethnic Disparities in Women’s Health

ACOG Committee Opinion #317 (2005)
• Health Literacy

ACOG Committee Opinion #391 (2007)

www.acog.org
Summary
• Although health care is increasingly guided by scientific,
evidence-based models, people are often guided by their
religious/cultural beliefs, which are anything but evidencebased
• Concepts of family planning and contraceptive use can
challenge deeply held cultural and religious beliefs about sex,
parenting, and gender roles
• Beliefs and attitudes may create barriers to contraceptive use
• Counseling should focus on identifying beliefs that are
barriers to contraception and offer information that will help
patients overcome these barriers
Thank you!