Cultural Issues in Health Care

When addressing culture in health care, the first question you must ask is are you aware of the cultural issues that may be important to this patient encounter? In this case, how much do you know about Latinas and specifically about the individual in front of you? Are there issues that impact on Latinas in general and how does this individual fit into her culture?

Inculturated individuals are those who have minimal influences from mainstream American culture. Beliefs and behaviors are primarily influenced by their ethnic community. Acculturated individuals, however, have adopted many behaviors and beliefs from the mainstream. Health care providers have the responsibility to learn about the cultures of patients for whom they are responsible, yet must retain the flexibility to judge how many of these values affect the individual patient.

Culture spans the spectrum of everything from the food we eat, the language we speak, the religion we practice, and how we relate to our families and other members of our community. The cultural factors that are most important to this patient encounter relate to religious values which impact on reproduction and sexuality, gender roles and expected behaviors between members of opposite gender, and societal expectations of what it is to be Latina (both from mainstream and community influences).

Latino culture, simplistically presented, presents women with conflicting roles. Women are expected to be sensual and alluring and yet at the same time be virginal and pure. Men are expected to be virile and powerful and their sexuality is supposed to be without restriction. In Latino couples, men are expected to be the dominant, authoritarian figure while the women are submissive and nurturant. Family structures typically have strong father figures who are protective of their teenage daughters and mothers whose role it is to mentor her daughter into adulthood, but not discuss unmentionable topics.

Sexuality is overt, yet not discussed. These attitudes have impact on behaviors in ways that are important for this patient. She may be reluctant to ask questions about sexual matters. For example, a straightforward discussion about condom use is wrought with issues: taboo against planning for sexual activity, guilt about restricting the man's behavior, and religious objections to condoms as contraception are just a few. Latina women, as a group, are more tolerant of domestic abuse, so our patient may be reluctant to discuss her concerns should they arise.

Latinos value formal behavior as defined by showing that you value yourself by being dependable, proud, invulnerable, and not bringing shame upon your family. Informal behavior is considered a sign of poor breeding, education, or class. Maria's behavior would not be viewed as appropriate and could bring shame to her family. Thus, she may not want to talk with her mother or let anyone know.

Furthermore, Maria is not living in San Juan or Tijuana, she is in Philadelphia. Ignoring her cultural beliefs or assuming that she shares all the beliefs of her community are equally fraught with dangers to the physician-patient relationship. Maria must be viewed as an adolescent who is trying to make her way in a very complicated world. Her community probably views her as moving away from their values, but the larger society does not view her as part of the mainstream. She is most likely suffering the typical adolescent angst of asking "Who am I?" and "Where do I fit in?" Adolescents, as a group, represent their own culture where different roles are being explored and boundaries being tested. The key to this being successful is having appropriate supports

Is Alex Latino or not? Does it matter? Maybe. Again, in analyzing cultural influences, understand group values and preferences need to be interpreted with the individual in mind. For example, if a visitor from outside the United States learned that Americans were patriotic and then met you, how applicable is the group value to you, the individual? In an effort to be inclusive to our patients and to avoid stereotyping, we need to look at group preferences as hypothesis or guidelines that must be testing with experiences and modified when applied to the patient sitting across from us.

Strategies for dealing with Latinas begin by initiating discussions early with mothers and daughters about sexual matters (including normal development and physiology). A discussion about sexual activity may be challenging with some Latinos where reserve and modesty are used when discussing one's body or sexuality. A women's menstrual cycle is often referred to in euphemistic ways ("that thing"). Thus, a vocabulary may not exist and may need to be taught. This modesty may play out in some patient's wanting their mother or partner in the room while being examined so that they can feel safe. This establishes a relationship that fosters future communication about difficult issues.

With this patient, the key to a fruitful encounter will be in recognizing that the situation is difficult for both physician and patient, emphasizing openness in communication, and providing opportunities for the patient to ask questions and encourage future encounters. This will provide a framework where the patient can build the necessary supports for successful navigation through adolescence.