Cultural diversity and healthcare: how sexologists could approach cross-cultural settings

Cultural diversity is increasing
Cultural diversity is much the status quo around the world.

In the USA, Hispanic and Latino ethnicities make up 17% of the population, African Americans 13%, and other non-white races about 12%, with such groups growing substantially over the past three decades. In fact, 2050 will presumably represent the point at which the Caucasian white population becomes a minority in the USA.

In Europe, ethnic groups have been spread widely across various regions and nations for centuries. With the recent influx of migrants and refugees, the impact of cultural diversity has taken on new dimensions, urgency, and impacts.

In non-Western countries, like sub-Saharan Africa and East Central and Southeast Asia, cultural differences are the product of colonial histories combined with the formation of nations based on geographic landmarks rather than homogenous peoples. The result is often a patchwork of regional and ethnic variations.

Of course, diversity is also defined by religion, tradition, and subculture values, often assuming a stronger role in contributing to the diversity of thought, feelings, and attitudes toward sexuality.

We also have subcultures within dominant cultures. Populations with special characteristics sometimes establish their own cultural identity and views, values, and attitudes regarding sexuality and gender. For example, we have regional and political cultures, body and aging cultures, disabled cultures, and so on. Coming to sexuality, we may think of lesbian, gay, bisexual, asexual, transgender, non-binary, Two-Spirit, queer, and intersex culture, fetish culture, polyamory or consensual non-monogamy culture, the Chemex, and party&play culture, to give some examples.

Although practitioners will never be able to understand people of every subculture, being aware of such diversity within the population enables healthcare providers to be more intentional in their efforts to be inclusive in their verbal and nonverbal communication.

Diversity and healthcare
The suggestion dates back to the ‘70s when the psychiatrist and medical anthropologist Arthur Kleinman described the phenomenon of “illness without disease,” the idea that negative emotional states such as anxiety and depression may be somatized in many cultures. Kleinman further noted that people in different parts of the world often have their own conceptual model of disease and how disease should be treated.

Understanding diversity and cultural differences has become paramount for the average clinician only in the last 30 years and is a topic of concern that needs to be addressed in healthcare.

Anticipating such a forthcoming need, in 1978, Kleinman suggested eight standard questions that every physician should ask the patient. These questions are meant to explore the patients’ perspectives on their problems without assuming a position of superiority toward them:

Culturally defined sexual issues vs universal
We know that sexual issues represent highly sensitive topics, not just to patients but also to clinicians. Most of us are not prepared to talk with patients about sexual issues. Also, we might not be aware of how our ideas about normality in sex are influenced by our cultural contexts and the culture of medicine itself.

Let’s share some snippets on significant and well-documented cultural differences in sexuality.

 

• For example, the social construction of what it means to be a “couple” and to marry someone is deeply embedded in culture. The sexes and numbers of people involved in marriage and expectations of it (from a reproductive partnership to the economic relationship to love and intimacy) reflect context-specific economic, political, and religious concerns.
• Similarly, some cultures view participation in sex as required or normative for adults (however variously defined), while others value celibacy for those of certain ages or social roles.
• For children born in one country whose parents have migrated to another, messages about sexuality at home may be radically different from those at school, from peers, or in the media, and therefore, might be conflicting. Assessing the acculturation degree and the intersectionality of different identities becomes crucial.
• Migrant and refugee women show low use of sexual and reproductive health services, among others, because of the assumption that such services for unmarried women are inappropriate. Talking about sex is sometimes taboo for women from specific cultures, and therefore, using sexual health services places women in a compromising situation that requires them to engage in forbidden behavior. These women experience feelings of disloyalty to their culture and religion, guilt, self-doubting, and shame as they want to explore and embrace an identity more accepted in the Western tradition.
• Male circumcision and female genital cutting are areas where strong cultural differences occur and where even Western medical experts disagree, as well as with cosmetic genital surgery.
• 62 countries have laws that criminalize private, consensual, same-sex sexual activity, mainly for men. 12 of them have jurisdictions in which the death penalty is imposed or at least a possibility for homosexuals. Same-sex sexual activity could be unremarkable in other countries but, in some contexts, stigmatized or perceived as inappropriate.
• Culture impacts also on which sexual problem people are more inclined to report and the degree of personal distress. For example, men from the Middle East and the Indian subcontinent reported premature ejaculation, semen anxieties, masturbation worries, and penile size issues as being significant concerns. In contrast, in the Western population, men are more likely to report a distressing lack of desire, pornography use, and erectile problems. In some conservative cultures, women’s primary sexual concern is vaginismus, and an unconsummated marriage would expose these women to traumatic experiences and loss of social status because of their dysfunction. Low sexual desire is most prevalent in Western women, while Asian women tend to report more orgasmic disorders, as lack of sexual desire is considered to be not a problem but a norm.
• Last but not least, Culture-Bound Syndromes (CBS) like Dhat and Koro syndromes are another manifestation of sociocultural influence on sexual dysfunctions.
  That said, it becomes clear that sexual concerns and dysfunctions and the associated distress occur within the framework of an individual’s cultural context, and a “single umbrella” classification might not fit all.

How do cultural differences impact health care?
It is becoming unlikely that healthcare professionals will not encounter patients (or families of patients) who hold values and ideas about sickness and health different from their own or the ones into which they have been educated.

Cultural differences typically revolve around some predictable issues that can impact interactions between patients and practitioners, such as:

The “clinical” realities for the patient and health care provider may be really worlds apart. Often, the rules of a culture are not overt or even discussed. Therefore, such differences may be hidden by both patient and practitioner, appearing irrelevant until they are broken—often when it is too late. For example, most clinical environments assume the patient will follow the physician’s advice. However, a patient may be reluctant to disclose all the relevant details of the problem, may not agree with or understand the physician’s diagnosis, may believe their family would not sanction the treatment, or is inconsistent with religious beliefs, all factors that would result in low or no compliance. Thus, while the practitioner—consistent with their training—sees and treats specific diseases as being similar across people, patients experience illness differently, often with their understanding of the disease at odds with that of the clinician.

Beyond these “in-clinic” concerns, cultural differences may also impact who has access to healthcare due to the status of certain patients within the social system (e.g., citizen or refugee, cisgender or non-binary, old or young, healthy or ill), their tradition of health-seeking behavior within the subculture, and the level of comfort the individual/family has with the specific health care system of the dominant culture or host country.

Open the door to cultural sensitivity
Beginning with a conversation that explores the patient’s (and sometimes their family’s) understanding of the cause of the disease or disorder and the solutions undertaken thus far is a crucial starting point, for example, using Kleinman’s questions. Such information can aid the clinician in obtaining a sense of the patient’s social construct of health, illness, and treatment.

We should overcome language barriers. The patient may not speak the native language or speak it without understanding specific terms or nuances, which can be embarrassing. Translation is not always the answer, although it is necessary sometimes and even better through a cultural mediator.

We need to review the reciprocal understanding. Clinicians should mirror what they understood from the sexual history taking, explain in simple words the rationale behind the plan of care, and ask the patient (through the interpreter if necessary) to repeat the key elements of the conversation along with any information and instructions in their own words. This process can help ensure that the communication has been clear.

We should promote a positive, trusting relationship. The development of trust depends on the perception of competence and goodwill—that the practitioner will act only in the patient’s best interest. Patients want and need to be treated with dignity and respect. Trustworthiness, validated through compassion, altruism, empathy, and honesty, is essential for developing a therapeutic alliance.

In other words, we need to embrace patient-centered care, given that the quality of the relationship between patient and practitioner weighs most heavily on the practitioner. Adopting a patient-centered approach characterized by compassion, understanding, and care that is obvious to the patient and family generally leads to greater patient satisfaction and better health outcomes. It involves some broad principles that drive communication and interaction, first of all, the knowledge, respect, and validation of differing values, cultures, and beliefs as opposed to taking an ethnocentric stance where one assumes the superiority of the methods and values of one’s own culture. However, this approach never implies that the practitioner retreats from professional standards and principles of ethics. The practitioner’s concerns always need to be addressed, for example, obtaining complete and accurate information even when the patient/family is reluctant to share. Treating patients as we would want to be treated during crises or times of vulnerability explains the essence of patient-centered care.

What we need to know or do to become culturally competent
We need to be aware of our own biases. Working across cultures is best learned by reflecting on oneself and on patients’ lives, beliefs, and actions. In other words, the idea is that we need to be intentional about the process and not merely assume we can improvise our way.

Most modern programs aim to improve knowledge, attitude, and skill. As an example, the LEARN program outlines a sequence of steps that can be used to guide the practitioner through a clinical session with the patient:

 Being aware of the need to be culturally sensitive (rather than trying to learn the details of many different cultures), paired with a person-centered attitude and effective verbal and non-verbal communication skills, is often sufficient to ensure positive practitioner-patient interactions in cross-cultural settings.

We have much to learn from medical anthropologists, too. They encourage providers to ask what patients want rather than assume. They think holistically, accounting for relationships between macro- and microlevel factors, from culture and economics to family interrelationships, to understand people in context. They also compare behavior across cultures to reveal the contextual nature of apparent “universals” in sexuality. Anthropologists argue that some of anthropology’s most basic tools (the centering of human variation and difference, prioritizing curiosity over judgment, relying on trust and qualitative methods of research, and denaturalizing sexual behavior by enumerating the social construction of norms) can be readily translated into clinical behaviors that facilitate better communication with patients about sex and sexuality.

First and foremost, adopting a stance that assumes less than more—about patients, their behaviors, and what is “normal”—goes a long way toward making room for variation among our patients. Being curious and “diagnostic” instead of judgmental and “prognostic” can enable more appropriate assessment and treatment of patients’ actual needs. When a patient says they are queer, for example, what might that mean regarding their gender identity and sexual practices? As a health care provider, I should ask what I don’t know about this term and what I should not assume, particularly regarding health or distress. Also, how could I revise my protocols to signal that I care and want to know more about their gender and sexual concerns?

Given that sexual health is a basic human right regardless of culture, and it is defined as the possibility of having pleasurable and safe sexual experiences free of coercion, discrimination, and violence, we clinicians may need an orientation on how to conduct sensitive dialogues with our patients that aim to integrate personal values, ethics, religious beliefs, cultural norms, and unconventional sexual interests or practices. As guidance, the six principles of sexual health (adapted from the WHO definition) provide a map to balance couples and family conversations about sexual activity, functioning, and sexual relationships when it becomes a problem or hurts someone. They are grounding rules related to consent, nonexploitation, protection, honesty, shared values, and mutual pleasure. Those who want to deepen their knowledge can easily find them online.

From awareness to safety
Though we are trained to understand illness and treatment in objective terms (and to view ourselves as neutrally positioned in delivering care), we should also remember that we are as culturally influenced as our patients.

This blog aims to inspire us to go through different steps.

1. Cultural awareness is the acknowledgment of difference. It is the first step in understanding cultural differences and involves observing those differences.
2. Cultural sensitivity is recognizing the need to respect cultural differences. It involves exhibiting behaviors that are considered polite and respectful by the person of the other culture.
3. Cultural competence is the ability to self-reflect on our cultural values and how these impact the way we provide care. It includes the ability to assess and respect persons from other cultures and respond properly in planning, implementing, and evaluating a plan of care that incorporates health-related beliefs, values, and treatment efficacy.
4. The ultimate goal is to achieve cultural humility, in which our practice enables cultural safety. It is a process of self-reflection to understand personal and systemic biases and develop and maintain respectful relationships based on mutual trust. Cultural humility involves acknowledging we are learners when it comes to understanding another’s experience and dismantling power imbalances in cross-cultural settings.
5. Finally, cultural safety is about the patient’s experience. It is an outcome based on respectful engagement in a healthcare system free of racism and discrimination, where people feel safe when receiving healthcare.

As a final note, attending international courses or congresses is a fruitful way to expose ourselves to understand and respect other perspectives. Still, not all of us have this opportunity due to several obstacles. For many healthcare providers, the main source of education relies on national programs and speakers. IOSS is built to provide this chance, as we strongly believe in continuous education delivered by renowned experts with special knowledge and attitudes on diversity, equity, and inclusion. You’re welcome to join us!

Francesca Tripodi

 

Main References

This blog post summarizes insights and data mainly from:

• Rowland D. Culture and Practice: Identifying the Issues. In Cultural Differences and the Practice of Sexual Medicine, Springer, 2020.
• Atallah S, Johnson-Agbakwu C, Rosenbaum T, Abdo C, Byers ES, Graham C, Nobre P, Wylie K, Brotto L. Ethical and Sociocultural Aspects of Sexual Function and Dysfunction in Both Sexes. J Sex Med. 2016 Apr;13(4):591-606.

Other References

• Bell K. Genital cutting and western discourse on sexuality. Med Anthropol Q. 2005;19(2):125–43.
• Cooper LA, Roter DL, Johnson R, Ford DE, Steinwachs DM, Powe NR. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med. 2003;139:907–15.
• Gabb J, Singh R. Reflections on the challenges of understanding racial, cultural and sexual relationship research. J Fam Ther. 2015;37:210–27.
• https://www.canada.ca/en/health-canada/services/publications/health-system-services/chief-public-health-officer-health-professional-forum-common-definitions-cultural-safety.html
• https://www.theharveyinstitute.com/six-principles-of-sexual-health
• Juckett G. Cross-cultural medicine. Am Fam Physician. 2005;72(11):2267–73.
• Kleinman A, Eisenberg L, Good B. Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med. 1978;88:251–8.
• Kleinman A. Core clinical functions and explanatory models. In: Patients and healers in the context of culture. Berkeley: University of California Press; 1980. p. 71–118.
• Laumann EO, Nicolosi A, Glasser DB, Paik A, Gingell C, Moreira E, Wang T; GSSAB Investigators’ Group. Sexual problems among women and men aged 40-80 y: prevalence and correlates identified in the Global Study of Sexual Attitudes and Behaviors. Int J Impot Res. 2005 Jan-Feb;17(1):39-57.
• Misra-Herbert AD. Physician cultural competence: cross-cultural communication improves care. Cleve Clin J Med. 2003;70(4):289–303.
• Mull JD. Cross-cultural communication in the physician’s office. West J Med. 1993;159:609–13.
• Surbone A, Baile WF. Pocket guide of culturally competent communication. I∗ Houston: The University of Texas MD Cancer Center Press; 2011.
• Wentzell E., Labuski C. Role of Medical Anthropology in Understanding Cultural Differences in Sexuality. In Cultural Differences and the Practice of Sexual Medicine, Springer, 2020.