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Discussion Items/Cases:
Latino masculinity and HIV transmission
Black and Latina womens health
Substance abuse/suicidality among Asian-Americans
South Asian cultural homophobia
Sexuality in the Black community
Transgender health
Native American two-spirit identities
Discussion Items
1. Item #1: Latino masculinity and HIV transmission
Recent information released by the CDC indicates that young Latino men who have sex with men (MSM) are becoming infected with HIV at a much higher rate than are their non-Hispanic white counterparts.
Item #2: Black and Latina womens health
Annual health maintenance, or well woman, exams are an excellent way to screen women on a regular basis for medical conditions responsible for a great deal of morbidity and mortality worldwide. However, evidence indicates that black and Latina women are at much higher risk than women of European descent for many preventable health problems.
Item #3: Substance abuse and suicidality among LGBT Asian-Americans
Studies in recent years have demonstrated a trend among LGBT Asian-Americans for substance use and abuse out of proportion to that of other ethnic groups. ADDIN EN.CITE Choi200577717Kyung-Hee ChoiDon OperarioSteven E. GregorichWilli McFarlandDuncan MacKellarLinda ValleroyCenter for AIDS Prevention Studies, University of California-San Francisco, 50 Beale Street, Ste.1300, San Francisco, CA 94105, USA. khchoi@psg.ucsf.eduSubstance Use, Substance Choice, and Unprotected Anal Intercourse among Young Asian American and Pacific Islander Men Who Have Sex with MenAIDS Educ PrevAIDS Educ Prev418-2917520052005 Oct(Choi, Operario et al. 2005) Additionally, suicidality among Asian-Americans within the LGBT community has also remained higher than non-Asian ethnic groups. ADDIN EN.CITE Leong200712121217F.T. LeongM.M. LeachC YehE ChouMichigan State University, Department of Psychology, Psychology Building, East Lansing, MI 48824, USA. fleong@msu.eduSuicide among Asian Americans: what do we know? What do we need to know?Death StudDeath Stud417-3431520072007 May-Jun(Leong, Leach et al. 2007)
Cases
Case #1: Akta
Akta is a young graduate student at your university who you have spoken to a few times at campus events and in passing at the medical school. She is pursuing a Ph.D. in molecular biology and always seems quite stressed about her current research. You know that her parents are first-generation immigrants to the U.S. from India and that they have very high expectations for Akta, both professionally and personally.
During a shadowing experience with the Emergency Department, you see Akta speaking with the triage nurse. She is visibly upset and looks up from her lap, which is filled with moistened tissues, to notice you across the room. Once the triage nurse has completed her initial exam, you approach Akta to assure her that she has no reason to be uncomfortable because of your presence. She bursts into tears and tells you that the reason she came to the E.D. was because she had nowhere else to go.
Over dinner that evening she fought with her parents after telling them she no longer wished to see the young man with whom they had set her up in hopes of arranging a future marriage. In her anger, she divulged that she recently had become involved romantically with another student at the university, a female with whom she had much in common. Her father became enraged, struck her forcefully, and told her there was no place in her culture for such ideas. He then banned her from the house and refused to discuss the matter further.
How would you counsel Akta initially regarding her current situation?
What kind of an effect might her fathers actions have on her mental health?
In what ways can Akta work to ensure her own happiness and success in school despite emotional distractions?
How do you think she reconciled her cultural background with her feelings of attraction toward another woman? Is her father correct in saying that there is no place in her culture for such ideas?
Further Reading:
Khan S. Culture, sexualities, and identities: men who have sex with men in India. J Homosex. 2001;40:99-115.
Kole SK. Globalizing queer? AIDS, homophobia and the politics of sexual identity in India. Global Health. 2007 Jul 11;3(1):8
Case #2: Mr. Johnson
Your preceptor has asked you to do an H&P on Mr. Johnson, a 49yo black male patient who has been coming to his practice for years for annual health maintenance exams. Because black men are at 50% higher risk for prostate cancer than white men, your preceptor explains, you are also to perform a screening digital rectal exam (DRE) due to Mr. Johnson being over age 45.
Mr. Johnson turns out to be quite pleasant and overall in good health. He has given up smoking in the past year at his wifes request, and his only complaint is the recent development of a case of hemorrhoids that just wont go away with Preparation H. On exam, Mr. Johnson is well appearing with no significant findings. DRE is negative for an enlarged prostate, but visually you note that Mr. Johnsons hemorrhoids look suspiciously like condyloma acuminata (anal warts).
You excuse yourself to report your H&P findings to your preceptor, wondering if your sexual history-taking should have been more thorough. Could Mr. Johnson be on the down low and acquired HPV from a male sexual partner?
How would you begin a conversation with Mr. Johnson about his possible HPV infection?
What are some ways that you might have taken a more detailed sexual history, considering that a married man may not necessarily be heterosexually monogamous?
How does the popular media portray the down low phenomenon, a term coined to describe (predominantly) black MSM who maintain heterosexual relationships publicly? Is media portrayal consistent with published reports that only about 20% of black MSM are on the down low ADDIN EN.CITE Wolitski2006 66617R.J. WolitskiK.T. JonesJ.L. WassermanJ.C. SmithDivision of HIV/AIDS Prevention, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA. rwolitski@cdc.govSelf-identification as "down low" among men who have sex with men (MSM) from 12 US cities.AIDS BehavAIDS Behav519-2910520062006 Sephttp://www.springerlink.com/content/w27l1544k4qw5103/9/10/07(Wolitski, Jones et al. 2006)? Are black men the only men who have different relationships in public and in private? How might the lens of race affect societies perception of these men, and the media portrayal of them?
Further Reading:
Miller M, et al. Sexual diversity among black men who have sex with men in an inner city community. J Urban Health. 2005;82(1 suppl 1):i26-i34.
Millett GA, et al. Greater risk for HIV infection of black men who have sex with men: a critical literature review. Am J Public Health. 2006;96:1007-1019.
Pathela P, et al. Discordance between sexual behavior and self-reported sexual identity: a population-based survey of New York City men. Ann Intern Med. 2006 Sep 19;145(6):416-25. Erratum in: Ann Intern Med. 2006 Dec 19;145(12):936.
Wolitski RJ, et al. Self-identification as down low among men who have sex with men (MSM) from 12 US cities. AIDS Behav. 2006 Sep;10(5):519-29.
Case #3: Trini
While volunteering at your medical schools mobile homeless clinic, you meet Trini, a recent immigrant from the Philippines. Her English is quite limited, but you are able to ascertain from her interview that she misses living in the Philippines because she has not had great success in finding work, housing, or a social network since immigrating to the U.S. As a transgender woman, who was born a man, she was very popular in her home country where gender fluidity was not so stigmatized; she even won pageants for transgender women and hosted many parades and festivals in and around Manila.
Her life has been quite different in the U.S., however, and she confides that she has turned to prostitution to provide for herself. She has met many other transgender sex workers, particularly of Asian background, but she does not identify with them. She tells you that she really has nothing else in common with them. When you ask about safe sex practices, she assures you that she always has condoms handy in case the men want to use them.
A few weeks pass and Trini misses a follow-up appointment at the clinic. Despite follow-up rates being extremely low due to the transient nature of the patient base, you were hopeful that you would be able to meet with Trini again, particularly since you were concerned that a fall down a few stairs she described at her last visit had somehow left her with a black eye.
What factors put Trini at particular risk for being a victim of violence? How does race/ethnicity contribute to this risk? Consider her transgender status (male-to-female), homelessness, Asian background, and her activities as a sex worker.
If Trini returns to mobile clinic, how might you counsel her on reducing her risk for being a victim of violence? How might her Filipino background be used as an advantage? How might this differ in a rural versus an urban area?
Further Reading:
Edwards JW, Fisher DG, Reynolds GL. Male-to-female transgender and transsexual clients of HIV service programs in Los Angeles County, California. Am J Public Health. 2007 Jun;97(6):1030-3.
Holland, A. (2006). A Girl Like Me: The Gwen Araujo Story. USA, Lifetime Movie Network. (FILM)
Laurent E. Sexuality and human rights: an Asian perspective. J Homosex. 2005;48(3-4):163-225.
National Coalition of Anti-Violence Programs. Lesbian, Gay, Bisexual and Transgender Domestic Violence in 2001. 2002.
Case #4: Eagle
During your pediatrics clerkship at a local community hospital, an exhausting afternoon in high-risk teen clinic finally is winding down when you pick up your last chart for the day. Eagle is a 16yo male of Apache descent. Until last year, he received medical services while living on the Mescalero Reservation in southeastern New Mexico. However, last year his mother left his father, an abusive alcoholic with post-traumatic stress disorder from serving in the Gulf War, and relocated with her four children to a low-income housing community near the hospital. Extensive notes in the chart detail a cycle of abuse that did not leave Eagle unscarred, both physically and emotionally.
Eagle greets you with an annoyed grunt when you enter the exam room and is quick to tell you that he is fine, all fine. When you ask how life has been for him since leaving the reservation, he is somewhat hesitant to respond but concedes that he is enjoying time away from his father. Just recently, Eagle explains, he has come to realize that he is two-spirited, an idea he suppressed while within the abusive confines of his former home life. He tells you that he no longer uses illicit drugs to help him cope with confusing identity issues and that he has made some open-minded friends at his new school.
His mother agrees that some progress has been made in terms of Eagles past drug usage, although she is not entirely convinced he is drug-free, but she worries deeply about disconnecting the family from their cultural heritage. She hopes that Eagles new friends and newfound comfort with being two-spirited does not detach him even further from the traditions by which he was raised.
What suggestions might you make to Eagles mother to support her son? In what ways might her efforts also encourage him to hold on to his Apache culture?
Given Eagles multiple minority status, how do you think he will cope with being different on two levels as he continues to grow into adulthood? What support mechanisms will he need to avoid substance abuse?
How might Native American ideas of spirituality, which in many ways embrace two-spiritness, contrast to the beliefs held by LGBT members of other cultures? What disadvantages might this create for two-spirit Native Americans in relating to the mainstream LGBT community?
Further Reading:
Balsam KF, et al. Culture, trauma, and wellness: a comparison of heterosexual and lesbian, gay, bisexual, and two-spirit native americans. Cultur Divers Ethnic Minor Psychol. 2004 Aug;10(3):287-301.
Barney DD. Health risk-factors for gay American Indian and Alaska Native adolescent males. J Homosex. 2003;46(1-2):137-57.
Garrett, MT,Barret, B. Two Spirit: Counseling Native American Gay, Lesbian, and Bisexual People. J Multicult Couns Devel. 2003 Apr;31(2):131-42.
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