MODULE SUMMARY
This module provides information about culturally diverse communities and their
experience with HIV/AIDS. Rehabilitation counselors must be prepared to deal with
the needs of all consumers who live with HIV/AIDS. One misapprehension about HIV/AIDS
is that it is exclusively a white gay male disease, when in actuality, HIV/AIDS affects
all communities that vary in socioeconomic status and by race and ethnicity. There
is a special need to evolve and effect prevention and delivery of services that meet
the needs of communities of color particularly since they are underserved by vocational
rehabilitation service delivery systems in general and are disproportionately affects
African Americans and Latinos. Further, there is a lack of information on the experience
with HIV/AIDS for Asian/Pacific Islanders. (Centers for Disease Control, 1995; National
Minority AIDS Council, 1992). Other communities such as gay men, lesbian women and
substance users/abusers and also hard hit either by the HIV infection itself or the
stigma and discrimination that accompanies this disease. People of color i.e., a
term used interchangeably throughout this module with the phrase racial/ethnic minority
groups.
GOALS
Training based on this module will lead the participant to understand the multicultural
dimensions of HIV/AIDS and the dimensions of the connection between race, ethnicity,
gender, substance abuse and HIV.
Participants will understand the multicultural issues related to HIV Disease and
AIDS.
Participants will understand the importance of cultural stressors and sociocultural
history of various cultural groups and the relationship of these stressors to HIV/AIDS
as a disability.
Participants will understand the social relationship between cultural linkages, HIV/AIDS,
and the vocational rehabilitation process.
OBJECTIVES
Information in this module will assist the participant of training to:
Identify their personal value systems and how this affects their attitudes toward
people with HIV/AIDS, racial/ethnic minorities, people who vary by sexual orientation,
people with HIV/AIDS, and substance abusers.
List the stages of identity development that affects self perception of racial-ethnic
minority people and people who differ in sexual orientation.
Describe why HIV/AIDS and substance abuse impacts particularly strongly on racial/ethnic
minority groups, people who are gay and lesbian, and substance users/abusers.
Use the Cultural Communities' Systems Model to guide interviewing with consumers
from varying cultural backgrounds and affiliations.
METHOD OF INSTRUCTION
Mini-Lecture
Overhead transparencies/slides
Video
Dialogue with Consumer
Small Group Activities and Discussion
MULTICULTURAL ASPECTS OF HIV/AIDS
RACIAL/ETHNIC MINORITY GROUPS AND INDIVIDUALS
'Ethnicity can be equated along with sex and death as a subject that touches off
deep unconscious feelings in most people' (McGoldrick, et al, 1982).
INTRODUCTION
HIV/AIDS CAN affect ALL people in every socioeconomic and cultural/racial/ethnic
group.
Cultural groups, particular communities of color are hard hit by HIV/AIDS related
more to engaging in risk behaviors.
Differences in such factors such as acculturation and ethnic identity, sexual attitudes,
psychological reactions to the disease, types of social support, family and societal
attitudes, and issues of death and dying are important to understanding in developing
interventions strategies and delivery of services to particular cultural groups.
Studies have shown that higher levels of behavioral acculturation are generally
associated with behaviors leading to a lesser risk of acquiring HIV/AIDS - behavior
like a better knowledge of HIV prevention, higher frequency of condom use, and initiating
sex activity at a later age (Garcia, Cartwright, Glenn, 1997).
In this day and age, cultural diversity training is a highly controversial topic.
The question of what it means to provide, in our case, vocational rehabilitation
services to all people versus what it means to provide services in a culturally sensitive
approach can inadvertently dichotomizes the issue. What is true is that we need to
understand that people are different, that cultural background/race/ethnicity influences
our personal value systems.
Understanding our own ethnic identity development in an open and understanding
way is equally as important as learning about specific factors of other cultural
groups.
Ethnic group refers to those individuals who conceive of themselves as alike by
virtue of their common ancestry, real or fictitious, and who are so regarded by others.
(Refer to Reference Section for Identity Development Models including racial/ethnic
and sexuality identity.
The positive aspects of ethnicity such as traditions, coping skills, and beliefs
systems, are often neglected.
Just as individuation requires that we come to terms with our families of origin,
coming to terms with our ethnicity is necessary to gain a perspective on the relativity
of belief systems so much so that even our definition of family can be very different
from group to group.
Acculturation can be defined as an interaction process with an individual moving
between two or more culture, affecting and being affected by all.
HIV/AIDS DISPROPORTIONATELY AFFECTS RACIAL/ETHNIC MINORITY GROUPS
Cultural groups (E.G., communities of color, communities that vary by sexual
orientation) encompasse many groups of people who are manifesting high and escalating
rates of HIV/AIDS. Cultural groups in its broadest sense can be inclusive to include
those based on race, ethnicity, gender, sexual orientation, and disability.
Terminology varies, however the term people of color came into usage in recognition
of the fact that skin color is a significant element in the life experiences of persons
of color in the United States exposing them to racial and ethnic discrimination.
Psychological and behavioral differences especially in relationship to HIV/AIDS
varies between individuals in particular cultural groups depending on cultural context.
Differences in acculturation are related to demonstration of behaviors that can
lead to acquisition of HIV/AIDS.
African Americans and Hispanics/Latinos combined account for almost 60% of HIV
infection yet only represent 30% of the US. population, the hardest hit racial/ethnic
groups hit by the HIV infection.
Prevention and early intervention efforts for communities of color are lacking
as is funding.
There is a lack of trust in social service and medical providers.
Health insurance is limited or non-existent.
Seeking help for HIV/AIDS is delayed because of denial as adaptation or is not
a priority (e.g., basic survival needs may supersede).
A comprehensive prevention strategy uses many elements to protect as many people
at risk for HIV as possible with the objective to design and implement effective
and equitable prevention programs for African Americans, Latinos, Asian Americans,
and Pacific Islanders, and Alaskan Natives and Native Americans, who are all at great
risk for HIV/AIDS.
Differential sexual attitudes, such as continuing to engage in unprotected sex,
exhibit between cultural groups.
The psychological reactions to HIV/AIDS of cultural groups varies and will depend
on level of acculturation.
Stress related to sexual orientation may be associated to homophobic feelings and
according to Garcia, et al (1997), gay Latinos may remain homophobic.
Depression, commonly experienced by HIV infected individuals, is no different for
people of color.
Social support is critical in mitigating the effects of HIV Disease and is a strong
cultural factors in communities of color.
AFRICAN AMERICANS
PROFILE
African Americans with disabilities are considered an unserved and underserved
population in the rehabilitation service delivery system.
African Americans accounted for over half of all AIDS cases among injection drug
users in 1994.
This community is heterogeneous in terms of race, ethnicity, socioeconomic status,
geographic location (e.g.,urban/rural), religion and history ( e.g., African Americans,
Africans, Caribbean, Latinos, Christian, Muslim, inner-city, descendants of slaves,
recent Caribbean immigrants).
African Americans constitute approximately 12% of the total U.S. population. It
is estimated that the growth rate among African Americans will increase nearly 2%
over the next 20 years, compared to the less than 1% anticipated growth among whites.
According to national data, 31% of African Americans live below poverty level,
have lower average family incomes, lower levels of education, and poor health compared
to their white counterparts.
Nearly 20.8% of all working age (15 year to 64 years) African Americans report
having a disability and 12.7% report having a severe disability.
Poor health, shorter life expectancy, low educational attainment and related language
issues, family unit concerns, and cultural identity issues constitute complicating
factors in life adjustment for African Americans.
STRESSORS
History of racism and institutionalized discrimination and resulting distrust,
fears of genocide conspiracy.
Homophobic attitudes.
Institutional inadequacies and unresponsiveness.
This history carries over into today's society where discrimination is a reality.
a. Contributions of African Americans are lost, not discussed or diminished
b. Stereotyping and pervasive negative views of African Americans still exist.
Socioeconomic related stressors disproportionately affect African Americans
a. Poverty
b. Unemployment
c. Availability of drugs
Psychological stressors resulting from socioeconomic stressors
a. Frustration with urban living
b. Hopelessness with lack of opportunities
c. Powerlessness
d. Lack of social support and role models
HIV/AIDS AMONG AFRICAN AMERICANS
Many African Americans are at risk because of the risk behaviors in which they
may engage such as injecting drug use or sexual behaviors, and not because of their
race or ethnicity.
There is a misperception that HIV/AIDS is a white gay mans disease and can act
as a barrier to perception of risk for HIV/AIDS.
Little information exists on risk factors for African Americans, especially among
injecting drug users because of lack of research.
They account for 47% of the total AIDS cases in the US. even though they make up
on 12% of the US population.
African Americans accounted for over half of all AIDS cases among injection drug
users in 1994.
More than half (57%) of AIDS cases among women were among African Americans in
1994.
Of all children with AIDS in the US. in 1994, 62% were African American.
In a 1992 research study completed in San Francisco, more than 50% of African American
gay and bisexual men in the San Francisco Bay Area reported unprotected anal intercourse,
much higher than compared with white gay men. This survey based research also showed
that these men were also more likely to be poor, have been paid for sex, and/or have
used injection drugs, had less social support.
Studies of African American injection drug users and gay/bisexual men are lacking
so little information is available on the impact of HIV/AIDS on these populations.
CULTURAL ASSETS AND COPING STRATEGIES
Spirituality maintained in multigenerational households.
Family as stabilizing cultural force.
Adaptability in roles with African American women taking on major role responsibilities
when necessary.
HIV/AIDS PREVENTION ISSUES
Underlying distrust of the white public health world in part because of such
studies like the Tuskegee Syphilis Study leading some African Americans to believe
that AIDS infection among African Americans is a genocidal conspiracy.
From 1932 to 1972, more than 400 African American Alabama sharecroppers and day
laborers were subjects in a government study designed to determine the effects of
untreated syphilis. It is reported that the researchers of the study did not fully
and truthfully inform the subjects with some believing they were being treated rather
than studied for the effects of syphilis and in essence were being denied treatment.
The African American community has responded to AIDS as primarily a gay issue which
dissuades homosexuality active African American men, including those who self-identify
as gay, to respond to prevention efforts for fear of homophobia and their strong
attachment to the minority community.
HISPANICS/LATINOS
PROFILE
The term "Hispanic" (parallel term frequently used is Latino) is
used by the US. Census Bureau as a non-mutually exclusive category separate from
the category of race. The category of Hispanic or Non-Hispanic is separate from the
category of race, i.e. (i.e., White, non-Hispanic, Black, non Hispanic, Asian/Pacific
Islander, and American Indian/Alaskan Native). This means that an individual can
identify as belonging to one of the four racial groups established by the federal
government, and by "ethnicity", i.e., Hispanic or Non-Hispanic.
It is estimated by the US. Bureau of the Census that approximately 98% of the Hispanic
category also identify in the white category, in these two non-mutually exclusive
Bureau of Census categories.
A high percentage of this community speak Spanish to varying degrees of fluency
depending on acculturation and ethnic identity..
Hispanics make up approximately 7% of the US population (19.4 million). Ninety
percent of Hispanics live in the Southwest united States, New Jersey, and New York.
It is estimated that Hispanics with disabilities are approximately 8.2% of the
population, similar to that of whites, however, classification problems mentioned
above makes this statistic strongly suspect.
HIV has become a major threat in Latino communities many of which were disadvantaged
even prior to HIV because of minority status, economic disparities and language barriers.
Hispanics/Latinos account for 17.4% of total AIDS cases in the US. yet represent
an estimated 8% to 12% of the US population. HIV prevalence among Latinos in the
US varies strongly by geographic region.
Latinos are an extremely heterogeneous group of people who varies in terms of identity
identification, educational attainment level, socioeconomic class, length of time
in US., level of acculturation, and legal status, for example.
Males are over-represented in injecting drug use link.
STRESSORS
Socioeconomic stressors including poverty, unemployment, and lack of education.
Language Issues
Acculturation status
Legal status
Homophobia
Internalized traditional values
Cultural conflict and marginalization
HIV/AIDS AMONG HISPANICS/LATINOS
HIV risk among Latinos varies depending on level of acculturation, life style,
where they were born, and where they live in the US.
17.4% of total AIDS cases, even though they constitute approximately 7 % to 8%
of the total population.
In the case of Hispanics, the connection between alcohol use and unprotected sex
is more common in less acculturated Hispanics.
Pediatric AIDS cases among Latinos total 24% of all AIDS cases among children.
HIV prevalence among Latinos in the US varies strongly by region. A high rate of
HIV exists among Latinos in the Northeast where many Hispanics are from Puerto Rico
and the Dominican Republic. Lower rates are reported for Latinos in the West/Southwest
where many are of Mexican and central/South American origin.
Sex roles and homophobia in this community creates sex role conflicts. Latino married
men (18%) are two times more likely to have multiple partners than are non-Latino
whites (9%).
Sixty percent (60%) of unmarried Latino men reported multiple sexual partners during
a twelve month period in a research study.
Latino males who have sex with men do not necessarily self identify as gay or bisexual.
Only 20% of Latinos with multiple partners report using a condom regularly with
their primary partner and 29% with their secondary partner.
Understanding the caveat against stereotyping groups by behaviors, cultural influences
such as machismo, familismo and homophobia may be internalized by Latino gay men
and make safer sex practices difficult. Machismo dictates that intercourse is a way
to prove masculinity.
Familismo refers to a traditional value that emphasizes the importance of family
as a social unit and source of support. This can be either a powerful factor to motivate
behavior change and provide support or a limitation to educating Latino consumers
who may be reticent to share their concerns.
For gay Latinos, familismo can create conflict because families perceive homosexuality
as sinful.
Latino gay males often achieve familial support through silence about sexual preference
which has the effect of instilling low self-esteem and personal shame among Latino
gay men.
Among Latino gay/bisexual men, rates of HIV infection are increasing faster than
among white gay/bisexual men, with a 40% increase for Latinos from March 1993 to
June 1994, compared to 29% for whites.
Rates of gay/bisexual Latino men are most likely underestimated because many Hispanic
men who have sex with men do not self identify as gay/bisexual.
CULTURAL COPING STRENGTHS AND STRATEGIES
Family and values are two important elements in the adaptation strength of
this cultural group with family unity, respect and loyalty to family as paramount.
Cooperation rather than competition is favored as the primary interpersonal relating
mode.
Spirituality in the form of Catholicism but also other us regional religious patterns.
STRESSORS
Socioeconomic poverty, unemployment and low educational attainment often related
to language issues.
Acculturation and ethnic identity resulting often in cultural conflict and confusion
Legal status.
Language Issues
PREVENTION
Traditional interpretations of cultural values and gender roles may be barriers
to maintaining safer sex practices for many Latino women.
A strong relationship exists between cultural and societal homophobia and HIV risk.
Similar to African Americans, few prevention programs addressing Latinos have been
evaluated and effective behavior change models are still being developed.
Policy on immigration and mandatory HIV testing contribute to an environment of
powerlessness and discrimination so that Latinos, like many communities of color
affected by AIDS, need greater access to education, health care and social benefits
and delivery of social services.
ASIAN/PACIFIC ISLANDER AMERICANS
PROFILE
Between 1980 and 1990, Asians and Pacific Islanders accounted for 12% of the
population and numbers approximately 3.7 million people. This increase is due in
part to changes in immigration laws which lifted restrictions to immigration for
particular groups such as Filipinos, Japanese, Koreans, and Asian Indians.
Since 1975, the admission of Southeast Asian refugees (e.g., Vietnamese, Cambodians,
Laotians) have also added to the rapid growth of this ethnic minority group. Almost
69% of this group speaks a language other than English at home.
While the absolute population is small, this group is the fastest growing of all
racial/ethnic minority groups identified by the US. Census Bureau.
This cultural community like the previous cultural groups discussed, is heterogeneous
with at least 43 different groups from more than 40 countries and territories speaking
more than 100 different languages.
This group differs along several dimensions including culture, religion, language,
socioeconomic status, place of birth (US. or another country), length of time in
US. Asian Americans are traditionally referred to as the model minority due in part
to their higher educational attainment compared to other minority groups, lower participation
in juvenile crime, and lowest reported incidence of disability (9.6%) and severe
disability (4.5%).
STRESSORS COMMON TO ASIAN/PACIFIC ISLANDER AMERICANS AND OTHER IMMIGRANT GROUPS
The Model Minority myth is that Asians are always successful in academic
and economic pursuits, are successful, compliant, quiet, in excellent health, and
subservient.
Culture conflict so that values, traditions, attitudes and beliefs may be different
from majority mainstream American culture and people who are Asians/Pacific Islanders
share similarities with other cultural group, especially Hispanics as can be seen
in the following list of common stressors.
Language issues and isolation from the educational system.
The acculturation process (adapting to the dominant or majority culture) can result
in a number of intra and inter group conflicts.
Intergenerational conflicts (acculturation gap between parents and children) can
result in identity crises and family instability.
Family conflicts: Priority often must be place don survival needs as speaking for
the family because the parents do not speak English.
Alienation and identity conflicts: Educated immigrants often are underemployed
and how low-status jobs in comparison to those held in their native country.
Newly-arrived immigrants often experience the stress of split families with one
family member arriving first and sending home for the other members at a later date.
HIV/AIDS AMONG ASIAN/PACIFIC ISLANDERS
Identified AIDS cases, according to the CDC, for this group are negligible
(i.e., a cumulative total of 3,457 cases for both males and females (0.7%).
It is believed that the actual number of AIDS cases for this group is much higher
than it appears. There are many reasons why there might be widespread underreporting:
misclassification in data gathered, especially since statistics were not gathered
for this group as a separate ethnic group until 1989.
Underreporting might occur if the person with AIDS is an immigrant because she/he
may return to their birth country before the case is reported; the individual with
AIDS may fail to seek treatment because of the stigma of homosexuality and drug use
usually attached to the disease; Many individuals mask their illness as cancer, leukemia,
or other illness, to avoid deportation by immigration officials.
When statistics were gathered for the subgroups in San Francisco, the Filipino
community was found to have been most affected by HIV/AIDS, accounting for nearly
46% of Asian and Pacific Islander AIDS cases followed by these percentages of other
Asian communities: Japanese, 19%, Chinese 20%, Polynesian/Hawaiian, 7%, and Vietnamese,
4%).
NATIVE AMERICANS/ALASKAN NATIVES
PROFILE
US. Census data indicate (1993) that this community has the highest rate of
disability (26.9%) and 11.7% rate of severe disability, similar to African Americans
and Latinos.
American Indians, Eskimos, or Aleuts (also referred to as Native Americans) are
the smallest ethnic minority group in the US. In 1990, American Indians numbered
1.9 million or about 8% of the US. population.
There are one and one-half million Native Americans belonging to over 500 federally-recognized
tribes and an additional 365 state-recognized tribes.
American Indians are mostly rural people with over one-half living outside of metropolitan
areas. Approximately one-half of Native Americans live in urban and suburban areas.
Of these, many migrate back and forth between the urban areas, which provide greater
economic opportunities, and the reservation with its family and tribal ties.
The Bureau of Indian Affairs (BIA) has designed 278 reservations and other trust
lands.
There are vast differences among Native American groups.
STRESSORS
The realities of Indian life have been obscured due to centuries of multi-layered
stereotypes which continue to confound understanding and communication. Stress and
anxiety is created for many Native Americans because of severe negative stereotyping.
Ones tribe (nation) (e.g., Choctaw, Mono, Okanagan, Caddo) is where ones primary
ethnic identity often lies with each tribe having developed its own language, customs,
and beliefs.
The majority of Native Americans are of mixed racial descent though they are often
treated as having a pan identity creating invisibility of who they really are.
Native Americans as a group are extremely socioeconomically depressed.
Literacy rates are low, with one-third classified as illiterate
Unemployment averages 30% on the reservations with many of the employed in very
low skills jobs.
High substance use and abuse rates.
High Tuberculosis rates.
Underrepresentation in data and research.
Dependency on federal government in separate funding streams
Life on the reservation
High crime rate
Poor health including the highest rate of fetal alcohol syndrome (FAS)
Severe negative stereotyping
Language and multilingual issues.
Negative stereotyping, prejudice and discrimination.
HIV/AIDS AMONG NATIVE AMERICANS/ALASKAN NATIVES
It is widely believed that identified AIDS cases are grossly underrepresented.
The cumulative total for AIDS cases for this community reported through 1995 is 1,283
or 0.3 % of all AIDS cases reported.
Substance use and abuse if reportedly extremely high for this group which places
them at great risk for behaviors that can expose them to HIV/AIDS.
Native Americans live in both rural and urban areas and require delivery of HIV/AIDS
and related services that must take this significant point into consideration.
AIDS cases have been reported among Native Americans in every region of the country,
among both men and women, and from almost every age category with the except for
ages 5 to 12 years.
Because of the misperceptions among non-Native Americans, efforts to inform Native
American communities about the risk of HIV/AIDS, and how to prevent the virus from
spreading, have been slow in getting off the ground.
Because of stereotyping, native American people have not been acknowledged as being
sexual in the same way as the rest of humanity although in the past few years, at
least three major books have been published on traditional and contemporary bisexuality
and homosexuality among American Indians.
Although most people associate alcohol abuse with Indian people, little is known
or written about their use of injecting drug use and/or experience with drugs such
as cocaine, methamphetamine, and heroin.
The Indian Health Service (IHS) is poorly funded and contrary to the mistaken perception
that the health needs of Indian people are met by the US. government, in fact, this
group has the poorest health in the country with the added burden of Fetal Alcohol
Syndrome.
Prevention efforts are particularly challenging for this cultural group because
they are not considered at risk because of low reported numbers.
FARMWORKERS AS A CULTURAL GROUP AND HIV/AIDS
Poor health, low socioeconomic status, language barriers, inadequate and substandard
housing.
Low perception of unsafe sex practices and risk behaviors
High risk at border areas including purchase of injectable medications from outside
the US.
Reliance on self treatment such as folk remedies.
Traditional values such as homophobia as barriers
Single male farm labor camps with rates as high as eight times the national seroprevalence
rate found among New Jersey farmworkers.
High rates of tuberculosis.
DEAF CULTURE AS A CULTURAL GROUP, AND HIV/AIDS
People who are deaf are redefining deafness, rejecting the old clinical pathological
model and many replacing it with the cultural model. They are rejecting the view
that deafness is a disability, and insisting instead that deaf people are a community
which is culturally distinct(Glickman, 1984, p. 25).
People who are deaf as a cultural group and on an individual basis are overlooked
in the HIV/AIDS crisis.
HIV/AIDS education and prevention for this community is a unique task for this
cultural group complicating HIV/AIDS education and prevention efforts.
WOMEN AND HIV/AIDS
PROFILE
Women represent a numerical majority in the US. However, they also represent
a minority for example with regard to inequitable work pay, lessened power and influence
in the sociopolitical infrastructure.
Research reveals that women are underrepresented in receiving services from the
state-federal vocational rehabilitation system.
Culture, power, empowerment and self esteem issues are complicating factors for
all women.
Women represent 52% of the US. population and 46% of the workforce. Most managers,
precision production workers, machine operators and laborers are men, and most clerical
and service workers re women.
Professionals which include teachers and nurses as well as doctors, lawyers and
accountants are nearly 50-50 in gender, as are technical and sales workers
In 1990, women's median weekly earnings were 70% of men's.
Evidence suggests that the socialization of people in most societies of the world
is greatly influenced by gender, and in each culture, the women as a group hold distinctly
different world view and socialization experiences compared to males.
Women have fewer financial resources and less insurance coverage than do men.
HIV/AIDS AMONG WOMEN
Rates of HIV/AIDS among women are rapidly increasing.
Heterosexual contact has replaced injecting drug use as the leading source of HIV
infection for women.
Stigma, shame and denial characterize womens experience with HIV/AIDS and there
is a reluctance to seek treatment making HIV/AIDS a hidden issue.
Sexual coercion and victimization experience places many women at risk for HIV/AIDS.
The etiology and course of HIV infection differs from that of men.
Women have high degree of denial which means that significant others may be unaware
of the seriousness of a woman's substance abuse or how it may put her at risky behavior
that can lead to exposure to HIV/AIDS.
In 1992, for the first time in the US., heterosexual contact replaced injection
drug use as the leading source of HIV infection for women. The reason for this are
twofold: there are more men than women in the US infected with HIV which increases
the likelihood that women would have an infected sex partner; and, HIV is more easily
transmitted from en to women because of the greater exposed surface area in the female
genital tract.
The annual number of women infected with AIDS increased from 8% between 1981 to
1987 to 17.5 in the period between 1993 - 1995.
The cumulative number of females reported with AIDS cumulative from 1981 to 1981
is 72,828 or 14.5% of all AIDS cases compared to 85.5% for males However, the AIDS
rate has declined from 92% reported from 1981 to 1987 to 82.5 for the period 1993
to October, 1995.
Women, because of familial obligations, may refuse to recognize their health problems
including HIV infection exposure..
Role clarification is a critical issue for all women especially women with HIV/AIDS.
Women are often financially and psychologically dependent on partners.
Women may need help in seeking a more independent life to enable them to increase
self-gratification and achieve their own goals
Some women prefer working with a female counselor who can provide a trusting and
supportive relationship and who can act as a role model.
A supportive, trustful and understanding male counselor may provide a corrective
emotional experience for women with HIV/AIDS who have had negative experience with
men.
Sexual coercion places many women at risk.
Stigma/shame of women with HIV/AIDS may result because of their perceived failure
to meet the higher social and moral standard imposed on women.
Victimization from society results in sexism and misogyny.
Victimization can occur of women within a personal relationship.
Late detection of HIV infection is common among women in part because of the androcentric
(male gender) bias in medicine.
Women fail to seek treatment because of the cost fearing increased health and family
problems.
Detection is less likely to occur through common casefinding methods.
Family Issues that weigh heavily on women include hazards in pregnancy to both
mother and child, lack of support from family, unwillingness or inability to give
up caretaking role in family to enter treatment, fear of losing custody or placing
children in foster care, and fear of loss of relationship with significant other.
HIV/AIDS AMONG WOMEN OF COLOR
The total of AIDS cases for women of color (African American, Native American
and Alaskan Native, Hispanic/Latino, Asian and Pacific Islanders) in the US made
up over three-quarters of the cumulative total for all female AIDS cases reported
from 1981 through December 1994 The rate continues to escalate.
African American women and Latinas are hardest hit among women of color by the
HIV/AIDS epidemic.
Common patterns found among African American Women with AIDS in a study by Lewis
(1993) showed that they lived in neighborhoods where substance use and abuse was
widely prevalent, exhibited high risk sexual behavior and needle use, did not use
condoms, had close friendships with both men and women who maintained patterns of
drug addiction, and maintained family ties even in the midst of drug addiction.
In a study of unmarried Latina women across the US., 20% reported a history of
sexual abuse or rape.
Information about Latinas and HIV/AIDS is difficult to come by, however Zambrana's
1994 study focused on Puerto Rican families and concluded that 88% studied had sex
partners who were injecting drug users, bisexual or HIV-infected, 20% of all HIV
positive women in New York, New Jersey, Florida, and Puerto Rico were HIV positive,
and that there was a 30% to 50% chance of mother-child transmission of HIV infection
for women who were HIV positive.
PEOPLE WHO ARE GAY, LESBIAN, BISEXUAL
General Facts
An individual's sexual orientation, whether bisexual, homosexual, or heterosexual,
is an essential part of sexual health and personality.
Data is not gathered by the Bureau of the Census in terms of sexual orientation
and demographic information is simply not gathered.
There is a prevalence of distorted information about differences in sexual orientation
and identity in part because of homophobia, misinformation, and stereotypes about
sexual orientation and identity.
The American Psychiatric Association removed homosexuality from its list of disorders
in 1973.
People who are lesbian or gay are now often perceived of as a quasi-ethnic, or
a cultural minority group that is struggling for civil rights.
In only four states (Wisconsin, Massachusetts, Hawaii, and Connecticut), discrimination
on the basis of sexual orientation is prohibited in employment, housing or services.
Identity as lesbian or gay carries with it deeply rooted fears of discrimination,
harassment, and the loss of occupational opportunity and advancement.
Sexual orientation can be defined as one's erotic, romantic, and affectional attraction
to the same sex, to the opposite sex, or both.
Sexual identity is an inner-sense of oneself as a sexual being, including how one
identifies in terms of gender and sexual orientation. Troiden's model of sexual identity
formation shown in the Reference Section, views sexual identity as something that
is internalized into one's self concept or mental image of self in the same way that
gender and racial/ethnic identity are formed. "Troiden's belief is that a perception
of the self as homosexual is an attitude, a potential line of action toward the self
and others that is mobilized in settings - imagined or real- defined as sexual, romantic,
or social in nature", (Crawford & Fishman, 1996, p. 108).
Sexual preference is a term once used to describe sexual orientation -- bisexuality,
homosexuality and heterosexuality - which is now outdated because sexual orientation
is no longer commonly considered to be one's conscious individual preference or choice,
but is instead thought to be formed by a complicated network of social, cultural,
biological, economic, and political factors although there is still debate on this
topic.
No single scientific theory about what causes sexual orientation has been suitable
substantiated. Studies to associate sexual orientation exclusively with genetic,
hormonal, and environmental factors have so far been inconclusive. Many interventions
aimed at changing the sexual orientation of lesbian women and gay men have succeeded
only in reducing sexual behavior and self-esteem rather than in creating or increasing
attractions to the other sex.
It is considered ethnically questionable by the professional psychological community
to seek to alter through therapy a trait such as sexual orientation that is not a
disorder and is extremely important to individual identity and sexual health.
STRESSORS
Two pivotal events are landmarks in the struggle of these cultural groups to
be allowed to be: 1) Coming Out (i.e., publicly self identifying as gay or lesbian)
is a significant sociopolitical challenge to the heterosexual assumption which has
created a strong activist infrastructure advocating for civil rights; 2) The HIV
pandemic which has been used to rationalize prejudice, discrimination, and violence
against people who are gay and lesbian.
Homophobia is the irrational hatred and fear of lesbian and gay people that is
produced by institutionalized biases in a society or culture
Several studies indicate that exposure to truthful information about lesbians and
gay men often leads to a reduction in homophobia.
Heterosexism is the institutional and societal reinforcement of heterosexuality
as the societal norm.
A common myth or false allegation leveled against many gay men and lesbian women
is that they are child molesters. In fact, 95% of all reported incidents of child
sexual abuse re committed by heterosexual men.
Gay men and lesbian women are the most frequent victims of hate crimes and are
at least seven times more likely to be crime victims than heterosexual people. At
least 75% of crimes against lesbian women and gay men are not reported to anyone.
According to several studies, including experiences of clinicians, 30 of gay men
and lesbian women experience substance abuse of some type as compared to 10-12% of
the general population. This significantly higher rate of abuse can be attributed,
in part, to the social oppression these groups experience in the face of homophobia.
Pressure to hid one's sexual orientation because of unequal civil rights protection
and societal rejection may contribute to the use of drugs Both individuals and the
gay and lesbian communities may turn to drugs to cope with fear, denial and anxiety
and as an expression of unity and identity In fact, substance abuse may be an important
means for many individuals of entering and participating in the gay and lesbian cultures.
HIV/AIDS PREVALENCE BY SEXUAL ORIENTATION
Gay men may exhibit high risk behaviors that can lead to HIV/AIDS exposure, however
HIV/AIDS is not a white, gay mans disease.
Rates of HIV infection are increasing for lesbians.
Bisexual behavior places individuals in exposure for HIV infection.
Rates for HIV infection are rapidly increasing for heterosexuals.
PREVENTION
The National AIDS Behavioral Surveys showed that among women with multiple
partners, only 25.5% of women always use condoms with their primary partner, and
34.1% always use them with secondary partners.
Women do not wear condoms, men do. For women to protect themselves from HIV infection,
they must not only rely on their own skills, attitudes, and behaviors regarding condom
use, but also on their ability to convince their partner to use a condom.
Gender, culture and power may be barriers to maintaining safer sex practices with
a primary partner. HIV prevention strategies must target both women and men in heterosexual
couples and address gender norms in sexual decision-making.
Interventions that address sexuality, family, culture, empowerment, self-esteem
and negotiating skills, as well as interventions located in varying community settings
are especially important.
HIV/AIDS AND SUBSTANCE USE AND ABUSE
Substance users and abusers can be viewed as a cultural group inasmuch as members
of this group loosely identify with other often using drugs in group settings and
participating in recovery together in milieu-like treatment settings forming networks
before and after treatment.
Substance use and abuse is related to particular behaviors such as alcohol use
(lowering sexual inhibitions) and injecting drug use.
Substance use can disinhibit sexual behavior leading to impulsive behavioral styles
that are not conducive to using HIV prevention techniques.
People who abuse alcohol, speed, crack cocaine, poppers or other non-injected drugs
are more likely than non-substance users to HIV positive and to become seropositive.
Alcohol does play a serious role in the AIDS epidemic altering an individuals sexual
behavior while under the influence.
One in every 250 people in the US has contracted the virus that ultimately lead
to AIDS.
A substantial number of men and women are at risk for HIV associated with risky
behavior either by injecting drugs or having unprotected sex. Although sharing used
needles is a high risk for HIV transmission, substance abuse and HIV goes beyond
the use of needles.
People with a history of non-injection substance abuse are also more likely to
engage in high risk sexual activities.
When an IDU is HIV positive, needle sharing may be the primary risk factor, but
other non-injected drug use may have a great effect on risk behaviors.
Substance abuse lowers sexual inhibitions and decreases the likelihood of following
safer sex guidelines This increases the susceptibility to HIV infection among gay
and bisexual men who remain the largest "at risk" population.
Internalized homophobia and isolation resulting from a lack of societal acceptance
may lead to substance abuse Drugs can be used as a means of reducing internalized
homophobia.
Lack of sensitivity within the drug treatment community to lesbian and gay issues
such as the dual stigma as drug user and a person who is gay or lesbian.
Recognition of the problems of substance abuse within the gay and lesbian communities
in the past 25 years has led to the establishment of 12 step meetings specific to
this population.
Crack cocaine use has been shown to be strongly associated with the transmission
of HIV.
According to a recent study, women who had recently had unprotected sex in exchange
for money or drugs, and men who had anal sex with other men were most likely to be
infected.
SUBSTANCE ABUSE COUNSELING GUIDE FOR VOCATIONAL REHABILITATION COUNSELORS (Adapted
from Lewis, et al , 1988)
Rehabilitation counselors should become knowledgeable about drugs of use and
abuse and how they vary by type of action on central nervous systems, routes of ingestion
and effects. A brief primer on drugs of abuse is included in the Reference Section
below.
Conceptualize substance abuse problems on a continuum rather than as an either/or
situation In other words, substance use/abuse varies from nonproblematic to problematic
depending on how life functioning areas are affected and individuals may move up
and down the continuum during various transitions and crises.
Provide services that are individualized in goals and interventions.
Consumers' self esteem and self efficacy should be enhanced in treatment and provisions
of services.
Remain open to new methods and goals in working with consumers who have a history
of using/abusing substances.
Be sensitive to the varying needs of diverse consumer populations.
PREVENTION
The goals of HIV prevention and substance abuse treatment are often contrasting
with many treatment programs focusing on stopping substance abuse altogether with
12 Step programs advocating sexual abstinence while in recovery in contrast, many
prevention program focus on safer sex using a Harm Reduction framework acknowledging
that relapse could occur these conflicting cultures may make it difficult to integrate
HIV prevention interventions into substance abuse programs.
Gay and lesbian specific treatment is needed in addition to specific treatment
for drugs such as crack cocaine
Some prevention efforts teach safer sex behaviors regardless of drug use such as
Sex, Games and Videotapes, a program for homeless mentally ill men in New York City.
The program allows for sex issues to be brought up in a non-judgmental way and reduced
sexual risk behavior.
Many substance abusers receive treatment only after they have been arrested and
are offered treatment as an alternative to jail or prison, or while they are incarcerated.
QUESTIONS FOR CONSUMERS TO SELF-EVALUATE DRUG USE/ABUSE
What do you think has caused your substance abuse problem?
Why do you think it started when it did?
What does you addiction do to you? How does it work?
How severe is your addiction?
What kind of treatment do you think you should receive?
What are the most important results you hope to achieve?
What are the chief problems that your substance abuse has caused you?
What do you fear about your addiction? What do you think might happen if you don't
get treatment for it?
AN UNFORTUNATE LINKAGE -- TUBERCULOSIS, HIV AND SUBSTANCE ABUSE
The association between the behaviors of substance abusers and HIV disease was
well documented during the first decade of the epidemic. In the second decade of
AIDS, a new factor has emerged: Tuberculosis cases, previously a leading cause of
death in the US, has surfaced as a major public health concern. One prominent public
health official has said: TB, substance abuse and HIV disease hang out together
and are a bad influence on one another. The similarities between individuals with
diagnosed AIDS cases and substance abusers have historically included:
The medically underserved.
An over-representation of ethnic and racial minorities.
Lower socio-economic status
Risky substance abuse and sexual behaviors.
CULTURALLY SENSITIVE REHABILITATION COUNSELING
Edna Szymanski (1995) suggest the following pointers to assist rehabilitation
counselors in feeling comfortable in their relationships with consumers whose cultures
differ from their own.
Learn as much as possible about your self. It is important that rehabilitation
counselors feel comfortable and effective in their relationships with consumers whose
cultures differ from their, that they interact in ways that assist consumers in feeling
positive about their interactions with rehabilitation counselors.
Learn to acknowledge your own culture and biases.
Be open to learning about your limitations.
Value and respect consumers culture.
Get to know consumers as individuals avoiding stereotypes yet remaining interested
in cultural identity.
Dont assume.
Learn about consumers beliefs related to cultural identity
Learn about the history of African Americans, Asian Americans and Pacific Islanders,
Latinos, native Americans, people who are deaf, gay men and lesbian women, and any
other cultural groups with whom you may be in contact with.
Consider acculturation and cultural identity in all aspects of rehabilitation counseling.
Consider cultural identity and acculturation in relation to world view.
Learn consumers career-related cultural and religious beliefs and consider in
your planning.
Consult and involve family members in planning if appropriate.
Learn about consumers ideas about independence or interdependence.
Consider consumers decision-making histories and current processes.
Plan culturally sensitive interventions that do not put consumers into conflict
with the traditions they may choose to follow.
Use culturally sensitive interview questions. (Refer to Cultural Group Interview
Guide in the module titled HIV/AIDS and the Vocational Rehabilitation Process.
Be very careful about imposing a disability or ethnic identity onto consumers that
might negatively influence how you interact with the individual.
In written and spoken interaction with consumers, be mindful of acquiescence which
may be covering difficulty in communication and understanding language.
Involve consumers in decisions about the use and choice of interpreters or translators.
CULTURAL COMMUNITIES' SYSTEMS' MODEL
It is imperative to integrate the culture and environment of people with HIV/AIDS
into the rehabilitation process. It is helpful to use a conceptual unifying framework
tin evaluating the impact of culture and cultural community group membership on delivery
of rehabilitation services to people of color, people with HIV Disease and AIDS,
and people who use and/or abuse substances. This approach takes into account both
the culture and the environment and those elements that will be most useful in facilitation
re-entry into gainful and fulfilling employment/career. The Cultural Communities'
Systems Model provides a systematic way for rehabilitation counselors to conceptualize
how cultural group psychosocial issues may impact an individual with a disability.
Although different cultural (i.e., minority) groups might be involved (i.e., gender,
a particular ethnic group, a particular disability), people with HIV Disease and
AIDS are the focus of our use of this model and related guide. This model focuses
on three cultural communities: 1) People with HIV Disease and AIDS, 2) People of
color (i.e. African Americans, Native Americans, Asians, and Latinos), 3) People
who use and/or abuse substances.
It is important to understand that these communities are systems with cultural elements
that may serve as barriers or as strengths in the vocational rehabilitation process.
Acculturation and ethnic identity which are closely connected may determine if cultural
behaviors (e.g., drug use/abuse, alcohol abuse, no use of condoms) make particular
communities vulnerable to HIV/AIDS exposure and infection. These behaviors are in
part related to poverty, unemployment and hazardous employment. The gender factor
also has recently been brought to light. HIV disease among women of color is rapidly
escalating according to the CDC.
The CCSM is based on the following assumptions.
a. People with disabilities are a cultural (i.e., minority) group.
b. They share low status in power and influence.
c. People with disabilities are a heterogeneous group and are culturally diverse
with varying affiliative identities.
d. The minority group model has served as an important paradigm in the achievement
of civil rights for people with disabilities.
e. People of color have disproportionately high rates of disability.
f. Cultural communities can be linked by low socioeconomic status, poverty, poor
health, and powerlessness functioning as interrelated systems in behavior that compromises
health and incurs disability.
g. Case management strategies are needed at the individual level to assist rehabilitation
counselors in guiding individuals with disabilities through the rehabilitation process.
CULTURAL COMMUNITIES' SYSTEMS MODEL POINTERS
Taking cultural community systems into consideration means that keen observation
and perception on the part of the rehabilitation professional are necessary and takes
into consideration how an individual's cultural affiliation and behavior interrelate
with disability and how these factors may surface during the rehabilitation process,
particularly in verbal and non-verbal behavior. Following the lead of Mellot and
Swartz (1996), contextual factors (language, cultural orientation) are considered
during any interaction with the consumer. Mellot's premise is that cultural and contextual
adaptation can best be assessed through looking at how satisfactory the consumer's
psychosocial adaptation is from their perspective. This is meant to be a guide to
be considered during the intake process or any rehabilitation process interaction
with consumers. The following areas must be considered:
Language Utilization
During interviews related to education and employment history, issues of language
use can be looked at. It is important to realize that clients who are proficient
in English or bilingual may not have language issues. Further, it should not be assumed
that verbal proficiency means that written proficiency of a second or third language
exists. Important here is that language special issues may become important particularly
in the vocational assessment and job placement phase.
Cultural Community Affiliations - Acculturation and ethnic identity are closely
connected. Questions related to birthplace, length of time in country, avocational
activities, will give clues as to what multiple affiliations an individual identifies
with. It is important to understand that manifestation of traditional cultural traits
and ethnic loyalty can be inversely related. That is, an individual have hold high
ethnic loyalty toward their cultural (i.e., minority) group and yet identify heavily
in non-traditional behavior and in general behavior of the dominant group.
Home Environment - Individuals hold multiple cultural memberships and affiliation.
It is important to know that the context determines which affiliation predominates
or is salient. This is what makes outreach to people of color so important because
of the power of cultural context.
Family Grouping - The definition of family has expanded to include not only primary
familial relationships, but extended relationships as well. Further, understanding
that families may include same sex partnerships must always be kept in mind.
Support Group Systems - Nuclear families can be very small in contemporary American
society, even in communities of color. Often, non-familial support group systems
are the key affiliation for some individuals. This must not be overlooked.
Communication Characteristics - Both non-verbal and verbal communication are important
factors. Non-verbal communication is the strongest bond between people although rarely
acknowledged. Observe both your own and the consumers communication style and track
this style by observation and remain conscious of the style that is being used.
Complicating Factors - Signs of substance use and abuse are easily overlooked,
both consciously and unconsciously. One of the most important factors for counselors
to realize is that failure to inquire about substance use routinely can mean overlooking
a serious problem.
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Table 1. Important Questions To Ask About Our Own Ethnic Identity
Who am I "ethnically"?
Who in my family most influenced by sense of ethnic identity?
What groups other than y own do I think I understand best?
What characteristics of my ethnic group do I like most and which do I like least?
Table 2. Summary Minority Identity Development Model
Stages of Minority Identity Formation Attitude toward Self Attitude toward others
of same minority Attitude toward others of different minority Attitude toward dominant
group
Stage 1 Conformity self-criticism or blame group-criticism or blame discrimina-
tory group-appreciation
Stage 2 Dissonance conflict between self criticism and self appreciation conflict
between group-criticism and group-appreciating conflict between dominant held views
of minority hierarchy and feelings of shared experience conflict between group-appreciating
and group-criticism or blame
Stage 3 Resistance and immersion self-appreciation group appreciation conflict between
feelings of empathy for other minority experiences and feelings of cultural-centrism
group criticism or blame
Stage 4 Introspection concern with the elements of self appreciation concern with
nature of unequivocal appreciation concern with ethnocentric basis for judging others
concern with the basis of group depreciation
Stage 5 Synergetic Articulation and Awareness self-appreciating group-appreciating
group-appreciating selective appreciation
Adapted from Donald d Atkinson, George Morten, and Gerald Wing Sue, (1989). Counseling
American Minorities: A Cross Cultural perspective, 3rd ed. Times Mirror Higher Education
Group, Inc. Dubuque, IA.
Table 3. What Does It Mean To Be Culturally Sensitive?
Cultural sensitivity refers not only to how we view others, but how we view our own
cultural selves. Cultural sensitivity can mean being sensitive to self and other.
The Minority Identity Model shown above indicates attitudes that people have toward
themselves and others as members or non-members of racial-ethnic groups. Historically,
cultural differences have been viewed as deficits rather than as strengths or assets.
Following are examples of a range of attitudes that may be held toward people from
other cultural backgrounds. The vocational rehabilitation counselor can assess his
or her own attitudes and determine how these attitudes affect their interaction with
consumers from diverse cultures. It is important to identify the major values, beliefs,
and behaviors that place racial/ethnic minorities and other cultural groups at risk
for HIV/AIDS
Repulsion: perceiving other cultures as crazy or evil.
Pity: Seeing other cultures as less developed or inferior to ones own culture.
Tolerance: tolerates divers culture groups, although does not see these groups
as equally deserving.
Acceptance: accepts individuals without regard to their cultural background.
Support: Supports civil rights because of the awareness that prejudice and discrimination
re unfair and illogical, yet may hold some unacknowledged negative attitudes toward
different cultural groups.
Admiration: Acknowledges the respectability of different cultural groups and works
toward combating own negative attitudes toward the groups.
Appreciation: Values the diversity of cultural groups and works to combat racism
Nurturance: Knowledge about the history, culture and contributions of different
cultural groups and views these groups as indispensable and valuable to society.
Adapted from NYUs Co-Star Project, 1993.
Table 4. Cumulative Totals From 1981 through December 1994 in the United States
for Female/Adult/Adolescent AIDS Cases by Exposure Category and Race/Ethnicity.
Exposure White
No./
% Black
No./
% Hispa-
nic
No./
% Asian/Pacific Island-
er
No./
% Amer.
Indian/
Alaskan Native
No./
% Total
No./
%
Inject-
ing drug use 6,141 (43%)++ 16,069
(50%) 5,519
(46%) 48
(17%) 79
(50%) 27,902
(48%)
Heterosexual Contact **** 5,207
(37%) 10,481
(33%) 5,125
(43%) 129
(44%) 56
(33%) 21,021
(36%)
Hemophilia/
Coagulation Disorder 65
(<1%) 25
(<1%) 0 1
(<1%) 0 97
(<1%)
Receipt of blood transfusion ***** 1,551
(11%) 776
(2%) 413
(4%) 68
(23%) 10
(4%) 2819
(5%)
Risk Not Reported 1,101
(8%) 4,470
(14%) 846
(7%) 44
(15%) 14
(9%) 6,589
(11%)
Total 14,166
(100%) 31,821
(100%) 11,909
(100%) 290
(100%) 159
(100%) 58,428
(100%)
* Not Hispanic
* Includes Pacific Islanders
*** Includes Alaska Natives
**** Includes: sex with injecting drug user, sex with bisexual male, sex with person
with hemophilia, sex with transfusion recipient with HIV infection, sex with HIV-infected
person, and, risk not specified.
***** Includes blood components, tissue.
+ Includes 83 women whose race/ethnicity is unknown and percent of total.
++ Percentages of column total are shown.
Table 5. A Model Of Sexual Identity Formation
Stage One Early (pre-age 13) and late (post age 13-17) Sensitization: feelings of
difference or marginality
Stage Two Begins in adolescence Identity Confusion: struggle to determine sexual
identity with altered perceptions of self, experience of heterosexual and homosexual
arousal and behavior, awareness of stigma, inaccurate knowledge about homosexuals
and homosexuality.
Stage Three During adolescence and early adulthood Identity Assumption: often referred
to as the coming out process
Stage Four Adulthood Commitment: adopting homosexuality as a way of life including
self acceptance and comfort with a gay identity and gay role; gay identity is perceived
of as legitimate
Adapted from Troiden's 1993 Model.