Literature Reivew

Latina Sexual Health Care the US: Community-based Participatory Research and Her Lived Experience Angela L. Lamsona, Rebekah J. Clarka, Roberta W. Bellamyb, Jennifer L. Hodgson a, Sharon M. Knighta, Eboni J. Baugha, and Jasmine Floresc

aCollege of Health and Human Performance, East Carolina University, Greenville, North Carolina, USA; bMedical Family Therapist, East Carolina University, Greenville, North Carolina, USA; cEast Carolina University, Greenville, North Carolina, USA

ABSTRACT There is a continuous upward trend in the number of Latinas living in the US; thus, their need for safe and accessible sexual health care ever-growing. This article addresses the sexual health of Latinas through the framework of critical theory, answering the research question: “What are Latina immigrants’ experiences with receiving sexual health care from providers in the United States?” The study was conducted through a community-based participatory research design in collaboration with Latina community members. Seven themes emerged that can enhance Latina’s sexual health care cultural humility and the role of family in treatment. Implications for family therapists include advocating for screeners and interven- tions that are indicated for Latinas.

KEYWORDS Healthcare; immigrant; Latina; sexual health; sexually transmitted infections

Introduction

Over the past 30 years, immigration patterns of Latinos/as have shifted dramati- cally in the United States (US). Currently, 36.1% of all immigrants in the US are from Mexico, El Salvador, Cuba, Guatemala, and the Dominican Republic, a notable difference in contrast to 1990 when these countries made up 30.7% of all immigrants, but even more compelling compared to 1960 when only 7% of immigrants came from these countries (Migration Policy Institute (MPI) tabula- tion of data from U.S. Census Bureau, 2018). Previously, California and Texas were home to many of the immigrants who were primarily from Mexico;, but in the twenty-first century, a shift began whereby immigration patterns for Latinos/ as from North and South America demonstrated an increased presence in many states across the Southeast US (e.g., Georgia, Florida, North Carolina) (Migration Policy Institute (MPI) tabulation of data from U.S. Census Bureau, 2018). In fact, Latinos/as are the fastest growing population in rural areas in the US and now comprise the largest minority group found residing in rural areas at 9% of the total rural population (United States Department of Agriculture [USDA], 2018).

CONTACT Angela L. Lamson [email protected] Department of Human Development and Family Science, College of Health and Human Performance, 235 Rivers West, Mailstop 505 Greenville, NC 27858 Rebekah is a master’s student in the Marriage and Family Therapy program at East Carolina University.

JOURNAL OF FEMINIST FAMILY THERAPY 2020, VOL. 32, NOS. 1–2, 76–96 https://doi.org/10.1080/08952833.2020.1755167

© 2020 Taylor & Francis Group, LLC

Growth in the number of Latinos/as in rural areas has resulted in a healthcare infrastructure that has struggled to meet their health-care needs (Schminkey et al., 2019). While the rise in and inclusion of immigrant populations has brought many strengths to the US, it has also generated subsequent challenges to ensuring that health and wellbeing needs are met. One example is the inability to meet Latinas’ (Latina women’s) sexual health-care needs. Latinas’ experiences with sexual health care involve many factors, some of which include cultural expectations and language barriers that widen rather than minimize the health disparities between Latinas and their white counterparts.

Receiving quality health care (pertaining to sensitive needs such as those related to sexual health), particularly in smaller, isolated, or rural communities is further complicated through misfires in patient–provider interactions and lack of culturally competent health-care systems (Schminkey et al., 2019). These factors together result in multiple concerns for Latinas’ well-being and increase their vulnerability to or progression of unidentified sexual health diagnoses and infections as they navigate support through a complex system of care.

Through the many shifts in US patient demographics and healthcare infrastructure, as referenced above, the adoption of multidisciplinary care teams has emerged. Through these systems, a variety of health-care profes- sionals may extend treatment to patients (i.e., clients) as part of their health- care visit. As such, the term provider in the context of this article includes medical (e.g., MD, nurse, nurse practitioner, physician assistant) and beha- vioral health (e.g., family therapist, psychologist, social worker) professionals. In many instances, participants in this study referenced their visit with a medical provider; however, the message about their experiences is also intended for behavioral health providers (such as family therapists), who are increasingly seeking employment in health-care settings (American Association for Marriage and Family Therapy, 2018). Therefore, the reader will notice the terms provider or professional throughout the article instead of clinician, and patient rather than client.

The purpose of this article is to investigate Latinas’ experiences of receiv- ing sexual health care from providers in the US and offer recommendations that promote their rights to safe and accessible sexual health care. Throughout this article, the authors (a) describe the prevalence and prog- nosis of sexually transmitted infections (STIs; i.e. the bacteria, viruses, and parasites that can be passed on via sexual contact) for Latina immigrants in context of Latino/a culture and immigration experiences, including factors that are not often understood by health-care providers who seek to evaluate and treat Latinas’ sexual health concerns, (b) discuss the framework of critical theory (in relation to critical feminist theories (Sharma, 2019)) and how it grounds the research question: “What are Latina immigrants’ experi- ences with receiving sexual health care from providers in the United States?” (c) highlight a community-based participatory research study that involves

JOURNAL OF FEMINIST FAMILY THERAPY 77

Latina community members as part of the research team, and (d) offer previously unexplored ways that health-care providers (i.e., both medical and behavioral health professionals) can develop cultural sensitivity and humility in order to better meet the needs of Latina immigrants. Finally, this article offers implications for family therapists by recognizing the ways in which critical theory and feminist theories can help to reduce sexism, racism, and classism in the care received by Latinas, so that they may be able to better navigate and access safe treatment for sexual health. Implications include opportunities to support advocacy toward screeners and interven- tions that are indicated for Latinas – giving voice to their specific needs.

Prevalence and Prognosis of STIs for Latina Immigrants

Researchers have provided evidence that Latinos/as who come to the US to live andwork are at a higher risk for contracting the human immunodeficiency virus (HIV), as well as other STIs, than those who live and work in their homeland (Althoff et al., 2017; Hong et al., 2015; Magis-Rodriguez et al., 2009; National Center for Farmworker Health, Inc, 2017). Along the US and Mexico border regions, Latinas’ primary risk factor for contracting HIV is having a sexual partner who has migrated to the US (Persichino & Ibarra, 2012). Researchers have recognized Latinas’ vulnerability to STIs (including those beyond HIV) for a number of years (Ertl et al., 2018; Mann et al., 2016), including reports of health outcomes aligned with heterosexual contact as primary transmission mode for women (Centers for Disease Control and Prevention, 2016). In fact, Latina heterosexual women comprise one of the fastest growing sub-population for STIs in the US (Centers for Disease Control and Prevention, 2019), and the south alone holds over half of the nation’s HIV cases (Centers for Disease Control and Prevention, 2017). The prevalence and prognosis for STIs become even more complicated given that a growing percentage of Latinos/as live in small towns and rural areas (Lichter et al., 2016; Schminkey et al., 2019), hence the geographical focus of this article.

The shift in STI prevalence for women has been on a global radar now for nearly 15 years (UNAIDS, 2004). The fourth global report from the Joint United Nations Program onHIV/AIDS stated that 50% of new infections occur between spouses, calling this a movement toward the “feminization of HIV/AIDS” (UNAIDS, 2004, p. 8), making the prevalence and prognosis of STIs with Latinas an important focus for clinicians, researchers, and policymakers. The most recent patterns of immigration and subsequent increase of Latino/a resi- dents in small rural communities have found providers unprepared to meet the health-care needs of the immigrant communities (Schminkey et al., 2019). Generally speaking, rural communities have fewer resources with which to address health-care issues, including provider shortages and lack of adequate services that can be provided to patients in their indigenous languages

78 A. L. LAMSON ET AL.

(Schminkey et al., 2019). In particular, a lack of resources as well as an absence in cultural competency exists in relation to Latinas’ sexual health care for STIs (Mann et al., 2016). These unmet needs and health disparities surrounding Latinas’ sexual health require health-care providers, researchers, and policy- makers to learn more from the voice of Latinas about cultural roles and expectations that influence the patient–provider relationship and provider’s sense of cultural awareness and humility.

Influence of Culture and Oppression of the Latina Voice

Many Latina immigrants face patient-provider language barriers, high costs for their health care, and lack of family support. Latinas may be separated from their social support temporarily or permanently due to immigration status or regula- tions associated with work visas. These barriers all increase Latinas’ likelihood for heath disparities (López-Cevallos & Harvey, 2016; Mann et al., 2016; Schminkey et al., 2019). These disparities include Latinas’ (a) tendency to enter treatment later than their white counterparts (Chen et al., 2012; Lopez- Quintero et al., 2016), (b) reduced likelihood to engage in STI testing or having health-care tests confirmed (Ganguli et al., 2013; Liddicoat et al., 2006; Parra et al., 2001), (c) lack of remaining in treatment after diagnosis (Lopez-Quintero et al., 2016; Torrone et al., 2010), and (d) ability to access medications or adhere to medication management (Fortuna et al., 2019; Zhang et al., 2013) across their lifespan (Chen et al., 2012).

Health disparities in the Latino community aremultifaceted and are often due to provider and/or institutional sexism, racism, or classism (Sharma, 2019) implicit bias, or discrimination as it interfaces with people of color’s experiences with historical oppression (Schminkey et al., 2019; Wiltz, 2015). For many, the cultural roles of Latinos/as within the family (i.e., roles that are influenced by ethnic, religion, or geographic rituals, traditions, or systemic oppression), including gender roles, are contributors to the complexity of seeking and sustaining sexual health care. Furthermore, traditional gender and family system roles, such as machismo, which is an emphasis on male dominance and mascu- linity, and familismo, which is an emphasis on loyalty to the family in Latino/a culture, play at least some part in whether Latinas feel able to voice concerns about their own sexual health within a relationship (Hargreaves et al., 2010; Lindsey, 2018; Mann et al., 2016; Tung, 2012). Sexual health disparities for this community are especially concerning, given that Latinas are at a heightened risk for being victimized by sexual assault or abuse (Fortun`a et al., 2019).

Researchers found traditional gender roles influence Latinas’ view of self and autonomy (or lack thereof) in relation to decision-making about sexual and reproductive health (Hargreaves et al., 2010; Mann et al., 2016; Parrado et al., 2005; Persichino & Ibarra, 2012; Viadro & Earp, 2000). Some suggested that the traditional machismo lens is a facilitator for Latina submissiveness to

JOURNAL OF FEMINIST FAMILY THERAPY 79

their partners (Hargreaves et al., 2010; Stephens et al., 2017), which can result in a marginalized voice when navigating sexual health decision-making (Hargreaves et al., 2010; Parrado et al., 2005; Peragallo Montano et al., 2019). Furthermore, Latinas’ attention to familismo ensures that the needs of her family are placed before her own. Researchers found familismo to be a contributor for Latina dropout rates in relation to healthcare treatment (Hargreaves et al., 2010). These factors, when interfaced with highly stigma- tized health issues, such as sexual health symptoms or diagnoses, result in a heightened disparity. Latino/as are then left with a reduced likelihood for seeking or sustaining health care or psychosocial treatment.

While only barriers to Latinas’ health care have been described to this point, facilitators are also known to exist that help to improve Latinas’ sexual health, and as such are important to acknowledge. Researchers have recognized that positive patient–provider relationships and interactions (once treatment has been sought out) may facilitate better health-care experiences and opportunities for Latinas (Beach et al., 2010; Lazcano-Ponce et al., 2004; Mann et al., 2016; Saha et al., 2013; Schuster et al., 2005), as well as improve patients’ perceptions of health-care providers (Infante et al., 2006; Schuster et al., 2005).

Providers have been identified as culturally sensitive to Latino/a patients when they embrace personalismo (i.e., the Latino/a sense of belonging, attachment to others, developing personal connections), simpatía, (i.e. kind- ness), and respeto, (i.e., respect) (Juckett, 2013). Personalismo is a cultural value shared among Latinos that emphasizes the importance of establishing a personal relationship with a health-care provider before pursuing treatment (Mogro-Wilson et al., 2016), and is noted in previous research to be an important cultural value that effects treatment adherence (Antshel, 2002). Simpatía and respeto are two examples of cultural competence in the clinical setting associated with equitable treatment and quality of care (Mann et al., 2016; Saha et al., 2013), both of which align strongly with feminist standpoint theory (i.e., understanding power differentials in structural practices; Harding, 1986). While barriers and facilitators to Latino/a health-care experi- ences appear in past literature, almost no research exists on Latinas’ experi- ences with health-care providers in the US. As such, the following provides a theoretical foundation and community-based participatory research design to answer this research question: What are Latina immigrants’ experiences with receiving sexual health care from providers in the United States?

Theoretical Foundation

The historical context that the US shares with the countries of Latin America is extensive (Chambers et al., 1987; Fernandez-Armesto, 2014; Goldfield et al., 2004) and riddled with oppressive outcomes (e.g., colonization, enslaving of indigenous peoples, women receiving fewer rights) that are morally unjustified

80 A. L. LAMSON ET AL.

(Chambers et al., 1987; Fernandez-Armesto, 2014). The resulting societal struc- tures and social positions continue to support the dominant race, while holding stagnant and less empowered the state of minority cultures and ethnicities (Fernandez-Armesto, 2014; Habermas, 1981, p. 1984). Critical theory (Habermas, 1981, p. 1984) provides us with a lens that highlights unjust power structures and brings attention to the need for emancipatory endeavors (e.g., advocacy toward political movement) (McCarthy, 1989). These tenants also intersect with numerous feminist theories as they interface with health-care systems (Sharma, 2019) and the need for promoting emancipatory knowledge.

According to critical theory (Habermas, 1981, p. 1984), emancipatory knowl- edge is self-reflection that produces a liberation from such social forces as institu- tions or environmental powers that stand to limit the control one has over their own lives. Critical theory was used to ground this study and give voice to Latina sexual health-care experiences in the US; which was further enhanced through a community-based participatory research (CBPR) design (Israel et al., 2013).

Given the sensitivity of this health topic (i.e., Latinas’ sexual health), CBPR was adopted in partnership with non-researchers who identified as Latina immigrants, constructed the research questions, developed the research protocol, and analyzed the study’s findings. CBPR focuses on an equitable collaboration between com- munity organizations or elders and university researchers to improve a community’s public health and health outcomes (Israel et al., 2013; Springer & Skolarus, 2019). There is a growing appreciation for the use of CBPR as a vehicle to explore and better understand health outcomes, specifically within minority populations (De Las Nueces et al., 2012; Viswanathan et al., 2004; Wallerstein et al., 2017). While attending to power differentials and validating voices within the targeted research sample, CBPR researchers are ultimately charged with the production of quality data via an ethical and rigorous research method.

The CBPR team assembled for this study, included multiple university- based bilingual researchers, as well as an executive director and members of a local grassroots Latino/a organization (that did not identify as researchers). The CBPR team’s community members included advocates who promote community participation and prosperity of Mexican and Latino/a immi- grants. Together, this team unified around critical theory Habermas (1981, p. 1984) as the foundation for this study and proceeded to co-construct the research questions and process of analyzing the data.

Method

This team utilized the transcendental phenomenology of Husserl (1960) to develop a CBPR project (grounded in Habermas’ critical theory (Habermas, 1981, p. 1984) that was approved by both the social science and biomedical university IRBs (IRB00000705, IRB00003781). The interview questions and research topic were developed in close collaboration with all members of the

JOURNAL OF FEMINIST FAMILY THERAPY 81

CBPR team in keeping with CBPR principles (Israel et al., 2013). Regular and confidential meetings between the university researchers and community advocates were key to fostering a well-developed study, quality data collec- tion, and productive outcomes (Israel et al., 2013; Viswanathan et al., 2004). While CBPR can be qualitative, quantitative, or mixed method in design, the team chose to implement a qualitative study to address the research question: “What are Latina immigrants’ experiences with receiving sexual health care from providers in the United States?”

Phenomenology was deemed an appropriate strategy of inquiry for this study, as it aligned with the core components and principles of CBPR (Israel et al., 2013), and promoted self-knowledge and reflection that is advocated for by critical theory (Habermas, 1962, p. 1989). It was determined that of all the qualitative designs, phenomenology would allow the team to explore and interpret a phenomenon through the eyes of the participant population studied (Husserl, 1960) consistent with critical theory (Habermas, 1981, p. 1984) and critical feminist theories (Sharma, 2019). This strategy of inquiry has been described as more of a method of questioning than a method of answering (Van Manen, 2014), thus selected as the design of best fit by the CBPR team.

Participants

The CBPR team worked collaboratively to create English and Spanish recruitment flyers that would be placed at mainly rural-based health depart- ments and clinics in one US southeastern state. Inclusion criteria for parti- cipant selection included: (a) identified as a first-generation Latina immigrant, (b) provided a sexual history in the context of a medical appoint- ment with a health-care provider, and (c) was at least 18 years old. Exclusion criteria ensured that potential candidates were not selected if: (a) they had not received health care in their life, (b) had not been asked about their sexual history in a health-care setting, or (c) were currently pregnant.

Interview Guide

An in-depth interview guide was co-created for this study (see Figure 1) by the CBPR team. The team developed 17 semi-structured and open-ended questions and determined that all interviews would be competed face-to-face. The interview guide was constructed such that participants could describe their experiences with receiving health care for sexual health concerns or being asked about their sexual histories during a medical visit in the US. The interview then moved into more specific questions about their health-care experiences and concluded with a final question encouraging the participant to add any additional information that they felt would be relevant to the study’s purpose.

82 A. L. LAMSON ET AL.

A 21-question demographic survey (e.g., nationality, time lived in US, age, marital status, education level, gender, and questions about healthcare appointment attendance both in the US and home country) was also con- structed. The survey was intended to give more context to the qualitative interview responses without having to extend the length of the qualitative portion of the interview. Participants filled out the demographic survey after completing the informed consent.

Grand Tour Question • Describe any experiences that you have had with your doctors, or other health care

providers, in your home country and the United States who have asked to complete a sexual history, screening, and/or assessment regarding sexually transmitted infections or diseases.

Mini-Tour Questions • Without disclosing any names, can you tell me about your thoughts or feelings about the

last provider that you went to for care? o How did the provider assess for sexual health concerns? STIs? o Did this appointment take place in the US or in your home country?

• Without disclosing any names, tell me why you chose to go to this provider? o In what ways was the experience a good one for you? o What did you not like about the visit?

• What concerns you most about going to a health care provider like a doctor for some problems you have been experiencing/have experienced?

• What health problems would be most difficult to talk about with a doctor? o What makes these discussions most difficult to discuss?

• If there comes a time when you are concerned about a sexually transmitted infection, who would you be most likely to talk to about it?

o How confident are you that this information would be accurate? • If you ever had to talk to a doctor about a sexually transmitted infection, what do you

think would make that discussion go the best way possible? o What do you think would make the discussion go as badly as possible?

• What concerns would you have, if any, about talking with your doctor about sexually transmitted infections?

• If you had concerns or questions about HIV who would you talk to about those concerns? • What messages do people receive from the community about being tested for sexually

transmitted infections? • What messages do people receive from the community about being tested for HIV? • What do you think would improve the chances that Latina immigrants would get

screened for sexually transmitted infections or diseases, or HIV? • What do you think would improve the chances that Latina immigrants would talk with a

doctor or other health care provider about sexually transmitted infections or diseases, or HIV?

• What do you wish US providers learned from providers in your home country about assessing for sexual health concerns, STIs, and HIV?

• What do you wish the providers in your home country learned from US providers about assessing for sexual health concerns, STIs, and HIV?

• Describe your preferred provider for sexual health issues: age, gender, ethnicity, etc. Interview Closing

• What have we not yet talked about that you think is important for me to know in relation to the purpose of this study?

Figure 1. Interview Guide.

JOURNAL OF FEMINIST FAMILY THERAPY 83

Procedure

The interviews were conducted by a university-based bilingual researcher and a bilingual, bicultural research assistant. Each participant was informed about the study’s purpose, its risks and benefits, and their confidentiality rights before being enrolled. Upon completion, participants received a gift card in the amount of 25 USD. To protect participant identity, during the data analysis process, researchers used a coding and numbering system in place of actual names.

Interviews lasted approximately one and a half hours and participants were informed that they could stop at any time. Participants were offered a choice of interview setting. Of the 11 face to face interviews conducted, seven interviews took place in participants’ homes and four took place at a local grassroots organization’s office. The latter was a location commonly used for regular meetings specific to Latino/a issues and was considered by the CBPR team to be a safe environment.

Analysis

Interviews were professionally transcribed from Spanish into English and non- identifying numbers replaced actual participant names. Following the transcrip- tion of the English recordings, Giorgi’s method (Giorgi, 2009) was applied to the data coding process. Giorgi’s four-step method was selected because it closely followed Husserl’s writings on phenomenology, which promoted theoretical consistency throughout the study. Giorgi’s method involves multiple reviews of the data and the development of “units of meaning” that help to establish significant themes from the data. These themes were then crossed-checked by consulting the literature, as well as discussing the results with members of the local organization who served as research collaborators.

The intended sample size for a phenomenological study is determined when the major thematic content reaches a point of saturation, namely, when the themes arising from new participants begin to replicate those found in previous participant’s answers. In this study, the research reached a point of saturation after 11 interviews. The point of saturation was confirmed through the multiple review process conducted by the CBPR team. This multi-review process further strengthened the indicators of rigor applied to the research study.

Indicators of Rigor

To ensure credibility and transferability, field notes and research logs were utilized by the team in order to highlight and attend to personal biases during the research process. Each team member wrote and periodically revisited his or her own bias statement, acknowledging systemic influences in keeping with a CBPR approach. The researchers also regularly engaged with the Latino/a

84 A. L. LAMSON ET AL.

community as a way to better understand participants’ responses in the context of culture. The time spent by the CBPR team in co-constructing each compo- nent of the study and analyzing the data from the interviews solidified the rigor that afforded Latina voices (involved in this study) to be shared with commu- nities of interest and professional audiences (Cypress, 2017).

Results

Sample

Eleven Latina immigrants between the ages of 31 and 64 participated in the study, with 46 as the mean age. All but one of the interviewees immigrated from Mexico; the remaining participant immigrated from Honduras. With one exception, interviews were conducted in Spanish. Six of the participants were married at the time of the interview, while four were single or “other,” and one was divorced. Seven of the participants earned a high school diploma or GED, two reported less than 2 years of higher education, and two reported a primary school level of education. Five of the women had no medical insurance at the time of the interview. The average number of years since immigration was 15 and ranged between 1 and 21 years.

Identified Themes

A total of 7 themes and 15 subthemes emerged from the interviews, con- structed from 266 separate units of meaning. The themes are organized in Table 1 from the most commonly mentioned to the least commonly men- tioned. Specifically, Table 1 shares the percentage of the 266 units of meaning that related to each particular theme. The identified themes punctuate ele- ments that both facilitated and negatively influenced Latina immigrants’ experiences with sexual health care in the US, often in contrast to experiences encountered in their home country.

The most commonly identified theme related to cultural differences in health care is communication style among Latina women and their health-care provi- ders. Communication style was particularly connected to the subthemes of personalismo and directive vs. nondirective communication styles. Personalismo was captured as a connection with the provider that included but extended beyond a caring atmosphere. This concept seemed to more deeply reveal a sense of belonging that participants felt when personalismo was present in treatment. One participant explained that when Latinas feel as though personalismo is absent in the health-care setting “that the doctor just doesn’t really care … [they are] much less likely to want to share anything.” A second subtheme associated with communication direct vs. nondirective styles. Participants described how challenging it was when health-care professionals

JOURNAL OF FEMINIST FAMILY THERAPY 85

Ta bl e 1.

Th em

es an d Su bt he m es

Re la te d to

La tin

as ’P

er ce pt io ns

of Se xu al

H ea lth

Ca re

in th e U S.

Th em

es U ni ts

of M ea ni ng

Su bt he m es

Th em

at ic Ex am

pl es

Q uo

te

1. Co

m m un

ic at io n

St yl e

21 %

A. Pe rs on

al is m o

B. D ire ct iv e vs .N

on -D ire ct iv e

A. Pr ov id er

es ta bl is he s a w ar m ,

ca rin

g at m os ph

er e.

B. Cl ea r, di re ct

co m m un

ic at io n fr om

th e he al th

ca re

pr ov id er .

A. “I f m an y th in k th at

th e do

ct or

[in th e U S]

ju st

do es n’ t re al ly

ca re

… [t he y ar e]

m uc h le ss

lik el y to

w an t to

sh ar e an yt hi ng

.” B.

“[ D oc to rs in

M ex ic o]

gi ve

yo u th e ad vi ce

st ra ig ht fo rw ar d …

w he re as

he re

it’ s m or e am

bi gu

ou s, in

th e U ni te d St at es .”

2. Ca pa ci ty

of th e

H ea lth

Ca re

Sy st em

21 %

A. In cl us io n of

se xu al he al th

as se ss m en ts

B. Ab

ili ty of

th e he al th ca re

sy st em

to m ee t he al th

ca re

ne ed s

A. Se xu al he al th

is m or e of te n

as se ss ed

in U S th an

in th e co un

tr y of

or ig in .

B. M ed ic al co nc er ns

ar e un

ad dr es se d

or le ft un

re so lv ed .

A. “I n [t he

U S]

… it’ s m uc h m or e no

rm al th at

th ey

as k yo u

qu es tio

ns ab ou

t it. ”

B. “H er e [in

th e U ni te d St at es ] th er e is a lo t of

ru nn

in g ar ou

nd an d

m ak in g ap po

in tm

en ts an d ju st so

m uc h in fo rm

at io n th at

no th in g is

be in g do

ne .”

3. Ac ce ss

to Ca re

18 %

A. Lo ng

w ai t tim

es B.

La ck

of do

ct or s

C. Tr av el

di st an ce

D .H

ig h co st s/ La ck

of in su ra nc e

E. La ng

ua ge

ba rr ie rs

A, B.

Pr ov id er

ca rr ie s he av y ca se lo ad

an d fu ll sc he du

le .

C. H ea lth

ca re

fa ci lit y re qu

ire s

ex te ns iv e tr av el

ca pa bi lit y.

D .I ns ur an ce

is no

t av ai la bl e or

do es

no t co ve r im po

rt an t te st s,

pr oc ed ur es ,a nd

/o r tr ea tm

en ts .

E. In te rp re te rs an d pa tie nt s of te n

kn ow

ea ch

ot he r ou

ts id e th e m ed ic al

se tt in g.

A, B. “[ T] he y to ok

w ay

to o lo ng

– tw o ho

ur s – fo r m e to

be se en

[in th e U S]

… th er e w er e no

do ct or s. ”

C. “O ve r th er e [in

M ex ic o] ,t he

re as on

Iw en t to

th at

do ct or

is be ca us e he

w as

th e m os t re ac ha bl e. ”

D .“ M on

ey do

a lo t w ith

ho w yo u ta ke

ca re

of yo ur se lf,

be ca us e …

yo u m ig ht

fin d so m et hi ng

th at

is go

in g on

w ith

yo u an d yo u do

n’ t

ha ve

ei th er

th e in su ra nc e or

th e m on

ey to

pa y fo r it [in

th e U S] .”

E. “A

co un se lw

ith a do ct or

[in th e U S] …

it’ s lik e go in g to

co nf es sio

n. ”

“[ I]t ’s m uc h ha rd er fo rm

e to be

ab le to te ll th e [U S] do ct or ev er yt hi ng

… be ca us e th e in te rp re te rb

el on gs

to th e co m m un ity .”

4. Ti m e O rie nt at io n

15 %

A. Pr es en t tim

e vs .F ut ur e Ti m e

A. H ea lth

ca re

cu ltu

re in

th e U S te nd

s to

as k pr ev en ta tiv e, or

fu tu re -

or ie nt ed ,q

ue st io ns .

A. “W

he n Ig

ot pr eg na nt ,I

w as

as ke d [b y th e U S pr ov id er ] if

Iw an te d th e AI D S te st

an d Iw

as th in ki ng

th at

m ay be

he th ou

gh t

th at

Iw as

sl ee pi ng

ar ou

nd .”

5. St ig m a

13 %

A. Co

m m un

ity pe rc ep tio

n of

H IV /

ST Is

B. Pr ov id er

pe rc ep tio

n of

H IV /S TI s

A. La tin

as fa ce

di sc rim

in at io n

co nc er ni ng

th ei r se xu al be ha vi or s in

th ei r co un

tr ie s of

or ig in .

B. La tin

as fe ar

pr ov id er

ju dg

m en t

re ga rd in g th ei r se xu al he al th .

A. “I f Iw

as in

M ex ic o,

Iw ou

ld st ay

qu ie t [if

Ih ad

an ST I]. ”

B. “T he

pe op

le th in k th at

th e [U S]

do ct or s w ill te ll th em

th at

th es e

ar e ju st

de ge ne ra te s, se xu al be in gs .”

6. Fa m ili sm

o 7%

A. Cu

ltu ra lp

ra ct ic e of

pl ac in g th e

ne ed s of

th e fa m ily

be fo re

th os e of

th e in di vi du

al B.

In cr ea se d co m fo rt le ve ls w ith

co m m un

ity m em

be rs th an

w ith

pr of es si on

al s

A. Fa m ily

ne ed s ca n be co m e

a ba rr ie r to

at te nd

in g to

he al th ca re

ne ed s.

B. D is cu ss in g he al th ca re -r el at ed

to pi cs

is m or e co m fo rt ab le

w ith

fa m ily

or pe er s pr es en t.

A. “E ve ry th in g co m es

be fo re

he al th

… th e ch ild re n,

to m ak e fo od

, he r jo b.

Sh e ca n’ t m is s w or k. ”

B. “[ Ip

re fe r] th at

[t he

do ct or ] di dn

’t te ll m e al on

e, th at

m ay be

he w ou

ld te ll m e w ith

th re e ot he r fr ie nd

s. ”

7. Pe rc ep tio

ns of

Ri sk

5% A.

Co m m un

ity m em

be rs do

no t

al w ay s un

de rs ta nd

w he n th ey

ar e at

ris k fo r co nt ra ct in g ST Is .

A. M ar rie d w om

en fe el

th at

th ey

ar e

sa fe

fr om

th e ris k of

se xu al di se as e.

A. “A

lo t of

pe op

le th in k be ca us e th ey

ar e m ar rie d an d th ey

ha ve

th ei r sp ou

se th at

th ey

ar e sa fe ,t ha t it ca n’ t ha pp

en to

th em

.”

86 A. L. LAMSON ET AL.

in the US used ambiguous or confusing words when asking questions or discussing treatment. “[Doctors in Mexico] give you the advice straightfor- ward … whereas here it’s more ambiguous, in the United States” was given as one example. Participants described their comfort in receiving more direct communication as they had often received in their home country.

Almost as prevalent was a theme related to the capacity of the healthcare system to address the Latina participant’s ability to feel adequately heard and treated by their health-care providers. Many expressed a belief that their health needs had not been met by the system, discouraging them from seeking further care. One participant expressed her frustration that “there is a lot of running around and making appointments and just so much information that nothing is being done.” A third and similar theme was that of access to care. Participants described their struggle to access appro- priate health care due to long wait times, not enough providers on staff, inability to travel to their providers, inability to afford services, lack of health insurance, and finally, language barriers when communicating with provi- ders. Often rural health-care systems utilize interpreters from their patients’ communities to navigate the patient’s health-care visit; one participant lamented that “a counsel with a doctor … is like going to confession.”

Occurring as a theme in 15% of the total number of meaning units, time orientation was coded when participants expressed what the researchers identi- fied as a conflict between the time orientation of a participant’s culture of origin and that of the US. health-care provider. Specifically, present time orientation (e.g., accessing health care only when there is a problem or symptoms) of their native culture sometimes clashed with the future time orientation (e.g., accessing health care for preventive care) of their new home country (Galanti, 2008). Some participants expressed concern that when providers ask proactive future- oriented questions about their sexual health, these providers are asking because they assume risky sexual behavior has occurred. This feeling ties into Latina concerns about how society perceives them, as evidenced through this quote: “When I got pregnant, I was asked [by the US provider] if I wanted the AIDS test and I was thinking that maybe he thought that I was sleeping around.”

Specifically, stigma was another theme that emerged, with participants expressing the taboo surrounding a discussion of HIV or other STIs in their native cultures. They suggested that in the US questions pertaining to sexual health were always the hardest questions to answer. If asked questions about STIs in their home country, they would stay quiet. Providers in the US ask proactive and open questions about sexual health as part of their practice; however, one participant feared that her provider considered Latinas to be “degenerates, sexual beings.”

There was a theme in the data related to familismo, the cultural practice in Latino/a families of placing family needs before individual concerns. Specifically, the Latinas in the study felt it was self-serving to attend to

JOURNAL OF FEMINIST FAMILY THERAPY 87

their own health-care needs at length, taking resources and time away from their family responsibilities. One participant explained that “everything comes before health … the children, to make food, her job. [Latinas] can’t miss work.” Familismo highlights the importance of the family system in Latino culture and is essential to understanding this culture. Some men- tioned that they would be more inclined to discuss sexual health concerns with a family member than speaking about such issues with a health-care professional. Furthermore, participants mentioned a comfort in having a family member or friend join them in their health-care visit.

The final theme that emerged from the participants was their perceptions of the risk of contracting an STI or HIV. Many did not feel that their heterosexual relationships could lead to infection. As one participant stated, “A lot of people think because they are married and they have their spouse that they are safe, that it can’t happen to them.” In fact, some believed that if a Latina woman was married then she was not at risk for a STI. Others felt that their religion would protect them from contracting a disease.

The Phenomenological Exhaustive Description: The Latina Voice

The Latina immigrants in our study encountered health care in a way that is unique to a bicultural immigrant experience (Ali & Johnson, 2016). Access to sexual health care for Latina immigrants was limited due to explicit barriers (e.g., long wait times, insufficient number of doctors, travel distance, language bar- riers, cost, and lack of health insurance), as well as concerns regarding commu- nication. Interpreters were often needed to help Latinas navigate their health- care visits and sexual health-care encounters. These encounters with interpreters created a strong cause for concern about confidentiality and often resulted in highly stigmatized communication. Stigmatized interactionsmeant that they did not feel safe and held back questions intended for the health-care professional. In some instances, participants mentioned they would not seek out sexual health information or access health care for sexual issues at all. The lack of access was further complicated by time orientation. They noted that health-care profes- sionals in participants’ home countries do not typically extend preventative care; thus, sexual health assessments in the US felt stigmatizing and confirmatory of poor sexual health decisions. In their native cultures, health-care professionals only assessed for what they thought was potentially a problem. Participants shared that when health-care professionals in the US did not take time to build rapport with the patient, participants often became uncomfortable. This lack of personalismo left them wondering if the provider is making a moral judgment about their character or suspecting that she may actually have a STI.

Overall, Latinas in this study experienced health care as confusing and some- times left visits not understanding what their diagnoses were. Whether due to language barriers or a deliberate avoidance of care due to stigma, they did not have

88 A. L. LAMSON ET AL.

a clear understanding of STIs/HIV, nor the ability to ask the questions that were necessary for clarification. Participants stated they would feel more comfortable if sexual health screenings were normalized (described as questions they ask all patients/clients) and that information be given to them routinely, in order to further normalize the otherwise taboo topic and experience. Furthermore, they mentioned that the presence of a family or friend as part of their health-care visit would likely enhance their experiences. They shared that particularly they would want a family member present if they were receiving news relate to sexual health. Familismo was shared as an important component of Latinas’ health care, in the following ways: (a) safety and trust were more easily established when a family member was part of the visit, (b)more personalismowas experiencedwhen health- care professionals asked about or involved her family members in the discussion, and (c) understanding how their own sexual healthmay influence the lives of their unborn or living children.

Discussion

Using critical theory (Habermas, 1981, p. 1984) as our guide, we employed a CBPR research study (Israel et al., 2013) as a culturally sensitive way to explore the sexual health-care experiences of Latina immigrants. Through critical theory, we sought to promote emancipatory knowledge by asking questions that invoked self (and other) reflection, institutional forces in health care, and the potential for outcomes from this study to influence Latina and family health care positively.

Critical theory (Habermas, 1981, p. 1984) (in alignment with critical feminist theories (Sharma, 2019)) was present throughout the CBPR design (Israel et al., 2013), giving attention to the importance of communities and universities mutually working together on issues that influence Latina and family health. Through this study, the CBPR team aimed for equity between all partners throughout the research process (Israel et al., 2013) and pro- moted the voice of Latinas through their US-based health-care experiences. While the research aim was the primary focus, unquestionably the university research team and the community advocacy members gained new skill sets that would have otherwise not occurred without a CBPR design (e.g., the university team would have missed the theme of time orientation in the analysis and the community team would not have understood the intricacies of research ethics).

Recommendations

While recommendations could be put forth for each theme, recommenda- tions will instead be aimed at bridging research findings with women’s health through peronsalismo, familismo, and feminist family therapy healthcare

JOURNAL OF FEMINIST FAMILY THERAPY 89

practices. A focus on these three topics may be most influential in carrying the voices of the Latina who participated in this study into direct clinical care.

Throughout the interviews, participants stated that it was important to them that they develop a relationship with health-care professionals before beginning any screenings, assessments, or treatment interventions. The cultural concept known as personalismo extends beyond the very quick joining process that com- monly occurs at the start of any session or health-care visit. Latinas’ reported safety was based on a sense of connection or belonging with health-care professionals, often absent in biomedicine’s patriarchal dominance stance (Sharma, 2019).

Regardless of the work context, but perhaps especially in systems that are fast-paced, it is important for family therapists and other health-care profes- sionals to nurture personalismo. Moving too quickly to assessment or treat- ment could fracture relationships or deepen experiences of oppression. Health-care professionals may benefit from recognizing that personalismo is a biological, psychological, social, and often spiritual (i.e., attributing mean- ing-making to a person or experience) connection to people and experiences. As such, it is recommended that health-care professionals take time with Latina patients to establish the relationship. Investing time in learning more about their cultural connections to health will likely promote a safer envir- onment for care that can improve their health outcomes.

The Latinas and CBPR team put forth the following specific recommendations to family therapists in relation to personalismo: (a) construct a first visit that emphasizes getting to know the client, her culture, and experiences that are meaningful to her, (b) address sexual health matters with Latina patients in a normalizing way. Explain that these questions are asked as part of good sexual health care for all clients in the practice regardless of gender, sexual orientation, ethnicity, etc., and (c) include sexual health-care questions or assessments indi- cated for their practice and the population served in that practice. Two or three assessment questions could be integrated into an intake or part of sessions with the provider to normalize the conversation. These questions may help to ensure that a safe environment exists in the health-care setting and that the client is biologi- cally, psychologically, and socially safe in the health-care encounter. This is recommended not only for females, but also for Latino males, in order to further normalize the conversation.

Participants also highlighted the concept of familismo as important to the health-care visit. This aligns with previous research (Hargreaves et al., 2010). Unfortunately, some researchers have documented familismo as a barrier to care or contributor to dropout rates in health care (e.g., Hargreaves et al., 2010). While it is important to attend to previous research, it is also important for family therapists and others on the health-care team to explore with patients’ ways in which familismo can be more central to their healthcare experience (i.e., encourage Latinas to bring a support person to their health-care visits and/or ask questions that attend to her relational safety, satisfaction, and well-being).

90 A. L. LAMSON ET AL.

Latinas did share that they often put the needs of their children before their own needs. However, participants in this study also suggested that emphasizing the importance of STI screenings for Latinas for the sake of their children’s health could be an effective approach to increasing the chances that they will get tested for HIV and STIs. The CBPR team added to this recommendation by clarifying that this should not be through a pathologizing conversation or one that is coercive or punishing but rather, a conversation that offers psychoeducation about how STIs can influence an unborn child. This conversation would be consistent with the goal of normal- izing assessment and discussions pertaining to sexual health.

Familismo is a concept that is expected to be known and applied by family therapists who are well trained in and attuned to diverse family systems, even when treating an individual client. Consistent with family therapists systemic training, it is essential to ensure that the family (however that is defined by the client) is present through descriptions, stories, or rituals even when they are unable to be physically present. The underscore cannot be pronounced enough around the role of safety when it comes to familismo. Clients will often know ahead of time (per communication within the community) which practices and providers are safer than others to go to for care. Another level of safety scanning will take place once a patient/client arrives to ensure that family-based conversa- tions can occur about any physical, psychological, relational, and/or spiritual concerns. While familismo may not have been the most frequently cited theme in this study, its role in a Latina’s life guides most of her health-care decisions.

As part of the US healthcare system, family therapists can provide such a positive influence on the care of Latinas and other immigrants that seek health care and a best life in the US. Their competency in relational health makes them an important collaborator for any health-care provider who extends sexual health-care education, screenings, assessments, and interventions. The Latina voices from this study along with inclusion of a diverse CBPR team offer a call to action for family therapists to engage in practice and research that can be more culturally sensitive and open up a self-reflection for both clients and health-care professionals to enhance our cultural humility toward a better healthcare system and improved health-care outcomes for all.

Conclusion

Community-based participatory research can be part of the feminist solutions that challenge the power dynamics which have historically subjugated vulner- able populations. If, through the avenues of CBPR, researchers are able to partner with Latino community organizations and community members in research, to be co-producers of knowledge, then knowledge can be exchanged for the sake of improving community health outcomes. Together, clinical researchers (such as family therapists) in tandem with community partners

JOURNAL OF FEMINIST FAMILY THERAPY 91

can influence present social structures and social issues that may inadvertently impede access to health care for Latinos/as. This research is an important contribution to science as it involves the Latina community both as co- researchers and participants in order to better understand sexual health-care practices in the US in contrast to the home countries of Latina immigrants. In addition, this research provides significant outcomes that health-care profes- sionals, such as family therapists can implement in order to reduce stigma, build trust, and bridge the divide between treatments and psychoeducation received in Latinas’ home countries and the US. Through this research (grounded in critical theory and aligned with critical feminist theories), Latinas were able to voice many barriers and facilitators to accessing sexual health care and participating in conversations around sexual health. By recognizing and honoring the many cultural differences that Latinas experience in the US, health-care providers can begin to offer a more culturally sensitive, feminist-informed, and humble approach to important screenings, diagnoses, and treatments for sexual health with their Latina immigrant patients/clients.

ORCID

Jennifer L. Hodgson http://orcid.org/0000-0001-5363-0215

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