Teenage Wasteland: Exploring Effective Sexual Health Interventions
Poverty is like punishment for a crime you didn’t commit. ~Eli Khamarov, “Lives of the Cognoscenti”
Lack of trust in the U.S. Health Care System and perceived racism, in conjunction with inequalities, prevent many marginalized African-American young adults from an open and honest dialogue about safe sex practices. The current research and available data suggests that broad based programs aimed at intervention and education do not adequately address cultural issues. Rates of STD’s AIDS and HIV are rising in young Americans, most visibly in the female African-American population. The statistics are alarming in regard to sexually transmitted diseases (STD’s): 2008 data from the CDC tells us that 25% of girls between 14 to 19 years of age have a STD, and half of these are African-American. Many STD’s are preventable with the use of condoms, and serious health risks are associated with the delay of visible symptoms that would normally cause one to seek advice or assistance (Weitz 2010:37).
According to the Health Belief Model, there are factors, which are sensitive to demographic, psychosocial, structural and external cues to action, which must be addressed for people to actively adopt health behaviors. Considerations of susceptibility, seriousness of risk, reduction of risk through compliance, and lack of barriers to compliance all come with social and culturally specific tenants. Limits to adoption of these behaviors confound this widely adopted model, as the limits on agency, or free will, are not addressed. This mindset represents a form of double-speak for the marginalized; those who are living in structured lives with socially created boundaries often do not recognize the opportunity for agency, and know only the limited choices set forth to them (Weitz 2010:41). Current modes of education and intervention are missing the mark with the young African Americans, and broad based policy efforts have met success with only those who relate to the dominant ideology.
There is a limited presence of flexible policy mandates in the bureaucracy and profession of medicine and health care, and those that make policy most often follow the dominant ideology and worldview. The shades of grey that color marginalized lives are largely absent from the scripted narrative of behavior awareness and modification of unsafe sexual practices (Calabrese 2008). Timely interventions couched in a culturally appropriate dialogue, in conjunction with parental support and communication, are supplemental methods that could increase the effectiveness of broad –based social health programs.
Historical events like the Tuskegee Syphilis Experiment, incepted in the 1930’s, shape how a minority might perceive the world, and how they feel they are perceived. Horrific events that violate human rights are copious in our world history, and damage cultural identities and diminish a sense of safety for those involved (Jones 1993). Chosen for the study by zealous physicians who perceived African Americans as more promiscuous, more than a quarter of the men died due to neglect; insanity, blindness and related chronic illness affected many more. These men were denied dignity and life within a ring of conspiracy: they were put on a “do not interfere” list of sorts: denied admittance into our military, where help would have been provided, and denied acknowledgement of the disease by area doctors who were complicit in the conspiracy. When this experiment was exposed in 1972, an attorney took action for the patients, garnering medical treatment and 40,000 dollars for each survivor as compensation. Studies that involved human subjects were addressed by the National Research Act of 1974 and President Bill Clinton offered a formal and public apology to the victims in 1997 (1993).
However it is vilified, the past is a major factor in perceptions of mistrust in the healthcare system. Trust is a necessary bond between those who seek information and those who satisfy this need, and stereotypes can be very damaging, and used to justify actions by others that would otherwise be socially unacceptable. Overcoming, or meeting, these perceptions with empathy and appropriate responses has become a critical issue in America today.
37% of black participants in a study of racism and trust measures in health care reported a lack of trust in their physician. 30% mentioned harmful experiments performed in the past and 33% agreed that hospitals want too much personal information from patients (Boulware et al., 2003). This data shows us that the past is a present concern, and advice about how to best protect one’s health is often met with suspicion and resentment. According to the U.S. Surgeon General in 2010, minorities comprise 6% of the practicing physicians. The atmosphere of most health care settings is very utilitarian and “institutionalized”, as are the processes and procedures. Personal and familial belief systems are very important to many minorities, and the tendency to be wary is passed down through generations. In light of current deficits in the medical field in regard to cultural sensitivity, a supplement to the current approach could co-employ culturally specific symbolism and narrative to the target audience, delivered by credible sources that can demonstrate a shared common goal and respect for the customs of that particular culture. According to Weitz, current efforts to address this issue include Harvard Medical Schools ‘New Wave” three-year program, designed to enhance cultural awareness in health outcomes (2010).
Can you understand me the way I need to be understood?
Lindberg and Orr link the 2002 national Survey of Family Growth Data with census tract data to examine the association between neighborhood disadvantage and sexual behaviors (2011). Those who have limited options in their daily lives make personal choices within that context and stereotypes of African Americans lead to many overt inequalities such as increased scrutiny of behaviors, more arrests, and harsher social sanctions. Covert stereotyping can result in less benefit of the doubt and fewer accommodations (Ford 2009). In our inner cities, police are often not called for crimes- some refuse to enter the ghettos. Social controls are replaced with cultural systems of coping. Many urban poor rely on self-policing, neighbor watches and social bonding as a measure of protection- initiating fewer attachments to society (Richardson, 2010). Rational choices, for these people, do not appear rational to others who do not share the situation. Additionally, the cycle of poverty and despair creates a present-time orientation with little regard given to delayed gratification.
Political-economical scaffolding supports the structure and interactive routes between health-care related products and services, and our governmental policies. These relationships define who receives access to services, and how they are administered. Traditional economic theories cannot be applied to health care issues due to the distribution-control factors that involve authority, power, wealth and origin of information (Goodman 2007). According to Health United States, 22 % of African Americans had no insurance coverage and only 46% reported a visit to a doctor in the previous year (Centers for Disease Control 2008). This number is similar to the 19% of whites without insurance, 45% of whom had a doctor visit in the same year. Where the data diverges is the socioeconomic status (SES) of Americans who experienced a negative event in that year: for income under 25,000, 25% reported negative events. For income over 75,000, only 7% disclosed a negative event. This reveals that many more poor patients experience factors that affect positive health care connotations.
It is likely that those factors could share common features, but may have unique characteristics and origins. Many sociologists acknowledge the importance phenomenology and symbolic interactionism as components of health behavior. Goffman, as cited by Conrad and Barker (2010), proposed in the 1960’s a schema called one’s “moral career”; crafting a sense of self from available contexts.
Phenomenology yields insights into coping with poor health, and the frailty of the “self”, relative to the context physical and social constraints (S68). Medical Dominance, in conjunction with corporatization-and the inevitable proletarianization , increasing governmental control, and decline of professional associations (Weitz, 2010: 285) has brought us a homogenized world view on health care and health related behaviors.
Studying the effectiveness of intervention programs in safe sex practices, Guzma, et al. declared that while fewer adolescents are having sexual intercourse, those who do are engaging in risky behaviors at a younger age. They posit that kids who have sex at a very young age are less likely to use condoms or other safe sex practices (2003). Condoms are not always available, and cost money-which is in short supply in most of our poor neighborhoods. Older siblings, relatives and parents are not always present and monitoring the younger family member’s behavior, for many reasons including economic, social and cultural. African American families in lower SES do not follow the family blueprint of the dominant ideology. Fathers are often absent and mothers are working, or navigating the quicksand of social services. Fortunately, in some situations, kinship networks are present and offer opportunities for reciprocating family duties (Allen and James 2003).
A growing health care worker shortage in inner-city and rural areas, where the greatest need is, contributes to inequalities for access to education, information and treatment of diseases. A great deal of legwork can be involved for those who have no insurance, no private transportation, internet access or the knowledge of who to ask for directions to the nearest clinic that can meet their needs. Shame and fear of disappointing others are valid concerns in an inclusive culture; resulting questions would arise as to the nature of the problem and curiosity as to why folk remedies or family members were not consulted before confronting the “institution of medicine”.
Once logistics have been addressed and familial inquiry overcome, psychological barriers must be faced. Great courage is needed for anyone, regardless of their social status, to expose one’s private life, and private parts to professional scrutiny. Issues of censure ship arise, as do questions of personal morality and religious belief structures. Health care professionals are more recently being exposed to ethics protocols; however, within the health care system there are wildly diverging attitudes and training experiences for the different levels, or hierarchy of the profession. Corporatization affects who provides health care services; cheaper, lesser trained staff allows for higher profits and time is abridged during visits. For someone who is not familiar with the norms of doctor visits, the time needed to build a measure of trust is just not available, and non-disclosure can result. A sense of frustration, embarrassment, or unrelatability can prevent that person from follow-up care or the ability to follow the treatment protocol. For many cultural groups, the time needed for discourse serves as a vital function in affirming and validating the patients’ experiences.
SES is linked to a host of factors that weave together to create negative emotional bonds, according to Lynch, et al. Derisive hostility, depression, substance use, poor diet and exercise habits and helplessness are linked to adults that were raised in very poor homes and those who receive little or no family support (Russell and Russell 2012). The notion that people make choices in the context of free-will that is often embraced by policy-makers, however, another point of view acknowledges that circumstances rule the context upon which available choices are considered (1997). Environmental racism, polluting the living spaces of the poor with the waste or trash of the rich, sends a message that “you are trash to us”. More than any other factor, race correlates to poverty, while health matters relate more to SES than other factors. Internal colonialism is the notion that internal colonies of minority groups are exploited by the dominant majority groups (Weitz 2010:72).
“Don’t tell me nuthin’ about no AIDS because that won’t impact me. And if I was to get it, all I’d have to do is take a pill in the morning and I’ll be O.K.” (Herbert 2001)
Sexual behaviors, especially in the repressed U.S., are considered taboo subjects to discuss publically, or in “mixed company”. Almost every facet of these kids’ lives are touched in some manner by institutions, in this context it would make sense that they would exert some resistance to intervention methods aimed to introduce or reinforce preventative health measures. According to Weinman, et al, the CDC’s 2004 Sexually Transmitted Diseases Surveillance Report, …” estimates that while 15–24 year olds represent only 25% of the sexually active population, they accounted for an estimated half of all new STDs.”(2008:12). Mainstream media portrays “hooking up” as a sexy, modern and carefree way to engage in sexual activity. While some look to social exchange theory to weigh the benefits of casual sex against the dangers, many young minorities attend to the more pressing concern of extrinsic morality (Link et al.2010).
Education, formal and informal, that occurs in the home is considered the most influential of all schemas when confronting and assessing conflict (Sanderson 2010). Findings of a study conducted by Manlove et al., in 2003, revealed that 63% of the 1027 teenagers surveyed reported consistent use of contraceptives during their first sexual relationship, although as time progressed, use became intermittent. Those who used condoms cite parental and peer influence, as well as self-efface and a positive feelings for condom use (in Weinman, et al. 2003). Discussing sex issues with parents and caregivers has a huge impact on decisions of when, why, and the safest way to embark on a sexually active identity. Power and control, two very absent factors in many marginalized youths’ lives are gained through parental support and direction. For boys, the temptation to actualize cultural expectations is peer-driven and therefore strong. For girls, lack of empowerment and economic assets are barriers to positively self-serving behaviors.
If the misery of the poor be caused not by the laws of nature, but by our institutions, great is our sin. ~Charles Darwin
Options and situations that take precedence in ones’ life are matters of extrinsic mortality, and may leave little time and energy to assess and/or implement preventative strategies for negative life events. Link and Phelen, in 1995, shared finding from research that SES and its link to mortality persists despite the eradication of certain diseases and an increase of preventative health care knowledge. Money and resources, in any given context, serve to promote better outcomes. These authors proposed reducing inequalities in health care resources, or distributing more equally those resources across diverse groups (Link, Link and Tehranifar 2010). Assessing the end-user of those resources will yield more effective results than budget concerns.
Broad stroke generalizations about a minority group can be dangerous and defeating. There are layers of generational and geographical considerations in the African American culture. For years there was widespread denial in the black community of the threat of AIDS, because of the social stigma attached and the amount of resources being directed at gay white males that made up the initial “epicenter of the problem”, according to Herbert (2001). With the rapid spread of sexually transmitted disease in this culture, he includes a quote from Dr. Helen Gayle, Centers for Disease Control (CDC), “It’s an overwhelming problem in the African-American community. It [H.I.V.] has continued to increase along a trajectory that we had talked about for a long time.”(2001).
Learned helplessness results from the myriad of social and economic barriers faced when attempting to make personal choices. Institutions, assistance programs, health policies and campaigns serve to reinforce contextual health lifestyles and stereotypes (Link et al. 2010). Some black women are reluctant to acknowledge black men as sexist oppressors, for in doing so they would have to denounce their allies. This attitude prevents them from facing the sexual politics of their lives and constructing a new basis of interaction with black men, according to Barbara Smith in her essay “Notes for Yet Another Paper on Black Feminism, or Will the Real Enemy Please Stand Up?” (1979). Young African American women face both female gender role expectations and minority status expectations. Media images to model dress, behavior and attitudes upon are a readily available outlet for basing identity formation. In the absence of a relatable, authoritative “voice of reason” to help achieve balance between the private and public self, young girls often look to others to see how they should behave. This is inherent human behavior, and is motivated by the need to fit into a group, and feel good about ourselves (Sanderson 2010).
Gender roles have long been known to be culturally constructed, and within the African American community, males are held to a standard of idealized masculine aggression and sexual prowess. Ferguson attributes three strategies of black male students for expressing masculinity: male heterosexual power, classroom performances designed to redirect the established flow of power and “fighting”. Heterosexual power is displayed by the objectification of women and girls as sexualized beings, oral performance is seen as male risk-taking behavior, challenging the hierarchy of the classroom and fighting. This is especially significant in black culture, seen as the opposite behavior of the “sissy” white boy. Fighting is an opportunity to explore trouble in the context of the construction of manhood (2004:155). Within the constraints of minority gender roles black males are further pressured to maintain the hyper-masculine gender role. Unprotected sex is a declaration of dominance; unintended pregnancies evidence of the ability to propagate. Unfortunately, the inability to delay gratification and look to future consequences can provide more hardship and challenges when faced with unplanned childbirth and/or a potentially deadly disease that is easily spread to others.
Personal costs are very high when engaging in risky sexual behaviors. Increased rates of substance abuse, depression, and suicide are positively linked to lack of family support and dialogue (Rothman, Sullivan, Keyes and Boehmer 2012). The ability to function in society, and develop into adulthood successfully is supported through improved health outcomes, a more positive outlook on personal growth opportunities and enhanced self-esteem.
My poverty is not complete: it lacks me. ~Antonio Porchia, Voces, 1943
Faced with a myriad of inequalities, the African American culture, diverse within the context of diversity, is a complex web of inclusion, refuge and self-preservation. Social scientists suggest that the internal dynamics and motives of black family life within America have not been thoroughly researched outside the stereotypical assumptions that portray a more one-dimensional platform. Economic, social and cultural shifts have forced many families to accommodate and adjust, but nevertheless, the black family remains a bastion of shared economic and emotional support (Allen and James 1998). Recently, there is a heightened awareness of the contribution of neighborhood level impacts on sexual and reproductive health, with researchers using individual and neighborhood SES as a factor in the association of poverty and risky sex behaviors in young men. Dis-allowing for race in the study, nevertheless the poorest neighborhoods shared characteristics including mothers who bore them before age 20, non-white ethnicity, not living in a two-parent household and income below the poverty line (Lindberg and Orr 2011). As a corroboration of sustained economic segregation in American neighborhoods, future research endeavors could focus on historical changes within communities and neighborhoods, as a tool for identifying specific issues in safe sex behaviors intervention program development.
American society incentivizes individuals for making the “right choices”, while levying sanctions on those who go against the dominant ideology. In creating avenues of support for young minorities, the health lifestyle theory, developed by Cokerham though analyzing social group patterns, can focus on better imparting wisdom in the available choices for healthy behaviors (Weitz 2010). Thinking patterns can be impactful on behaviors, which in turn affect habitual dispositions. By following this route, thinking patterns, addressed within cultural and social contexts, is the most important consideration in supporting change. For many African Americans, strong ties to religion are present, and the church represents salvation, faith and hope. Degrees of clergy, especially in the southern states, vehemently denounce pre-marital sex and alternate forms of sexuality. This creates a conundrum, as the statistics and visible evidence proves that a large percentage of young minorities are unwed mothers with absent fathers.
Many of those infected with STD’s are unaware of the presence of the disease, and by the time symptoms present may have serious reproductive and other damage. Risky sexual behaviors can spread the diseases to many others, all within the same neighborhood that they socialize within, threatening the future of an entire cultural enclave. As family norms are the most impactful, this behavior is cyclic. Financial costs for everyone encompass biological, social and psychological aspects. For instance, the unwed, impoverished teen mother is perpetrating the stereotypes that intimate ignorance, promiscuity and continuation of the cycle of poverty, which in turn strengthens race divisions and inequalities. Without the trust and access to seek basic health care, economic burdens are placed on emergency and indigent care, which are shared by all. Medical institutions continue to perceive certain people as unworthy of redirecting their attention from exciting, profitable acute illnesses, and the cycle of dismissal continues. The frustration and learned helplessness of the individual creates a mental and physical strain, which results in greater illness and despair.
All illnesses are not the same; social and cultural meanings are attached and may have independent corollaries for patients and their health care offerings and responses (Conrad and Barker 2010). Society responds to certain health concerns within the context of stereotypes, about who gets the illness or disease and appropriate responses. Acceptance and acknowledgement of STD’s, for African-American youths, is tantamount to the perpetuation of negative stereotypes, such as black people as promiscuous and therefore deserving of the resulting consequence.
Churches, as a bastion of solace for many, would be a rational context to open a community-based dialogue that could share relevant and accurate information. Public information does not have to translate to public disclosure. Armed with specific questions and a general understanding of the risks, our youth can feel empowered to exercise their right to equal access to public information and confidential services. “Jesus was a sociologist”, claims Smith in his textbook for students (1994:208). He explains that Jesus adopted the Pharisac notion of realizing change within the structure of society. Pharisees gave emphasis to categorizing people as clean or unclean, righteous or sinner while Jesus taught empathy and kindness to all. He viewed social barriers as a contradiction to the compassion of Yahweh, and challenged the status quo. Christian value systems, which include precepts such as, “The meek shall inherit the earth”, or the notion that outcasts enter heaven before the just confounds many but comforts the marginalized and provides hope and solace in the face of overwhelming injustices. With a desire to continue to triumph over past stigmas, and to preserve the past and embrace the future, this puts great pressure on the entire African-American community and those who believe in dignity investiture for all mankind.
The Community Awareness Motivation Program (CAMP) has developed an effective audience-specific program. Responding to the younger age of sexually active youth and the alarming lack of condom use among minorities, this teen theater program is effective in addressing issues of HIV/AIDS awareness, substance abuse, sexual abuse and rape prevention (Guzma, et al 2003). By bringing recognizable faces with relatable messages into the schools, education and information can be understood on a level playing field. Going a step forward, this type of engaging format can be adopted in neighborhood church youth groups, and community centers. The inclusion of parents and caretakers would yield greater positive results.
Where racism and inequality is not overt, there is a mistrust, or perceived racism, brought about from past experiences, and within our current models of “best practices” in social services and programs. As “social prophets”, challenging the status quo and supporting an alternate vision of human society can be achieved from within. A collaboration that includes our medical and social institutions would bring together the realities of daily life, structure and expertise. Positive outcomes will result, but some inequalities just are; they are inherent in our social structure and derived from our cultural doctrines of individuality and competition for scarce resources.
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