Handbook of Consultation-Liaison Psychiatry

22. Cultural Aspects of Consultation-Liaison Psychiatry

Wen-Skiing Tseng and Jon Streltzer

CONTENTS

22.1 Obtaining a Psychiatric Consultation: The Influence of Culture

22.1.1 The Physician's Referral for Psychiatric Consultation

22.1.2 The Consultant's Introduction to the Patient and Family

22.2 Culture Influences the Exploration of Clinical Problems

22.2.1 The Dynamic Nature of the Patient's Presentation of Complaints

22.2.2 Understanding the Potential Gap Between "Disease" and "Illness"

22.2.3 Culture-Related Mind-Body Issues

22.2.4 The Patient's History of Self-Management: Utilization of Indigenous or Traditional Remedies

22.3 The Interview Process

22.3.1 Culturally Appropriate Physician-Patient Relationship

22.3.2 Culturally Appropriate History-Taking

22.3.3 Culturally Relevant Mental Status Examination

22.3.4 Use of Interpreters

22.4 Culture and Consultation-Liaison Psychiatry

22.4.1 Respecting Culturally Suitable Privacy and Confidentiality

22.4.2 Breaking the News: Informing the Patient and Family of the Diagnosis

22.4.3 Family Involvement

22.4.4 Ethnic Considerations in the Recommendation of Medication

22.4.5 Communication to the Referring Physician and Staff

22.5 Some Specific Clinical Issues

22.5.1 Culturally Stigmatized Medical Diseases

22.5.2 Sex-Related Medical Conditions or Issues

22.5.3 Culturally and Ethically Controversial Medical Practices

Culture influences thoughts, emotions, and behaviors in individuals, groups, and communities, and thus it can have a significant impact on the illness behavior and the practice of health care. Increasingly culturally competent medical practice is the goal for patients of diverse ethnic or cultural backgrounds (Bigby, 2003; Tseng and Streltzer, 2007). The consultation-liaison psychiatrist should be aware of cultural aspects not only of the assessment of the patient, but also of the consultation process itself. This chapter elaborates broadly on cultural aspects of consultation-liaison service, including the process of referral, the nature of the clinical problems, the interview, and clinical management and liaison work.

22.1 Obtaining a Psychiatric Consultation: The Influence of Culture

Associated with the increase of medical knowledge in contemporary society, patients and families have become more familiar and comfortable with the work of psychiatry. However, perceptions by people of different cultural backgrounds vary about psychiatrists and their patients. In some cultures, such terms as brain doctor and psychological doctor are used to avoid the negative connotations of "psychiatrist." This reflects culturally stimulated stigma.

22.1.1 The Physician's Referral for Psychiatric Consultation

Before performing the consultation, it is desirable to know from the referring physician why psychiatric consultation is sought, how the referral has been explained to the patient, and how the patient reacted to the idea of psychiatric consultation.

For patients or families who have misconceptions about psychiatry, and equate psychiatric problems with psychosis or insanity, the primary physician's explanation about the need for psychiatric consultation is critical. If not done carefully, patients might react negatively, interpreting that the physician was dismissing them as being "crazy" and then failing to cooperate with the consulting psychiatrist.

22.1.2 The Consultant's Introduction to the Patient and Family

Ordinarily, the consultant introduce him- or herself as a consulting psychiatrist, or simply a psychiatrist, or doctor, depending on the situation. The interaction and relationship that is going to develop with the patient is more important than the particular form of introduction. A relaxed, confident manner is far more likely to initiate a therapeutic alliance than a timid, apologetic tone, in which patients may feel that they are being asked to put the consultant at ease.

22.2 Culture Influences the Exploration of Clinical Problems

Factors that shape the process of exploration of clinical problems include such things as the personality of the clinician, professional orientation and experiences, and the medical culture within which the service is provided. In addition, the cultural backgrounds of the patient and the physician are going to interact during the process of the clinical exploration and assessment.

22.2.1 The Dynamic Nature of the Patient's Presentation of Complaints

The presentation of complaints by the patient and the assessment of problems by the doctor occur as a process that is subject to various factors (Tseng, 2001, pp. 446-449). On the patient's part, it starts with the experience of problems or distress, which is subject to the patient's personality, personal background, and environmental context. The nature of the stress encountered is subject to the patient's perception of the stress and coping style. Finally, the presentation of the problems by the patient to others depends on additional factors including the patient's conception and understanding of the problems, motivation and expectations, and orientation about the care system and the physician, psychiatrist, or other medical staff. The patient's presentation then influences how the clinician interacts with the patient while making an assessment.

On the clinician's part, the process of assessment and diagnosis is influenced by the clinician's sensitivity, perception of a morbid condition, familiarity with the problems, and professional definition of pathology. Furthermore, clinicians are subject to the influence of their professional training, their choice of theoretical background, the classification system utilized, the medical culture within which they practice, and their personality and personal experience. In another words, clinical assessment is a dynamic process subject to the impact of various factors, including social and cultural factors of both the patient and the clinician.

22.2.2 Understanding the Potential Gap Between "Disease" and "Illness"

The consultation-liaison psychiatrist needs to understand the potential conceptual gap between "illness" and "disease," a distinction related to professional and popular ideas of sickness (Eisenberg, 1977).

The term disease refers to the pathologic or malfunctioning condition that is diagnosed by a clinician. It is the physician's conceptualization of the patient's problem, which derives from the paradigm of disease in which the physician (including psychiatrists) was trained. For example, a biomedically oriented psychiatrist is trained to diagnose "mental disease," a pathologic condition that can be grasped and comprehended from a medical point of view, providing an objective and professional perspective on how the sickness may occur, how it is manifested, how it progresses, and how it ends.

In contrast, the term illness refers to the sickness that is experienced and perceived by the patient and family. It is the patient's subjective perception, experience, and interpretation of his/her suffering. Although the terms disease and illness are linguistically almost synonymous, they are purposely used differently to refer to two separate conditions. Their usage is intended to illustrate that disease as perceived by the physician-healer may or may not be similar to illness as perceived and experienced by the patient who is suffering. This artificial distinction is useful from a cultural perspective because it illustrates a potential gap between the healer (physician) and the help-seeker (patient) in viewing the problems. Although the biomedically oriented physician tends to assume that disease is a universal and medical entity, from a medical anthropological point of view, all clinicians' diagnoses, as well as patients' illness experiences, are cognitive constructions based on cultural schema.

The potential gap between disease and illness is an area that warrants the clinician's attention in order to make the clinical assessment meaningful and useful, particularly in a cross-cultural situation.

22.2.3 Culture-Related Mind-Body Issues

A cultural perspective is particularly helpful in understanding the clinical ramifications of beliefs about the mind-body relationship. Often unaware of the philosophical implications, Western physicians commonly view the issue in dualistic terms, body and mind, conceptualized as separate, dichotomized things. Closely associated with this epistemologic view is the notion that it is more mature or superior to express psychological problems through psychological complaints rather than somatic complaints. Eastern medical philosophies do not necessarily hold the same view. By viewing body and mind as integrated parts of a whole being, they do not distinguish distinctly between them, and do not try to view psychological or somatic manifestations in a hierarchical way. For many cultures, people learn how to express their emotions through language pertaining to the body.

22.2.4 The Patient's History of Self-Management: Utilization of Indigenous or Traditional Remedies

The consultation-liaison psychiatrist may want to explore the patient's and family's folk concept of sickness and history of possible utilization of indigenous or traditional remedies. Patients from both Eastern and Western cultures, developed modern societies and undeveloped traditional societies, use traditional remedies to try to heal their medical condition. They often do not inform their physician about their use of traditional remedies, because they may believe that it is a separate matter. It may not be so separate, however, if there are drug interactions between modern and traditional medicine, for example. Patients may hesitate to reveal that they are using indigenous healing methods, concerned that the modern physician will disparage such methods. The consultationliaison psychiatrist needs to gently ask if traditional and modern treatments are being utilized simultaneously by the patient.

22.3 The Interview Process

To carry out culture-relevant and competent clinical assessment, several issues warrant attention, beginning with how to maintain a culture-appropriate physicianpatient relationship.

22.3.1 Culturally Appropriate Physician-Patient Relationship

Most consultations are not initiated by the patient, and therefore rapidly building rapport is a special skill extremely desirable for the consultation-liaison psychiatrist. The relationship is itself a therapeutic tool and the outcome of the consultation may vary significantly depending on the quality of this relationship. This is particularly true with patients of different cultural backgrounds from the consultation-liaison psychiatrist.

An important perspective can be seen by examining contemporary American culture. In the medical setting, the predominant form of the physician-patient relationship is egalitarian, based on an implied contractual agreement between the two that is influenced heavily by an ideologic emphasis on individualism, autonomy, and consumerism. In contrast, in many traditional Asian cultures, there is more emphasis on an idealized form of hierarchical relationship. The physician is seen as an authority figure who is endowed with knowledge and experience. An ideal doctor should have great virtue and be concerned, caring, and conscientiously responsible for the patient's welfare. In return, the patient must show respect and deference for the physician's authority and suggestions. This respect and deference may inhibit the patient from asking questions and discussing choices and alternatives.

22.3.2 Culturally Appropriate History-Taking

The interview is the major aspect of the psychiatrist-patient interaction. How patients present complaints and inform the consultation-liaison psychiatrist of their problems and how the psychiatrist, reciprocally, listens, asks questions, and provides relevant explanations to the patient are key areas of communication that closely relate to the achievement of meaningful and effective clinical service.

From a cultural point of view, the clinician should judge to what extent the patient is familiar with the psychiatric interview, and provide explanations if necessary for those who feel unfamiliar with this type of communication. Whenever appropriate, the interviewer should ask patients whether they identify with their ethnic or parental culture. If the patient does, it would be a good idea to tell the patient to let the interviewer know if some of the questions or discussions touch on culturally sensitive areas. The interviewer should then use an active style to obtain basic information needed for assessment of disease, but make sure that the patient is given the opportunity to communicate concerns and problems from the perspective of illness. The ability to skillfully intertwine these two interview styles is an indication of competence from a clinical as well as a cultural perspective.

Although it is desirable for patients to communicate freely about their personal background, illness history, and other related information to the consultationliaison psychiatrist, this does not always happen in clinical situations. The patient's ability to describe things and willingness to communicate are often influenced by clinical condition, motivation, and understanding of the purpose of doing so. In addition, there is a cultural impact on the process of problem communication.

Emotional problems and personal feelings are generally considered highly private matters, not to be revealed to strangers. In many cultures, doctors are exempt from this prohibition, but there is variation. In some cultures, talking about one's inner feelings is almost as taboo as parading nude in public. Family conflicts are often regarded as "inside" problems that should not be revealed, even to a doctor.

One's sex life and sexual problems are often difficult areas to explore. For instance, with the traditional Chinese, the anatomic terms penis and vagina should be avoided. They should instead be referred to indirectly as the "yang part" and the "yin part." The Japanese may refer to them as "shameful parts" of the body. Also, it may be considered crude and offensive to refer explicitly to sexual intercourse between husband and wife. Depending on the culture, many different terms, such as "intimacy between couple," "business in the (bed) room," and "making a baby," are used by people as delicate and sophisticated ways of inferring sexual intercourse.

Further, clinicians should be aware that in some cultures, it is gauche to reveal certain things to others. Inquiring about a woman's age may be socially impolite in Western society, while asking about the cause of a parent's death is a breach of a taboo in certain cultures, such as in Micronesia, that will invite fear of punishment.

22.3.3 Culturally Relevant Mental Status Examination

As a part of the initial diagnostic interview, the consultation-liaison psychiatrist often performs a formal mental status examination. The contemporary method of mental status examination taught to medical students or psychiatric residents is derived from clinical experience with Western patients, mostly with American patients. However, it may not suitable for patients of other cultures, and may need to be modified (Tseng, 2003, pp. 231-232).

For example, asking, "Do you hear any voices?" may not be understood by some patients as inquiring into the presence of auditory hallucinations. Instead, they may answer that their hearing ability is intact. This caution is needed for all patients, particularly those who are unfamiliar with psychiatric terms and concepts, and especially those whose cultural backgrounds include few experiences with psychiatric jargon. "How do you feel?" and "Are you depressed?" are other examples of questions that sound simple in daily English but can be very confusing from the language and conceptual perspectives of those who use language without referring to "feeling" or states of depression. The following questions may be more suitable to ask: "Do you feel tired?" "Do you have the energy to do daily work?" "How is your appetite for eating?" "Do you have interest in your daily activities?"

As a part of the mental status examination, clinicians often ask questions such as, "Who is the President of the United States?" to examine the patient's level of general knowledge. This is a proper question to ask if the patient is a citizen of the United States with adequate contact with the social environment through news media. However, failure to answer such a question means little when it is addressed to a foreigner or someone who hardly ever has access to social media.

When communication is difficult, as is more frequently the case when there are cultural differences, a clinician may wonder if a thought disorder is present. A psychiatrist may choose to ask for proverb interpretations to test abstracting ability. Proverbs, however, are a cultural product and their interpretations are subject to cultural influence. The commonly used proverbs, "A rolling stone gathers no moss," and "The grass is greener on the other side of the fence," for example, have their roots in British language and culture, and are foreign to the point of meaninglessness to many non-Westerners.

Asians and others may use their own proverbs to express certain issues that may or may not be familiar to the Westerners. For example, a Japanese proverb is "Even kappa (a legendary animal good at swimming) would drown in the river," and a Chinese one is "Monkeys will fall from trees." Interestingly, a German proverb is "The best swimmer drowns first." These proverbs have the same basic meaning, yet are expressed in different ways. However, some proverbs are culturally unique. For instance, a Korean proverb is "After three years, even a dog in school will learn how to bark poems," implying the virtues of persistence and diligence. A Japanese proverb is "Fortune is contained in the leftover (food)," suggesting that a person should not compete with others. These proverbs may be entirely unfamiliar to other cultures.

A useful technique to determine if a proverb is culturally appropriate is to ask patients if they have ever heard that proverb or old saying. If the patient has heard of it, but still fails to abstract it, the information is potentially useful. A somewhat culturally universal proverb might be, "Don't judge a book by its cover."

22.3.4 Use of Interpreters

Problems of communication between the consultation-liaison psychiatrist and the patient are highlighted when they do not share the same language and have to rely on the assistance of interpreters to communicate. Who serves as the interpreter, whether a close family member, a friend, a member of the same ethnic group, or a trained interpreter with mental health knowledge and experience, will affect significantly the process and quality of translation and interpretation. Proper translation that is relevant and meaningful for clinical purposes is difficult to achieve (Tseng, 2003, p. 231).

Selecting the proper interpreter and utilizing the interpreter to effectively communicate with the patient during a psychiatric consultation is a matter of clinical skill and art. Ideally, an interpreter trained to work in medical or mental health settings is employed. There are several different ways to use an interpreter: wordfor-word translation is needed for areas that are delicate and significant; a summary translation is sufficient for areas that require abstract interpretation; and meaning interpretation is needed for areas that entail elaboration and explanation in addition to translation. By coaching the interpreter in these different styles of interpretation, the process will be more efficient and useful.

In a consultation setting, sometimes a family member is visiting the patient and may be capable of interpreting. There are pros and cons when a family member is the translator. The bilingual relative will have been acculturated to a greater or lesser extent and may be able to provide insight into the cultural factors influencing the patient's behavior, motivations, and expectations. On the other hand, if the psychiatric assessment involves complicated personal emotional issues or delicate interpersonal or family matters, the family member may perform one of the common translation errors: deletion or omission of information, distortion of meaning, or exaggeration or adding of information. The consultation-liaison psychiatrist should be sensitive to the possibility of bias affecting the translation, as well as a reluctance on the part of the patient to be forthright because of the lack of confidentiality or because of an anticipated reaction from the relative.

Sometimes, a member of the hospital staff is available as a translator, such as a nurse or nurse's aide. If this person is medically knowledgeable and experienced as an interpreter, it may work out very well. This is not always the case, however, and even if the person is not a relative, he or she may be a member of the patient's same community. The patient may be reluctant to speak in front of this person, or the cultural expectations of this interpreter may distort the translation.

In general, the interpreter needs orientation, and perhaps training, for the work that is to be done.

22.4 Culture and Consultation-Liaison Psychiatry

22.4.1 Respecting Culturally Suitable Privacy and Confidentiality

The concept of privacy and confidentiality varies greatly among people of different cultural backgrounds. For cultures that emphasize the importance of individuality, as exemplified by the United States, medical practice tends to respect the privacy of individual patients as much as possible. Physicians have the professional and ethical duty to keep medical information confidential, not revealing it to others, even the patient's parents, spouse, or other family members, without permission from the patient. In contrast, for cultures that value family and interdependence more than individual autonomy, parents may demand that physicians inform them about the medical condition or problems of their adult children. Similarly, spouses may expect medical information to be shared about their marital partners. Protecting individual privacy and confidentiality but at the same time not defying the cultural expectation of sharing information within the family, or even the relatives or friends, is a challenge for the consultation-liaison psychiatrist.

22.4.2 Breaking the News: Informing the Patient and Family of the Diagnosis

Another important and delicate issue is how to inform the patient and family of the medical diagnosis. In Western Europe and North America, following contemporary medical practice, a physician often openly and frankly informs the patient of the diagnosis of the disorder from which the patient is suffering, even when the news is ominous and expected to be frightening to the patient. Otherwise, the physician would fear a malpractice suit.

However, in contrast, in many societies, such as Japan and other East Asian societies, it is normal for a physician to conceal the actual medical diagnosis from the patient, particularly of a serious or fatal illness, to protect the "vulnerable" patient. (This was a practice also common in the United States prior to the 1960s.) The actual diagnosis is told only to the family. If physicians were to reveal a potentially fatal diagnosis to the patient without the family's consent, they might be subject to resentment from the family. This is a complex matter, in which the physician needs to act according to proper medical ethics as well as the culture of the society.

22.4.3 Family Involvement

Involving the family in the patient's medical care, including examination, assessment, and even treatment, is particularly challenging to clinicians in Western societies. The consultation-liaison psychiatrist sometimes has referrals generated primarily because the primary physician is uncomfortable dealing with family members who are attempting to be actively involved in a patient's care. It is almost impossible to exclude the family in cultures that are very familyoriented (rather than individually oriented), such as is common in Eastern societies. Based on clinical experience, we know that involvement of the family in an interview sessions has both advantages and disadvantages.

Among the advantages, in addition to relieving the family's anxiety, is the enabling of the clinician to obtain needed collateral information to assist in the process of assessment, and to provide an opportunity for the interviewer to observe how the patient and family interact. Working with the family increases their ability to support the patient's recovery.

Disadvantages are that family involvement may discourage the patient from expressing personal concerns or communicating about family conflicts. This is also true in reverse, with family members hesitant to express concerns about the patient in front of the patient. Therefore, it is sometimes best to approach the patient and family separately at some time during the interview process.

From a cultural point of view, however, family can serve not only as a resource for collateral information, but also as a base from which to check cultural reality. Unless major family pathology is present, the consultation-liaison psychiatrist can obtain from the family members a culturally objective indication as to what extent the thoughts and behaviors manifested by the patient are normal, unusual, or deviating from the sociocultural norm. The interviewer also can learn culturally relevant coping techniques available to the patient to resolve problems. Generally speaking, family involvement is helpful to the process of liaison work. This is particularly so for patients with a strong family-oriented background.

22.4.4 Ethnic Considerations in the Recommendation of Medication

Modern Western medicine is based on a technology that prepares drugs in pure abstract forms to perform specific pharmacologic functions. Modern physicians usually prescribe a single medication for a specific purpose, and for multiple problems they may prescribe multiple medications. Usually the least number of medications possible is considered to be the goal. In contrast, herbal medicines used in traditional medical practice are thought to work by combining multiple remedies in their raw forms. Multiple herbs are always prescribed, as there is not too much concern over combining medications. In general, in societies where traditional medicine is still used, Western medicine is considered "strong" and useful for combating the specific etiology of a disorder, but there are usually unwelcome side effects. Traditional herbal medicine is viewed as "harmonious," with fewer side effects, and will "strengthen" the body so that it can overcome the disorder, or not get it in the first place.

Modern Western physicians make no secret about the name and nature of prescriptions, and often make it a goal to explain to the patient the drug mechanism as well as potential side effects. Traditional physicians, on the other hand, sometimes keep prescriptions secret and in some Asian countries, such as Japan, China, and Korea, the patient may not expect or desire the physician to give a full explanation.

Associated with this is the tendency of patients to feel that there is no need to follow the physician's orders in taking the medication. If the medicine works immediately (within a day or so), the patient will take it. If the symptoms subside, the patient may feel no obligation to continue the medication, even when directed by the physician.

Beyond psychological issues relating to prescribing and receiving medication, there are also biologic issues as well. There are potential ethnic differences in the pharmacokinetics and pharmacodynamics of drugs that are used. In general, Asian patients and patients of some other ethnic/racial groups need smaller doses than textbook recommendations, which are based on studies of Caucasians.

22.4.5 Communication to the Referring Physician and Staff

The consultation-liaison psychiatrist communicates to the referring physician in several ways. For uncomplicated consults, a note in the chart may suffice, but direct communication is usually preferable. Increasingly, clinicians are becoming sensitive to cultural issues, and they are likely to be interested if the consultationliaison psychiatrist discusses cultural issues as part of the recommendations for care.

22.4.5.1 Case Example

An internist known to be rather autocratic asked a consultation-liaison psychiatrist to see a patient to determine if he needed to be committed to a mental hospital. The patient was a Russian immigrant who had been working as a radiology technician. The patient was in his final few days of intravenous antibiotics for a cellulitis. The patient, a diabetic, had been arguing with the nurses about his insulin doses. The psychiatrist discovered that the patient was a physician who had not been licensed in the United States. He had always managed his diabetes without difficulty and was rather obsessional about how it should be done, and about his need to care for himself. The consultationliaison psychiatrist reported to the internist that the patient was not committable to a psychiatric facility.

In this case, the patient was a Russian man, brought up in a society where his status as a physician made him an authority, well respected and valued for his competence and self-confidence. In addition to personality factors, the patient's demanding behavior could be partly explained on the basis of a cultural need for self-management. This formulation allowed the consultation-liaison psychiatrist to suggest that, since the patient had never demonstrated difficulty, why not let him have more say about his insulin dosing? The internist was able to comfortably relax his control of the diabetic management by viewing this as culturally appropriate, and the rest of the hospital course passed uneventfully.

22.5 Some Specific Clinical Issues

The variety of clinical issues encountered by consultation-liaison psychiatrists is endless. Some of them are heavily related to culture and warrant mention.

22.5.1 Culturally Stigmatized Medical Diseases

Because of their poor prognoses and historically limited effectiveness of treatment, the diagnoses of certain medical diseases still carry substantial stigma, despite an improvement in medical management. Leprosy, pulmonary tuberculosis, epilepsy, and venereal disease, as well as mental disease, are some examples of diseases that are still associated with strong negative views as a result of cultural beliefs, which intensely influence patients' emotional lives as well as their illness behavior. The patient's and family's medical knowledge has an impact on attitude toward various kinds of disease.

22.5.2 Sex-Related Medical Conditions or Issues

There are certain medical disorders that are perceived as sex-related and, in turn, subject to cultural interpretation and reaction. Breast cancer is one of them. The varying degrees to which female breasts have a sexual role in different cultures may influence the patient's understanding of the causes of breast cancer. Regarding attitudes toward risk factors for breast cancer, there have been two broad cultural models. The Anglo-American model emphasizes family history and age as risk factors. The Latin model associates breast trauma and "bad" behaviors (such as alcohol and illegal drug use) as risk factors for breast cancer. This reflects a moral framework within which disease is interpreted.

Pregnancy and giving birth are not only major events in the parents' lives, they also have substantial cultural significance and are impacted by cultural beliefs. For instance, when the ideas and experiences of pregnancy and childbirth of Asian and non-Asian women in east London was compared, it was found that although Asian women demonstrated a strong commitment to Western maternity care, they continued to follow traditional cultural practices such as observing a special diet in pregnancy and following restrictions on certain activities in the postpartum period. Asian women tended to want their partners present at delivery and to express a greater concern about the gender of the child.

In some ethnic groups, great attention is paid to postpartum care. In traditional Chinese belief, a woman is expected to observe one month of confinement after giving birth. She is not allowed to go outside of her house, to eat "cold" foods (such as fruits), or to bathe or even wash her hair. A woman is supposed to eat a lot of "hot" foods (such as chicken cooked with sesame oil and ginger). These customs were observed in the past, perhaps to prevent postpartum infection, and are still faithfully observed by some traditional women. In Micronesia, a traditional "pregnancy taboo" requires the wife to return to her family of origin once she discovers she is pregnant. She does not return to her husband's house until her child is old enough to hold his or her breath under water or to jump across a ditch, activities that ensure a greater likelihood of survival.

Breast-feeding is a very natural way to feed a newborn baby. However, despite the widely acknowledged evidence supporting the benefits of breast-feeding (fewer childhood infections and allergies), the prevalence of breast-feeding in Western countries remains low This may be due to the development of baby formula or time demands on a working mother. However, the cultural notion of the female breast as a primarily sexual object places the act of breast-feeding in a controversial light and can be one of the most influential factors in a woman's decision not to breast-feed.

In many cultures, reproduction is considered one of the major functions of women, and losing the uterus is considered to be losing the power of being a woman. Many women fear a change in sexual desire after a hysterectomy, and that their husbands will not want them because they are "incomplete" women. As a result, they might refuse to have their uteruses removed, or develop anxiety and depression after a hysterectomy.

Although menopause is a biologic phenomenon, the intensity of menopausal symptoms varies among ethnic and racial groups. This may be due partially to diet, with a recent study revealing that Asian women may experience fewer hot flashes because of estrogen derived from soybean products in their meals. To what extent sexual attitudes contribute to emotional adjustment or attitudes toward menopause is a subject that requires future investigation.

22.5.3 Culturally and Ethically Controversial Medical Practices

Many medical practices are culturally proscribed, or prescribed, and are often as a result, ethically controversial. The following are some examples:

Artificial abortion is the subject of an intense emotional, political, and ethical debate in many countries. In the United States, there is no foreseeable resolution to the conflict, which has involved radical acts such as the bombing of abortion clinics and the shooting of physicians who perform abortions. However, in many countries, abortion is an accepted and uncontroversial part of family planning. This is particularly true where there is societal acceptance of the concept of population control. Thus, abortion is not merely a medical choice, but also a social, cultural, and political matter.

From a medical point of view, sterilization is a simple surgical operation and a way of family planning. However, there may be a significant psychological impact depending on how the procedure is seen by the patient's culture. In some cultures, particularly those that strongly emphasize the need for many children, sterilization can be most unwelcome. In such cases, sterilization for men may even be considered nearly equal to castration, even though medically it is not.

Whether physicians are allowed to offer active assistance for patients to end their lives is a controversial subject in many societies. In Holland, euthanasia is actively practiced by physicians. In Germany, assisted suicide is a legal option, but is usually practiced outside of the medical setting. In almost all of the United States, withdrawing from or refusing treatment is the only means currently permitted by law, and then only with legal documentation from the patient or family.

It is important that the consultation-liaison psychiatrist know that medical practices developed by physicians for treatment of disease may be perceived and reacted to in various ways by patients and families not only because of personality-specific factors but also because of cultural background. This is the foundation for providing a culturally competent consultation service.

References

Bigby J, ed. Cross-Cultural Medicine. Philadelphia: American College of Physicians, 2003.

Eisenberg L. Disease and illness: distinctions between professional and popular ideas of sickness. Culture Med Psychiatry 1977;1(1):9-23.

Tseng WS. Handbook of Cultural Psychiatry. San Diego: Academic Press, 2001.

Tseng WS. Clinician's Guide to Cultural Psychiatry. San Diego: Academic Press, 2003.

Tseng WS, Streltzer J. Cultural Competence in Health Care: A Guide for Professionals. New York: Springer, 2007.



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