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Reflection on the Padlet assignment as a whole.

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Explanation of chosen articles.

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Marina posts videos to her YouTube channel aimed at educating younger generations about feminism (p 158 – 162).

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marinashutup vlogger 22 "marina shutup" "shit nerdfighters say" nerd california wonderly feminism female youtuber social justice sarcasm feminist fridays intersectional

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My videos have been described as "mildly entertaining" and "the worst editing I have ever seen". Here we vlog about feminism and my bio professor. I put up videos weekly and I've been told that I take sarcasm to the point of making people sick. Let's have some good times.

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Lady Gaga brought sexual assault awareness to the center of the Oscar stage, standing with other sexual assault survivors while singing her song "'Til It Happens to You" (p 153 – 155, 158, 174 – 176, 179 – 180)

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Mark Ralston/AFP/Getty Images

Lady Gaga has been killing it lately: Fans loved her performances at Super Bowl 50 and her tribute to David Bowie at the Grammys.

And now her performance at the Oscars can be added to the list.

"You tell me it gets better, it gets better in time," she opened as she performed the nominee for Best Original Song, " Til It Happens to You." It's the song Gaga wrote with Diane Warren for the documentary "The Hunting Ground," which follows alleged incidents of sexual assault on college campuses in the United States.

Gaga sat at a grand piano and played as she sang lyrics like, " Till it happens to you, you don't know how it feels, how it feels."

Gaga has talked openly before about when she was raped at 19.

Mid-performance, dozens of victims stepped forward on stage and held out their arms, with words written on them like "Unbreakable" and "Not your fault."

The singer received a standing ovation, with many celebrities looking solemn and even teary as they clapped.

Earlier in February, Gaga opened up to CBS News about how personal the song is for her, saying, "I know I feel really and truly like I bared my soul. It wasn't until I was almost, I think, 27 years old that I did even acknowledge that this happened in my life. Like, 'Oh yeah, that.'"

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Oscars 2016: Lady Gaga performs touching tribute to rape victims

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Lady Gaga has been killing it lately: Fans loved her performances at Super Bowl 50 and her tribute to David Bowie at the Grammys. And now her performance at the Oscars can be added to the list.

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The ItsOnUs Campaign aims to address sexual harassment and assault specifically on college campuses. The organization focuses on educating the public on how to practice bystander intervention (p 153 – 155, 158, 161, 174 – 176, 179 – 180).

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Take the pledge and make a personal commitment to help keep women and men safe from sexual assault.

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Hannah Witton, a YouTuber, recently created a series about the potential birth control options and to normalize menstruation (p 158 – 162).

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Trying a Menstrual Cup for the First Time! | The Hormone Diaries Ep. 9 | Hannah Witton

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Aerie model Iskra Lawrence runs a YouTube channel devoted to showing younger women that "every body is beautiful" (p 158 – 162, 168).

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Hi everyone I'm Iskra :) This will be our little place on the internet to be friends, where I'll share...vlogs, Makeup, skincare and hair tutorials, shopping hauls, real talks about SELF-CARE and random fun shiz :P British model living in NYC The Aerie Real role model National Eating Disorder Association

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Allure, a beauty company, begins a video campaign to dispel the myths behind beauty ideals (p 168, 174).

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What Makes "The Ugliest Woman in the World" Feel Beautiful | Dispelling Beauty Myths | Allure

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The Women's March on Washington continued their campaign by organizing "A Day Without a Woman" to show how much women impact society (p 161, 164, 170).

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In the same spirit of love and liberation that inspired the Women's March, we join together in making March 8th A Day Without a Woman, recognizing the enormous value that women of all backgrounds add to our socio-economic system--while receiving lower wages and experiencing greater inequities, vulnerability to discrimination, sexual harassment, and job insecurity.

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Numerous tweets show the hilarity of some men's reactions to being in the "friend zone" while bringing light to the problems within current society (p 158 – 161, 168).

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18 Jokes About The Friend Zone That Will Make Women Laugh

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'Forget the friendzone, tell him he's the son you've always wanted.'

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After being bullied in school, 10-year-old girl joins Instagram and receives love and support regarding her skin color (p 156, 158 – 161, 168).

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This is the Pollard family from Los Angeles. Erika Pollard is mom to 22-year-old Taylor and 10-year-old Kheris. Kheris is currently in the 5th grade, but she's had a tough time navigating her elementary school years.

Kids would constantly tease Kheris about her darker complexion throughout grade school. Their mom eventually decided to transfer her to a different school because the bullying was severely affecting Kheris' self esteem.

Taylor Pollard

Taylor said the first elementary school Kheris was enrolled in had only four black girls in her class, which she believed attributed to the teasing.

"She started to notice she was different," Taylor told BuzzFeed News. "She would cry a lot, and talk about how she doesn't like her skin tone."

Kheris told BuzzFeed News that during an exercise years ago in grade school her teacher asked students to draw themselves, then handed her a black crayon. "I'm not that dark... I'm brown," she replied.

By the second grade, their mom decided to enroll Kheris in a different school and school district that was more diverse.

Taylor said the bullying did subside a bit, but Kheris was still coming to her with negative comments she'd hear about her skin tone - this time, however, they were coming from other black students, which surprised Taylor.

Taylor Pollard

"A couple of girls at school would tease her about being skinny and about her skin tone, but it's weird because it came from people who are black as well," Taylor said.

Taylor and her mom were feeling helpless. But after a fateful Wiz-inspired fashion show, and a subsequent tweet that went viral, things started to slowly change.

When Taylor showed Kheris the flood of comments calling her "beautiful" and her skin "gorgeous," Kheris's face lit up.

"She was obsessed with the comments," Taylor said. "So many people's comments gave her a positive outlook on her skin. It gave her reassurance."

"I was overwhelmed," Kheris said. "There were so many comments that they loved my skin and my hair."

It was then that Taylor had the idea to help Kheris run her own Twitter account, and fill it with photos from their own creative fashion shoots. Taylor said she and their mom closely monitor the account, and do the majority of the posting.

There were people who pushed back and had concerns about a 10-year-old already having a social media account, but Taylor said she had a Myspace at a very young age.

The Pollards mostly hope that the outlet not only helps Kheris with her self-image, but that she will use it to empower other young girls.

"I told Kheris now that she has the attention she should use it as a positive outlet," Taylor said. "I think it's important to use the platform to positively influence other kids."

Kheris said the support she's received from strangers across the internet "made me feel more confident about myself."

Tanya Chen is a social news reporter for BuzzFeed and is based in New York.

Contact Tanya Chen at tanya.chen@buzzfeed.com.

Got a confidential tip? Submit it here.

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This 10-Year-Old Said Social Media Made Her More Confident After Being Bullied For Her Dark Skin

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This is the Pollard family from Los Angeles. Erika Pollard is mom to 22-year-old Taylor and 10-year-old Kheris. Kheris is currently in the 5th grade, but she's had a tough time navigating her elementary school years. By the second grade, their mom decided to enroll Kheris in a different school and school district that was more diverse.

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First woman that ran in the Boston Marathon and was attacked completed this year's marathon amid support and celebration (p 165 – 166).

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Monday, 50 years later, Kathrine Switzer crossed the finish line of the Boston Marathon wearing the same bib number an official tried to rip off her clothing in the 1967 race.

This was Switzer's 40th marathon and her ninth time running the Boston race. The 70-year-old walked through water stations, stopped for pictures and interviews and still finished under qualifying time: 4:44:31 and an average mile of 10:51.

The 1967 encounter was captured in an iconic photo that turned Switzer into a hero and launched her career as an advocate for women in sports.

Switzer has said she did not intend to break barriers by entering the race. After all, another woman, Roberta Bingay Gibb, had completed the Boston Marathon in 1966 without a bib. But the photo exposed the ugly nature of sexism in sports, thrusting Switzer into the spotlight.

"What happened on the streets of Boston 50 years ago completely changed my life and changed other people's lives," she said in a phone interview after the race. "The race today was a celebration of the past 50 years; the next 50 are going to be even better."

'No dame ever ran the Boston Marathon'

Plenty has changed in running since 1967, thanks in part to Switzer's efforts. To start, women are welcome in the Boston Marathon and other major races.

Unlike Gibb, Switzer managed to score a bib in 1967 by signing up with her initials, K.V. Switzer. As she tells it, there were no official written rules saying only men could enter the race. Nor was there a spot on the entry form to select gender.

But in those days, women rarely participated in professional or competitive sports. Even her coach at Syracuse -- where Switzer trained with the men's cross-country team -- told her the distance was too long for "fragile women."

"No dame ever ran the Boston Marathon!" coach Arnie Briggs told her, according to her memoir, " Marathon Woman." But if she could run the distance in practice he promised to take her to Boston.

When Switzer completed the 26-mile trial, Briggs insisted she sign up officially. She said she used her initials because her first name was misspelled on her birth certificate, Kathrine, and she was tired of repeating the error. Plus, she said she wanted to be a writer, and using her initials, like J.D. Salinger and e.e. cummings, seemed like a "cool, writerly" thing to do.

Her bib number would come to represent fearlessness in the face of adversity for female runners ever since. The Boston Marathon will retire number 261 in Switzer's honor.

'Give me those numbers!'

Switzer said she did not try to hide the fact she was a woman. She wore lipstick, earrings and burgundy shorts, but ended up wearing baggy sweats over her "feminine" running gear because of the wintry weather.

It was snowing by the time she and her teammates reached the starting line in Hopkinton. One of them told her to wipe off her lipstick so organizers would not notice her. She refused and began the race.

A few miles in she saw a man with a felt hat and overcoat in the middle of the road shaking his finger at her as she passed. Then, she heard the sound of leather shoes, a distinctly different noise from the patter of rubber soles, and knew something was wrong.

"Instinctively I jerked my head around quickly and looked square into the most vicious face I'd ever seen. A big man, a huge man, with bared teeth was set to pounce, and before I could react he grabbed my shoulder and flung me back, screaming, 'Get the hell out of my race and give me those numbers!'" she wrote in her memoir.

The man was race director Jock Semple. Press photographers captured Semple's contorted face as he grabbed at Switzer's numbers while her boyfriend pulled Semple off her.

She ran from the scene bewildered. She ambled on for a few miles before her anger transformed into energy and she took off for finish line. Dropping out was not an option, she said on her website.

"...I knew if I did that no one would believe women could run distances and deserved to be in the Boston Marathon; they would just think that I was a clown, and that women were barging into events where they had no ability. I was serious about my running and I could not let fear stop me," she said.

She finished the race in four hours and 20 minutes, but would later be disqualified and expelled from the Amateur Athletic Union.

Support soon eclipsed the fallout and she became a celebrity.

'I could not let fear stop me'

Switzer used her influence to campaign to get women into the Boston Marathon by 1972. She went on to run 39 marathons, and achieving her personal best in 1975, 2:51:33, when she finished second in Boston. She won the New York City Marathon in 1974 in a moment that was captured by legendary photographer Ruth Orkin.

She created the Avon International Running Circuit of women's-only races in 27 countries, paving the way for the first women's Olympic marathon in 1984. She became an author and TV commentator for the Olympics, World and National championships before returning to marathons at 64.

Along the way, 261 became a rallying cry among female runners. Switzer formed 261 Fearless, a nonprofit running club for women that has groups across the country. Some of its members will join Switzer for her victory lap on Monday, wearing the 261 bib to raise money for charity.

Photographers swarmed Switzer on Monday as she crossed the finish line and a race official placed a medal around her neck.

"Running is a social revolution now. Women are not just doing it to get into races or to lose a couple of pounds, they're doing it for fun, for their self esteem. It's transformative," she said.

"We've come a light year but we still have a long way to go."

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boston marathon 2017: 1st woman to officially run does it again 50 years later - cnn.com

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1st woman to officially run Boston Marathon does it again, 50 years later

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Monday, 50 years later, Kathrine Switzer crossed the finish line of the Boston Marathon wearing the same bib number an official tried to rip off her clothing in the 1967 race. This was Switzer's 40th marathon and her ninth time running the Boston race.

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Teen woman points out Senator's relative privilege regarding women's reproductive rights (p 180).

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On Thursday, H.J. Res 43 was signed by President Donald Trump. The bill will allow states to block organizations like Planned Parenthood from receiving the Title X funds they currently use to cover the cost of cancer screenings, birth control, and STI tests for low-income patients. Fresh from helping Senate Republicans pass this bill, Arizona Sen. Jeff Flake held a town hall meeting Thursday in Mesa, Arizona, to hear from his constituents.

And hear from them he did. On the same day President Trump signed the bill overturning an Obama-era rule prohibiting states from withholding Title X family-planning money from health care centers and organizations that offer abortion services, a teenager schooled Sen. Flake on Planned Parenthood's importance.

Flake's decision to support legislation enabling states to block health care organizations which provide abortion services - like Planned Parenthood - from being able to receive Title X family-planning money made him a target for criticism for many of his constituents. Among those outraged constituents was 16-year-old Arizona resident Deja Foxx, who taught the senator a few lessons about women's health care and the importance of Title X-funded health centers.

"I just want to state some facts," Foxx said after taking the microphone at Flake's town hall. "I'm a young woman; you're a middle-aged man. I'm a person of color, and you're white. I come from a background of poverty, and I didn't always have parents to guide me through life; you come from privilege."

Foxx went on to address Flake's support for legislation, which opens the door to defunding Planned Parenthood. "I'm wondering, as a Planned Parenthood patient and someone who relies on Title X, who you are clearly not, why is it your right to take away my right to choose Planned Parenthood and to choose no co-pay birth control?"
American Bridge 21st Century on YouTube
While cheers from the crowd make the end of Foxx's question inaudible, her message was clear: Why was Flake supporting legislation that would ultimately have major repercussions for women both in Arizona and across the United States? In Arizona alone, the Title X program helps roughly 36,000 people (82 percent of whom are women) each year, the Phoenix New Times reported.

"I'm glad to hear of my privileged childhood," Flake responded, telling Foxx he grew up in a family with 11 children and had been made to pay for his own college education.

"Privilege comes in many forms," Foxx said, to which Flake agreed.

"I've had a lot of advantages that others haven't," he conceded. "What I want is to make sure that everyone can realize the American Dream. That's why I support the policies that I support."

Yet something in Flake's answer wasn't matching up for Foxx. "Why would you deny me the American Dream?" she asked, pointing out to Flake that Planned Parenthood provides services which help her, and other young women like her, be successful and reach for higher education goals. Foxx raised an important point. According to the Arizona Family Health Program, Arizona's teen pregnancy rate would likely jump by 22 percent if Title X-supported services were taken away. The state's rate of unintended pregnancy, unplanned birth, and abortion would likely increase 27 percent.

In a patient roundtable held before Sen. Flake's town hall, Foxx reportedly said she was looking to study political science and later run for office. "Someone has got to stop these political attacks on our reproductive rights," Foxx reportedly said, according to a transcript of the roundtable provided to Refinery29 by Planned Parenthood.

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A Teenager Schooled Jeff Flake On Planned Parenthood & What It Actually Does

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On Thursday, H.J. Res 43 was signed by President Donald Trump. The bill will allow states to block organizations like Planned Parenthood from receiving the Title X funds they currently use to cover the cost of cancer screenings, birth control, and ST

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Woman posts on social media about how the simple placement of her tights on her waist changes her body shape (p 158 – 161, 168).

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"Same girl, same day, same time," she captioned the photos. "Not a before and after. Not a weight loss transformation. Not a diet company promotion."

Milly says she's comfortable with the way she looks in both, pointing out that neither body is more worthy than the other. "Neither makes me more or less of a human being. Neither invites degrading comments and neither invites sleezy words," she says. "We are so blinded to what a real un-posed body looks like and blinded to what beauty is that people would find me less attractive within a five-second pose switch! How insanely ridiculous is that!?"

Milly says she loves taking these kind of photos because it helps her get over her body dysmorphia, a mental illness in which people obsessed over perceived flaws in their appearance, and helps her rationalize her negative thoughts about her body. "Don't compare, just live for you," she says. "The world doesn't need another copy, it needs you."

Milly's powerful post makes her one of a growing number of people who have used social media to show that appearances can be deceiving. In late December, Olympic gymnast-slash-total badass Simone Biles shut down trolls who said she didn't look good in a bikini by simply stating on Twitter: "You all can judge my body all you want, but at the end of the day it's MY body. I love it & I'm comfortable in my skin." Last week, body positive model Ashley Graham shared a close-up of her cellulite on Instagram with the caption, "I work out. I do my best to eat well. I love the skin I'm in. And I'm not ashamed of a few lumps, bumps or cellulite... and you shouldn't be either." Fitness blogger Anna Victoria also posted side-by-side pics on Instagram of herself standing and sitting in a bikini. "Me 1% of the time vs. 99% of the time. And I love both photos equally," she captioned the pics. "Good or bad angles don't change your worth."

The message is clear: Love your body, no matter what it looks like. You only have one, after all.
Feeling stressed? This yoga pose can help:

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This Woman Took A Picture Wearing Just Tights To Make A Powerful Statement About Body Image

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"Same girl, same day, same time," she captioned the photos. "Not a before and after. Not a weight loss transformation. Not a diet company promotion." Milly says she's comfortable with the way she looks in both, pointing out that neither body is more worthy than the other.

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Explanation of chosen articles.

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Sofie Jawed-Wessel discusses the intersecting oppressions of pregnant women (p 122 – 127, 136 – 138).

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The lies we tell pregnant women | Sofia Jawed-Wessel

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A spoken word poem addresses being a women and being black. A commenter drives an intersectional discussion on being a black woman (p 115 – 117, 120 – 121).

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Darius Simpson & Scout Bostley - Lost Voices

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The comments on this article about an interracial, lesbian couple in the media show their intersecting identities (p 88 – 89, 136).

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Samira Wiley And Lauren Morelli Got Married And I'm Not Crying, You Are

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The intersecting identities of this small, ranching town go beyond the "single story" for typical Republicans (p 117 – 118).

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One in three residents, or 33% of the under-65 population, bought insurance on Obamacare exchanges, official data from a year ago show. The national average is just 5%, which raises the question: In a place so tied to the Affordable Care Act, why would people back the man who vowed to repeal it? Wouldn't that seem a vote against the community's own interests?

"People may think we're slow," explains one man, "but we're not stupid."

In their world, one they feel is overlooked by those in big cities or on the coasts, their actions make perfect sense. You can't possibly understand, they say, unless you've lived here. I set out to try.

Breaking the news

Just mention politics to a group of men unwinding over gas station coffee and the insults come fast and fierce, political correctness be damned.

"The black bomb" is how one rancher describes Trump's predecessor. "This guy came out of the sewers of Chicago. How could he be good?"

The rancher's not about to give his name to someone with the "Clinton News Network" -- what he calls CNN -- but he and his friends are happy to rail against the former administration. Obamacare is right up there on the list of things gone wrong, they say.

The hands they extend for shakes are rough and callused, symbols of how hard people here work. They are self-sufficient and don't like being told what to do any more than they like taking handouts. They take care of themselves, and each other, and don't need government stepping in to muck things up.

That their county leads the nation in Obamacare enrollees is news to everyone I meet.

"If they're on it, they're not saying," one man theorizes. People are on it only because the government "put a gun to people's heads," offers another. And just because they're on it, they warn, doesn't mean they like it.

No other choice

Walking through Hyannis, the county seat, I hear stories of skyrocketing premiums, deductibles that can't be met and brewing resentment. If people don't want to pay the penalty for not having insurance, which is taken out of the tax refunds they rely on, they're trapped.

What they tell me might give pause to Obamacare experts, who say the Affordable Care Act is complicated, is hard to navigate and often leaves people misinformed about costs and choices. But these are the experiences and perceptions of how the law has played out in Grant County.

Some have appreciated newfound coverage: With it, they were able to take care of longstanding problems, like the woman with a prolapsing uterus who could finally have a hysterectomy. But most people I meet complain that they're on Obamacare only because they have no other choice.

Unless they work for the school, the county, the railroad or the electric company -- and the vast majority of people in cattle country don't -- these aren't Americans fortunate to be covered by an employer's insurance plan.

Some might have been so lucky in the past, but that luck ran out when the Affordable Care Act came in, they say.

Ginger Fouse curates the Grant County museum in the county courthouse. She's rushing to make a doctor's appointment in Alliance, 60 miles away and home to the closest hospital. Before she goes, she makes her feelings about Obamacare clear: "Nothing but horseshit."

Fouse's husband is a ranch hand, and they used to get coverage through the ranch. But once Obamacare hit the scene, she says, the rancher believed everyone could take care of themselves. Only problem is, Fouse says, she and her husband can no longer afford the premiums. So they're now covered by nothing.

"We're not going to quit eating to pay insurance," she says before heading out the door.

Ellen White, a museum volunteer, steps in to introduce me to the area she's always called home.

She shows off aged photographs: the old town hall where they used to dance, images from the 1949 blizzard that wiped out cattle and snapshots from the first old-timer rodeo.

A man's barbed-wire collection is on display, as is memorabilia from the deceased military doctor who delivered White and countless other locals.

The highlight, though, is a collection of keepsakes from the late Chuck Hayward, who took his horses to Hollywood and worked as John Wayne's stuntman. Included are action shots, the saddle Hayward used while filming in Afghanistan and wooden stirrups from a shoot in Chile. There's also a saddle said to have been used by Wayne himself during the filming of "True Grit."

White, 69, describes a time she wishes younger generations would appreciate. She grew up on a ranch south of Ashby, an unincorporated community just west of Hyannis. She, like so many others, rode a horse to her country school.

She had three older brothers, and if they told her she couldn't do something, she proved she could. She was able to drive a team of horses by age 5 and helped milk 12 to 15 cows every morning and night.

Life was tough, but it made people who they are. They worked for everything they had.

Sometimes she watches HGTV and is stunned by house hunters shopping for $500,000 homes.

"They'll pay on those houses forever and ever," she says. "We didn't buy anything unless you could pay cash for it."

It's that sort of responsibility and practicality that courses through this ranching community's veins.

Assessing life here

Roughly 150 ranches dot the county, most of them passed down through families. It's an area where the first homesteaders arrived in the 1880s, tried to farm and failed. The sandy soil worked against them but proved a sweet spot for cattlemen, who snatched up tracts of land.

The ranches are private and sit far off the main roads, in some cases miles off, and are impossible to assess by driving past. Ask a rancher about the size of his land or his herd, and he'll keep those numbers to himself.

The question is uncouth, explains Dan Vinton, a lifetime rancher and longtime county commissioner; it's like prying into a person's salary.

"We have enough grass to feed the cows," says Vinton, 66. "We have enough cows to take care of the grass."

Over chicken-fried steak in the Hyannis Hotel Restaurant, one of a handful of businesses on Main Street, Vinton and fellow Commissioner Tom White -- who worked in the feed business and is married to Ellen, the museum volunteer -- regale me with their own stories of growing up in Grant County.

They didn't have electricity till the 1950s, got up and went to sleep along with the sun and like to say they "had running water because you had to run and get it." They took Saturday night baths in the same water used by their siblings.

"We didn't know we were stinky little buggers because we all smelled the same," White, 71, says with a laugh.

Life here has always made sense to them, no matter the challenges. When White needed chemo and radiation to treat cancer a couple months back, he and his wife simply rented an apartment near the hospital in Scottsbluff, more than 100 miles away, for five weeks. They'll travel to Denver for his upcoming surgery.

They aren't city folk and don't want to be. Vinton drives that point home when he admits he and his wife have cell phones only so they can find each other when they get separated in the Walmart, which is well over an hour from home.

Vinton's son works at the family ranch and is on Obamacare. His folks and the Whites aren't on it themselves, but they look forward to the day when it's abolished. They hear people complain about rates rising and call the program "ridiculous."

Not wanting to be dependent

A 31-year-old woman sits in the restaurant beside her towheaded boy. To her, Obamacare is maddening, and she unleashes her frustration.

She's a college grad who does her research. When she and her husband got married, they picked out a policy and were happy. But then, Obamacare changed everything.

They could no longer afford the private plan they liked. The number of companies she could choose from on the Obamacare exchange dwindled; only two choices exist today. They switched to one company only to see it get absorbed by another. They watched their premiums and deductibles increase, along with out-of-pocket expenses. They've been on four plans in two years.

She's married to a rancher, and in ranching, it's hard to estimate how much a person will earn each year. When cows sell high, ranchers do well. But, as in any market, the numbers fluctuate. One year, her family might make $20,000; another $50,000, she says. Financial uncertainty makes planning a crapshoot.

A stunning thing happened, though, when she got pregnant with her son. Suddenly, she was told she qualified for Medicaid, a notion that made her Republican head spin.

"I want to be responsible for myself. I don't want to be dependent," says the woman, who didn't want her name used. "But you priced me out of what I did to take care of myself and forced me into government assistance."

Pregnancies only last so long, though, and she doesn't meet the Nebraska Medicaid qualifications for parents. That means she's back to fretting about what this year's premiums will be.

"I have to get knocked up," she says, half joking, half disgusted. "Mama needs dental care."

Fans turned foes

Across the street in the grocery store, I spot Clarissa "Casey" Sanchez working behind the counter. She was a fan of Obamacare at first.

Paying $50 a month for herself was both doable and a source of comfort for the 30-year-old employee.

But then she got married. With their combined gross incomes, she says, her monthly premium jumped to more than $600, and they make too much to qualify for Medicaid. Her husband has his own private policy, but she says she can't join it because she's pregnant. He bought the low-premium policy before Obamacare, and it doesn't include maternity coverage.

Sanchez is determined to take care of herself but feels punished for trying. She's 13 weeks pregnant, scared and crossing her fingers.

"I'm going without insurance and hope Trump does something quick," she tells me.

Nearby, working at a cash register, Julie Braun, 36, chimes in: "I got married to get off Obamacare."

She, too, once enjoyed low premiums -- just $30 a month -- only to see them soar. She needed two ankle surgeries last year, and with a high deductible, copays, therapies, braces and boots -- which aren't covered -- she says she's staring down a $20,000 bill she can't pay. She makes $9 an hour and even with her husband's salary plans to file for medical bankruptcy.

Though Braun and her husband had intended to marry at some point, they moved up their wedding date by a couple years. He teaches in the school and has good benefits, and that was all she needed to rush down the aisle.

'A scam and racket'

People here say they've had it with Washington and "mealy-mouthed politicians," the sort who speak pretty but say nothing, one local explains. This is why they backed Trump en masse. They like that he has a business record and trust that he can do better by them.

"The man didn't get rich as he is by being stupid," says one man who refuses to give his name but pulls me aside to tell his own story.

He's 50 and has never paid for health insurance. He calls the health care system "a scam and a racket." When he had a cracked tooth not long ago -- the first dental problem he'd ever had -- the dentist told him it would cost more than $4,000 to fix. "For one tooth!" he exclaims.

So he looked at the dentist and asked how much it would cost to pull out all his teeth and give him fake ones instead. It was half the price, so he came back with his checkbook and had every tooth yanked.

He now says he's facing a stiff penalty for not having insurance, which enrages him.

"I pay for my own medical, and now I have to pay for someone else's?" he says. "Don't get me wrong; I want to do my part. But when does my part stop?"

'Garden of Eden'

The Sandhills Oil Company gas station -- just "the station" to locals -- is a popular gathering spot where people gab over coffee.

Robin Jameson, 56, sits in the corner office. She moved here to oversee the station, one of several in a family business portfolio.

"It felt like home immediately," she says. She likes how people watch out for one another, donating propane and groceries to those in need, and she gives back in her own way.

An old rancher strolls into her office, seeking help deciphering a credit card bill. Retired ranchers down the road visit whenever their grandson competes in out-of-town rodeos, so she can set them up on a computer to watch the live-stream.

One of the regulars at a station table is Woody Thompson, 76. He landed in this area more than 60 years ago, when he came out of the Dust Bowl looking for work. He says he was brought here by "a drunk and a horse thief."

For decades, he worked on ranches. It's been a life rich in independence and great neighbors, the sort who once kept reselling a white leghorn rooster to raise money for a friend dying of brain cancer. These qualities made even the toughest days worthwhile. Digging harnesses out of snow drifts, riding miles and miles in 30-below temperatures, the winter of '78-'79 when the ground never saw less than 3 feet of snow -- he wouldn't take back his time here for anything.

"It might not be heaven, but it's the Garden of Eden," Thompson says.

A heart problem eventually took him away from ranching. Twice a month, he drives 70 miles south to see his Denver cardiologist, who meets him in Ogallala -- the nearest town on the nearest interstate. (Locals like that the interstate runs through flat Nebraska, allowing them to keep their hills to themselves.)

Thompson, who moved to Hyannis 15 years ago, hands over one of his business cards. He's now a traveling rep for a company that performs castrations. With a couple golf balls in a bag, he demonstrates how they're done.

Like so many people in this county, he says that Trump's business know-how spoke to him -- even if he doesn't suspect that he'd like the guy personally.

"I have three daughters," Thompson says. "If Megyn Kelly had been my daughter, I would have beat the hell out of him."

Respecting the law

A couple blocks uphill, in the old courthouse, I find Christee Haney. She's in her second term as county clerk and keeps official records in the same books and logs used by clerks in the late 1800s.

When she was elected seven years ago, it was to fill multiple offices. In an area as rural as this, she's more than the country clerk. She's also the county assessor, the registrar of deeds, the clerk of the court and the election commissioner.

Party registration doesn't dictate votes here, where 81% of registered voters cast ballots in November. She has 40 registered Democrats, she says, but only 20 people voted for Hillary Clinton. Haney's cousin is one example; she's a Democrat who voted for Trump and refused to back Obama, whom she never trusted.

Haney, 54, considers the high rate of Obamacare enrollment in Grant County and offers this: People are abiding by the law, simple as that.

"It's a matter of respect out here, and that's what we've all taught our kids," she says.

The K-12 school in Hyannis, which serves several counties and has fewer than 150 students, is a source of pride here. The teacher-to-student ratio is 1-to-9, the principal tells me. Students are more than cowboys and cowgirls: They test above the national average, are given their own laptops, flourish in the arts and play sports that draw the community together.

Parents who've raised kids here brag about them getting scholarships; one proud dad says his daughter turned down Stanford, MIT and Yale because she wanted to be a Cornhusker. She graduated from the University of Nebraska with perfect grades.

People here may not have what big cities offer, but that suits them. When Haney takes a day to run errands in Ogallala, population 4,570, she finds the traffic and all the people exhausting.

She and others here prefer this quiet life with wide-open spaces and fewer stresses. They aren't facing a drug epidemic and don't worry about crime. They leave their keys in the ignition and don't lock their doors. They don't have a homeless problem and don't fret about unemployment. If anyone wants to work, there's work to be had.

The folks in Grant County wish people elsewhere would take responsibility in their own lives and stop blaming others for their problems.

"People on welfare in big cities make more money not working than we do working," says one woman. She's not the only one I meet who believes this.

Not wanting to go without

In a small house on the north side of the tracks, where the railroad carries coal from Wyoming and Montana, Terry Keys feeds and burps his 3-month-old son, Deacon.

The baby shouldn't be this old. He was born two months early, when severe preeclampsia sent Terry, 34, and his wife, Trish, on an emergency trip to Lincoln at the end of October. Trish and Deacon had to stay there for a month until it was safe to bring the baby home. Terry, who helps drill and service wells, drove more than 300 miles each way to join them on weekends.

Trish, the village's 37-year-old salon owner, curls up in the chair beside her husband and son and recounts an odyssey she's still processing.

The couple, both Trump supporters, had been uninsured when Obamacare came along. The first year, they paid a penalty of $90. But fearing the prospect of steeper fines, they signed up. With the Affordable Care Act, they could purchase what had previously evaded them for about $150 a month.

"It was reasonable, and we didn't have insurance before," Trish says. It helped them, she says, until it didn't.

She'd been told their policy would cover Deacon and the exorbitant neonatal intensive care expenses for the first 30 days of his life "no matter what." But she says the insurance company stopped the family's policy without notice. Trish and Terry found out only when they stepped into a pharmacy in Lincoln for flu shots and were told they had no coverage.

A panicked phone call later, she was told they qualified for Medicaid and should apply, which meant a flurry of paperwork and bureaucracy. After the trauma of having a preemie and being stuck in a city far from the world she knows, Trish came home to the stress of fighting a $104,000 bill. She still isn't sure who's responsible -- Medicaid or the insurance company -- and only knows she and Terry won't be able to pay it.

"There has to be a simpler way. I feel like they've overcomplicated everything," she says.

"It's mind-boggling to me," she says before turning her gaze to her son, who finally weighs 9 pounds. "Now that this has happened, you don't want to go without insurance."

She hopes to still be able to afford it. And like others in this remote heartland county, she trusts that her new president won't let her down.

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where trump support and obamacare use soar - cnn

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Where Trump support and Obamacare use soar

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One in three residents, or 33% of the under-65 population, bought insurance on Obamacare exchanges, official data from a year ago show. The national average is just 5%, which raises the question: In a place so tied to the Affordable Care Act, why would people back the man who vowed to repeal it?

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A person's intersecting labels heavily influence the probability of that person developing a mental illness and the way that they express their mental illness outwardly to others (p 134 – 136, 141 – 143).

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Introduction

To better understand what happens inside the clinical setting, this chapter looks outside. It reveals the diverse effects of culture and society on mental health, mental illness, and mental health services. This understanding is key to developing mental health services that are more responsive to the cultural and social contexts of racial and ethnic minorities.

With a seemingly endless range of subgroups and individual variations, culture is important because it bears upon what all people bring to the clinical setting. It can account for minor variations in how people communicate their symptoms and which ones they report. Some aspects of culture may also underlie culture-bound syndromes - sets of symptoms much more common in some societies than in others. More often, culture bears on whether people even seek help in the first place, what types of help they seek, what types of coping styles and social supports they have, and how much stigma they attach to mental illness. Culture also influences the meanings that people impart to their illness. Consumers of mental health services, whose cultures vary both between and within groups, naturally carry this diversity directly to the service setting.

The cultures of the clinician and the service system also factor into the clinical equation. Those cultures most visibly shape the interaction with the mental health consumer through diagnosis, treatment, and organization and financing of services. It is all too easy to lose sight of the importance of culture - until one leaves the country. Travelers from the United States, while visiting some distant frontier, may find themselves stranded in miscommunications and seemingly unorthodox treatments if they seek care for a sudden deterioration in their mental health.

Health and mental health care in the United States are embedded in Western science and medicine, which emphasize scientific inquiry and objective evidence. The self-correcting features of modern science - new methods, peer review, and openness to scrutiny through publication in professional journals - ensure that as knowledge is developed, it builds on, refines, and often replaces older theories and discoveries. The achievements of Western medicine have become the cornerstone of health care worldwide.

What follows are numerous examples of the ways in which culture influences mental health, mental illness, and mental health services. This chapter is meant to be illustrative, not exhaustive. It looks at the culture of the patient, the culture of the clinician, and the specialty in which the clinician works. With respect to the context of mental health services, the chapter deals with the organization, delivery, and financing of services, as well as with broader social issues - racism, discrimination, and poverty - which affect mental health.

Culture refers to a groups shared set of beliefs, norms, and values ( Chapter 1). Because common social groupings (e.g., people who share a religion, youth who participate in the same sport, or adults trained in the same profession) have their own cultures, this chapter has separate sections on the culture of the patient as well as the culture of the clinician. Where cultural influences end and larger societal influences begin, there are contours not easily demarcated by social scientists. This chapter takes a broad view about the importance of both culture and society, yet recognizes that they overlap in ways that are difficult to disentangle through research.

What becomes clear is that culture and social contexts, while not the only determinants, shape the mental health of minorities and alter the types of mental health services they use. Cultural misunderstandings between patient and clinician, clinician bias, and the fragmentation of mental health services deter minorities from accessing and utilizing care and prevent them from receiving appropriate care. These possibilities intensify with the demographic trends highlighted at the end of the chapter.

Culture of the Patient

The culture of the patient, also known as the consumer of mental health services, influences many aspects of mental health, mental illness, and patterns of health care utilization. One important cautionary note, however, is that general statements about cultural characteristics of a given group may invite stereotyping of individuals based on their appearance or affiliation. Because there is usually more diversity within a population than there is between populations (e.g., in terms of level of acculturation, age, income, health status, and social class), information in the following sections should not be treated as stereotypes to be broadly applied to any individual member of a racial, ethnic, or cultural group.

Symptoms, Presentation, and Meaning

The symptoms of mental disorders are found worldwide. They cluster into discrete disorders that are real and disabling ( U.S. Department of Health and Human Services [DHHS], 1999). As noted in Chapter 1, mental disorders are defined in the Diagnostic and Statistical Manual of Mental Disorders( American Psychiatric Association [APA], 1994). Schizophrenia, bipolar disorder, panic disorder, obsessive compulsive disorder, depression, and other disorders have similar and recognizable symptoms throughout the world ( Weissman et al., 1994, 1996, 1997, 1998). Culture-bound syndromes, which appear to be distinctive to certain ethnic groups, are the exception to this general statement. Research has not yet determined whether culture-bound syndromes are distinct from established mental disorders, are variants of them, or whether both mental disorders and culture-bound syndromes reflect different ways in which the cultural and social environment interacts with genes to shape illness ( Chapter 1).

One way in which culture affects mental illness is through how patients describe (or present) their symptoms to their clinicians. There are some well recognized differences in symptom presentation across cultures. The previous chapter described ethnic variation in symptoms of somatization, the expression of distress through one or more physical (somatic) symptoms (Box 1-3). Asian patients, for example, are more likely to report their somatic symptoms, such as dizziness, while not reporting their emotional symptoms. Yet, when questioned further, they do acknowledge having emotional symptoms ( Lin & Cheung, 1999). This finding supports the view that patients in different cultures tend to selectively express or present symptoms in culturally acceptable ways ( Kleinman, 1977, 1988).

Cultures also vary with respect to the meaning they impart to illness, their way of making sense of the subjective experience of illness and distress ( Kleinman, 1988). The meaning of an illness refers to deep-seated attitudes and beliefs a culture holds about whether an illness is "real" or "imagined," whether it is of the body or the mind (or both), whether it warrants sympathy, how much stigma surrounds it, what might cause it, and what type of person might succumb to it. Cultural meanings of illness have real consequences in terms of whether people are motivated to seek treatment, how they cope with their symptoms, how supportive their families and communities are, where they seek help (mental health specialist, primary care provider, clergy, and/or traditional healer), the pathways they take to get services, and how well they fare in treatment. The consequences can be grave - extreme distress, disability, and possibly, suicide - when people with severe mental illness do not receive appropriate treatment.

Causation and Prevalence

Cultural and social factors contribute to the causation of mental illness, yet that contribution varies by disorder. Mental illness is considered the product of a complex interaction among biological, psychological, social, and cultural factors. The role of any one of these major factors can be stronger or weaker depending on the disorder ( DHHS, 1999).

The prevalence of schizophrenia, for example, is similar throughout the world (about 1 percent of the population), according to the International Pilot Study on Schizophrenia, which examined over 1,300 people in 10 countries ( World Health Organization [WHO], 1973). International studies using similarly rigorous research methodology have extended the WHO's findings to two other disorders: The lifetime prevalence of bipolar disorder (0.3-1.5%) and panic disorder (0.4-2.9%) were shown to be relatively consistent across parts of Asia, Europe, and North America ( Weissman et al., 1994, 1996, 1997, 1998). The global consistency in symptoms and prevalence of these disorders, combined with results of family and molecular genetic studies, indicates that they have high heritability (genetic contribution to the variation of a disease in a population) ( National Institute of Mental Health [NIMH], 1998). In other words, it seems that culture and societal factors play a more sub-ordinate role in causation of these disorders.

Cultural and social context weigh more heavily in causation of depression. In the same international studies cited above, prevalence rates for major depression varied from 2 to 19 percent across countries ( Weissman et al., 1996). Family and molecular biology studies also indicate less heritability for major depression than for bipolar disorder and schizophrenia ( NIMH, 1998). Taken together, the evidence points to social and cultural factors, including exposure to poverty and violence, playing a greater role in the onset of major depression. In this context, it is important to note that poverty, violence, and other stressful social environments are not unique to any part of the globe, nor are the symptoms and manifestations they produce. However, factors often linked to race or ethnicity, such as socioeconomic status or country of origin can increase the likelihood of exposure to these types of stressors.

Even though there are similarities and differences in the distribution of certain mental disorders across populations, the United States has an aggregate rate of about 20 percent of adults and children with diagnosable mental disorders DHHS, 1999; Table 1-1. As noted in Chapter 1, this aggregate rate for the population as a whole does not have sufficient representation from most minority groups to permit comparisons between whites and other ethnic groups. The rates of mental disorder are not sufficiently studied in many smaller ethnic groups to permit firm conclusions about overall prevalence; however, several epidemiological studies of ethnic populations, supported by the NIMH, are currently in progress ( Chapter 7). Until more definitive findings are available, this Supplement concludes, on the basis of smaller studies, that overall prevalence rates for mental disorders in the United States are similar across minority and majority populations. As noted in Chapter 1, this general conclusion applies to racial and ethnic minority populations living in the community, because high-need subgroups are not well captured in community household surveys.

Family Factors

Many features of family life have a bearing on mental health and mental illness. Starting with etiology, Chapter 1 highlighted that family factors can protect against, or contribute to, the risk of developing a mental illness. For example, supportive families and good sibling relationships can protect against the onset of mental illness. On the other hand, a family environment marked by severe marital discord, overcrowding, and social disadvantage can contribute to the onset of mental illness. Conditions such as child abuse, neglect, and sexual abuse also place children at risk for mental disorders and suicide Brown et al., 1999; Dinwiddie et al., 2000.

Family risk and protective factors for mental illness vary across ethnic groups. But research has not yet reached the point of identifying whether the variation across ethnic groups is a result of that group's culture, its social class and relationship to the broader society, or individual features of family members.

One of the most developed lines of research on family factors and mental illness deals with relapse in schizophrenia. The first studies, conducted in Great Britain, found that people with schizophrenia who returned from hospitalizations to live with family members who expressed criticism, hostility, or emotional involvement (called high expressed emotion) were more likely to relapse than were those who returned to family members who expressed lower levels of negative emotion Leff & Vaughn, 1985; Kavanaugh, 1992; Bebbington & Kuipers, 1994; Lopez & Guarnaccia, 2000. Later studies extended this line of research to Mexican American samples. These studies reconceptualized the role of family as a dynamic interaction between patients and their families, rather than as static family characteristics Jenkins, Kleinman, & Good, 1991; Jenkins, 1993. Using this approach, a study comparing Mexican American and white families found that different types of interactions predicted relapse. For the Mexican American families, interactions featuring distance or lack of warmth predicted relapse for the individual with schizophrenia better than interactions featuring criticism. For whites, the converse was true ( Lopez et al., 1998). This example, while not necessarily generalizable to other Hispanic groups, suggests avenues by which other culturally based family differences may be related to the course of mental illness.

Coping Styles

Culture relates to how people cope with everyday problems and more extreme types of adversity. Some Asian American groups, for example, tend not to dwell on upsetting thoughts, thinking that reticence or avoidance is better than outward expression. They place a higher emphasis on suppression of affect Hsu, 1971; Kleinman, 1977, with some tending first to rely on themselves to cope with distress ( Narikiyo & Kameoka, 1992). African Americans tend to take an active approach in facing personal problems, rather than avoiding them Broman, 1996). They are more inclined than whites to depend on handling distress on their own ( Sussman et al., 1987). They also appear to rely more on spirituality to help them cope with adversity and symptoms of mental illness (Broman, 1996; Cooper-Patrick et al., 1997; Neighbors et al., 1998.

Few doubt the importance of culture in fostering different ways of coping, but research is sparse. One of the few, yet well developed lines of research on coping styles comes from comparisons of children living in Thailand versus America. Thailand's largely Buddhist religion and culture encourage self-control, emotional restraint, and social inhibition. In a recent study, Thai children were two times more likely than American children to report reliance on covert coping methods such as "not talking back," than on overt coping methods such as "screaming" and "running away" ( McCarty et al., 1999). Other studies by these investigators established that different coping styles are associated with different types and degrees of problem behaviors in children ( Weisz et al., 1997).

The studies noted here suggest that better understanding of coping styles among racial and ethnic minorities has implications for the promotion of mental health, the prevention of mental illness, and the nature and severity of mental health problems.

Treatment Seeking

Research indicates that some minority groups are more likely than whites to delay seeking treatment until symptoms are more severe (See Chapters 3 & 5). Further, racial and ethnic minorities are less inclined than whites to seek treatment from mental health specialists Gallo et al., 1995; Chun et al., 1996; Zhang et al., 1998. Instead, studies indicate that minorities turn more often to primary care Cooper-Patrick et al., 1999a; see later section on Primary Care. They also turn to informal sources of care such as clergy, traditional healers, and family and friends Neighbors & Jackson, 1984; Peifer et al., 2000. In particular, American Indians and Alaska Natives often rely on traditional healers, who frequently work side-by-side with formal providers in tribal mental health programs ( Chapter 4). African Americans often rely on ministers, who may play various mental health roles as counselor, diagnostician, or referral agent ( Levin, 1986). The extent to which minority groups rely on informal sources in lieu of, or in addition to, formal mental health services in primary or specialty care is not well studied.

When they use mental health services, Some African Americans prefer therapists of the same race or ethnicity. This preference has encouraged the development of ethnic-specific programs that match patients to therapists of the same culture or ethnicity ( Sue, 1998). Many African Americans also prefer counseling to drug therapy ( Dwight-Johnson et al., 2000). Their concerns revolve around side effects, effectiveness, and addiction potential of medications ( Cooper-Patrick et al., 1997).

The fundamental question raised by this line of research is: Why are many racial and ethnic minorities less inclined than whites to seek mental health treatment? Certainly, the constellation of barriers deterring whites also operates to various degrees for minorities - cost, fragmentation of services, and the societal stigma on mental illness ( DHHS, 1999). But there are extra barriers deterring racial and ethnic minorities such as mistrust and limited English proficiency.

Mistrust

Mistrust was identified by the SGR as a major barrier to the receipt of mental health treatment by racial and ethnic minorities ( DHHS, 1999). Mistrust is widely accepted as pervasive among minorities, yet there is surprisingly little empirical research to document it ( Cooper-Patrick et al., 1999). One of the few studies on this topic looked at African Americans and whites surveyed in theearly 1980s in a national study known as the Epidemiologic Catchment Area (ECA) study. This study found that African Americans with major depression were more likely to cite their fears of hospitalization and of treatment as reasons for not seeking mental health treatment. For instance, almost half of African Americans, as opposed to 20 percent of whites, reported being afraid of mental health treatment ( Sussman et al., 1987).

Mistrustful attitudes also may be commonplace among other groups. While insufficiently studied, mistrust toward health care providers can be inferred from a group's attitudes toward government-operated institutions. Immigrants and refugees from many regions of the world, including Central and South America and Southeast Asia, feel extreme mistrust of government, based on atrocities committed in their country of origin and on fear of deportation by U.S. authorities. Similarly, many American Indians and Alaska Natives are mistrustful of health care institutions; this dates back through centuries of legalized discrimination and segregation, as discussed in Chapter 4.

Stigma

Stigma was portrayed by the SGR as the "most formidable obstacle to future progress in the arena of mental illness and health" ( DHHS, 1999). It refers to a cluster of negative attitudes and beliefs that motivate the general public to fear, reject, avoid, and discriminate against people with mental illness ( Corrigan & Penn, 1999).

Stigma is widespread in the United States and other Western nations Bhugra, 1989; Brockington et al., 1993 and in Asian nations ( Ng, 1997. In response to societal stigma, people with mental problems internalize public attitudes and become so embarrassed or ashamed that they often conceal symptoms and fail to seek treatment Sussman et al., 1987; Wahl, 1999. Stigma also lowers their access to resources and opportunities, such as housing and employment, and leads to diminished self-esteem and greater isolation and hopelessness Penn & Martin, 1998; Corrigan & Penn, 1999. Stigma can also be against family members; this damages the consumer's self-esteem and family relationships ( Wahl & Harman, 1989). In some Asian cultures, stigma is so extreme that mental illness is thought to reflect poorly on family lineage and thereby diminishes marriage and economic prospects for other family members as well Sue & Morishima, 1982; Ng, 1997).

Stigma is such a major problem that the very topic itself poses a challenge to research. Researchers have to contend with people's reluctance to disclose attitudes often deemed socially unacceptable. How stigma varies by culture can be studied from two perspectives. One perspective is that of the targets of stigma, i.e., the people with symptoms: If they are members of a racial or ethnic minority, are they more likely than whites to experience stigma? The other perspective is that of the public in their attitudes toward people with mental illness: Are members of each racial or ethnic minority group more likely than whites to hold stigmatizing attitudes toward mental illness? The answers to these cross-cultural questions are far from definitive, but there are some interesting clues from research.

Turning first to those who experience symptoms, one of the few cross-cultural studies questioned Asian Americans living in Los Angeles. The findings were eye-opening: Only 12 percent of Asians would mention their mental health problems to a friend or relative (versus 25 percent of whites). A meager 4 percent of Asians would seek help from a psychiatrist or specialist (versus 26 percent of whites). And only 3 percent of Asians would seek help from a physician (versus 13 percent of whites). The study concluded that stigma was pervasive and pronounced for Asian Americans in Los Angeles ( Zhang et al., 1998).

Turning to the question of public attitudes toward mental illness, the largest and most detailed study of stigma in the United States was performed in 1996 as part of the General Social Survey, a respected, nationally representative survey being conducted by the National Opinion Research Center since the 1970s. In this study, a representative sample was asked in personal interviews to respond to different vignettes depicting people with mental illness. The respondents generally viewed people with mental illness as dangerous and less competent to handle their own affairs, with their harshest judgments reserved for people with schizophrenia and substance use disorders. Interestingly, neither the ethnicity of the respondent, nor the ethnicity of the person portrayed in the vignette, seemed to influence the degree of stigma ( Pescosolido et al., 1999).

By contrast, another large, nationally representative study found a different relationship between race, ethnicity, and attitudes towards patients with mental illness. Asian and Hispanic Americans saw them as more dangerous than did whites. Although having contact with individuals with mental illness helped to reduce stigma for whites, it did not for African Americans. American Indians, on the other hand, held attitudes similar to whites ( Whaley, 1997).

Taken together, these results suggest that minorities hold similar, and in some cases stronger, stigmatizing attitudes toward mental illness than do whites. Societal stigma keeps minorities from seeking needed mental health care, much as it does for whites. Stigma is so potent that it not only affects the self-esteem of people with mental illness, but also that of family members. The bottom line is that stigma does deter major segments of the population, majority and minority alike, from seeking help. It bears repeating that a majority of all people with diagnosable mental disorders do not get treatment ( DHHS, 1999).

Immigration

Migration, a stressful life event, can influence mental health. Often called acculturative stress, it occurs during the process of adapting to a new culture ( Berry et al., 1987). Refugees who leave their homelands because of extreme threat from political forces tend to experience more trauma, more undesirable change, and less control over the events that define their exits than do voluntary immigrants Rumbaut, 1985; Meinhardt et al., 1986.

Although immigration can bring stress and subsequent psychological distress, research results do not suggest that immigration per se results in higher rates of mental disorders (e.g., Vega et al., 1998). However, as described in the chapters on Asian Americans and Latinos, the traumas experienced by adults and children from war-torn countries before and after immigrating to the United States seem to result in high rates of post-traumatic stress disorder (PTSD) among these populations.

Overall Health Status

The burden of illness in the United States is higher in racial and ethnic minorities than whites. The National Institutes of Health (NIH) recently reported that compared with the majority populations, U.S. minority populations have shorter overall life expectancies and higher rates of cardiovascular disease, cancer, infant mortality, birth defects, asthma, diabetes, stroke, adverse consequences of substance abuse, and sexually transmitted diseases DHHS, 2000; NIH, 2000. The list of illnesses is overpoweringly long.

Disparities in health status have led to high-profile research and policy initiatives. One long-standing policy initiative is Healthy People, a comprehensive set of national health objectives issued every decade by the Department of Health and Human Services. The most recent is Healthy People 2010, which contains both well defined objectives for reducing health disparities and the means for monitoring progress ( DHHS, 2000).

Higher rates of physical (somatic) disorders among racial and ethnic minorities hold significant implications for mental health. For example, minority individuals who do not have mental disorders are at higher risk for developing problems such as depression and anxiety because chronic physical illness is a risk factor for mental disorders DHHS, 1999; see also earlier section. Moreover, individuals from racial and ethnic minority groups who already have both a mental and a physical disorder (known as comorbidity) are more likely to have their mental disorder missed or misdiagnosed, owing to competing demands on primary care providers who are preoccupied with the treatment of the somatic disorder Borowsky, et al., 2000; Rost et al., 2000. Even if their mental disorder is recognized and treated, people with comorbid disorders are saddled by more drug interactions and side effects, given their higher usage of medications. Finally, people with comorbid disorders are much more likely to be unemployed and disabled, compared with people who have a single disability ( Druss et al., 2000).

Thus, poor somatic health takes a toll on mental health. And it is probable that some of the mental health disparities described in this Supplement are linked to the poorer somatic health status of racial and ethnic minorities. The interrelationships between mind and body are inescapably evident.

Culture of the Clinician

As noted earlier, a group of professionals can be said to have a "culture" in the sense that they have a shared set of beliefs, norms, and values. This culture is reflected in the jargon members of a group use, in the orientation and emphasis in their textbooks, and in their mindset, or way of looking at the world.

Health professionals in the United States, and the institutions in which they train and practice, are rooted in Western medicine. The culture of Western medicine, launched in ancient Greece, emphasizes the primacy of the human body in disease. Further, Western medicine emphasizes the acquisition of knowledge through scientific and empirical methods, which hold objectivity paramount. Through these methods, Western medicine strives to uncover universal truths about disease, its causation, diagnosis, and treatment.

Around 1900, Western medicine started to conceptualize disease as affected by social, as well as by biological phenomena. Its scope began to incorporate wider questions of income, lifestyle, diet, employment, and family structure, thereby ushering in the broader field of public health Porter, 1997; see also Chapter 1.

Mental health professionals trace their roots to Western medicine and, more particularly, to two major European milestones - the first forms of biological psychiatry in the mid-19th century and the advent of psychotherapy (or "talk therapy") near the end of that century ( Shorter, 1997). The earliest forms of biological psychiatry primed the path for more than a century of advances in pharmacological therapy, or drug treatment, for mental illness. The original psychotherapy, known as psychoanalysis, was founded in Vienna by Sigmund Freud. While many forms of psychotherapy are available today, with vastly different orientations, all emphasize verbal communication between patient and therapist as the basis of treatment. Today's treatments for specific mental disorders also may combine pharmacological therapy and psychotherapy; this approach is known as multimodal therapy. These two types of treatment and the intellectual and scientific traditions that galvanized their development are an outgrowth of Western medicine.

To say that physicians or mental health professionals have their own culture does not detract from the universal truths discovered by their fields. Rather, it means that most clinicians share a worldview about the interrelationship among body, mind, and environment, informed by knowledge acquired through the scientific method. It also means that clinicians view symptoms, diagnoses, and treatments in a manner that sometimes diverges from their patients. "[Clinicians'] conceptions of disease and [their] responses to it unquestionably show the imprint of [a] particular culture, especially its individualist and activist therapeutic mentality," writes sociologist of medicine Paul Starr (1982).

Because of the professional culture of the clinician, some degree of distance between clinician and patient always exists, regardless of the ethnicity of each ( Burkett, 1991). Clinicians also bring to the therapeutic setting their own personal cultures Hunt, 1995; Porter, 1997. Thus, when clinician and patient do not come from the same ethnic or cultural background, there is greater potential for cultural differences to emerge. Clinicians may be more likely to ignore symptoms that the patient deems important, or less likely to understand the patient's fears, concerns, and needs. The clinician and the patient also may harbor different assumptions about what a clinician is supposed to do, how a patient should act, what causes the illness, and what treatments are available. For these reasons, DSM-IV exhorts clinicians to understand how their relationship with the patient is affected by cultural differences ( Chapter 1).

Communication

The emphasis on verbal communication is a distinguishing feature of the mental health field. The diagnosis and treatment of mental disorders depend to a large extent on verbal communication between patient and clinician about symptoms, their nature, intensity, and impact on functioning ( Chapter 1). While many mental health professionals strive to deliver treatment that is sensitive to the culture of the patient, problems can occur.

The emphasis on verbal communication yields greater potential for miscommunication when clinician and patient come from different cultural backgrounds, even if they speak the same language. Overt and subtle forms of miscommunication and misunderstanding can lead to misdiagnosis, conflicts over treatment, and poor adherence to a treatment plan. But when patient and clinician do not speak the same language, these problems intensify. The importance of cross-cultural communication in establishing trusting relationships between clinician and patient is just beginning to be explored through research in family practice ( Cooper-Patrick et al., 1999) and mental health (see later section on"Culturally Competent Services").

Primary Care

Clinician Bias and Stereotyping

Misdiagnosis also can arise from clinician bias and stereotyping of ethnic and racial minorities. Clinicians often reflect the attitudes and discriminatory practices of their society ( Whaley, 1998). This institutional racism was evident over a century ago with the establishment of a separate, completely segregated mental hospital in Virginia for African American patients ( Prudhomme & Musto, 1973). While racism and discrimination have certainly diminished over time, there are traces today which are manifest in less overt medical practices concerning diagnosis, treatment, prescribing medications, and referrals Giles et al., 1995; Shiefer, Escarce, & Schulman, 2000. One study from the mental health field found that African American youth were four times more likely than whites to be physically restrained after acting in similarly aggressive ways, suggesting that racial stereotypes of blacks as violent motivated the professional judgment to have them restrained ( Bond et al., 1988). Another study found that white therapists rated a videotape of an African American client with depression more negatively than they did a white patient with identical symptoms ( Jenkins-Hall & Sacco, 1991).

There is ample documentation provided in Chapter 3 that African American patients are subject to overdiagnosis of schizophrenia. African Americans are also underdiagnosed for bipolar disorder Bell et al., 1980, 1981; Mukherjee, et al., 1983, depression, and, possibly, anxiety Neal-Barnett & Smith, 1997; Baker & Bell, 1999; Borowsky et al., 2000. The problems extend beyond African Americans. Widely held stereotypes of Asian Americans as "problem free" may prompt clinicians to overlook their mental health problems ( Takeuchi & Uehara, 1996).

The following chapters of this Supplement each cover diagnostic errors and inappropriate treatment in greater detail. They also address the extent to which each racial or ethnic minority group utilizes services or receives treatment in conformance with treatment guidelines developed from controlled clinical trials. For example, minority patients are less likely than whites to receive the best available treatments for depression and anxiety Wang et al., 2000; Young et al., 2001.

To infer a role for bias and stereotyping by clinicians does not prove that it is actually occurring, nor does it indicate the extent to which it explains disparities in mental health services. Some of the racial and ethnic disparities described in this Supplement are likely the result of racism and discrimination by white clinicians; however, the limited research on this topic suggests that the issue is more complex. A large study of cardiac patients could not attribute African Americans' lower utilization of a cardiac procedure to the race of the physician. Lower utilization by African American versus white patients was independent of whether patients were treated by white or black physicians ( Chen et al., 2001). The study authors suggested the possibility that institutional factors and attitudes that were common to black and white physicians contributed to lower rates of utilization by black patients. Some have suggested that what appears to be racial bias by clinicians might instead reflect biases of their socioeconomic status or their professional culture ( Epstein & Ayanian, 2001). These biases, whether intentional or unintentional, may be more powerful influences on care than the influence of the clinician's own race or ethnicity.

Culture, Society, and Mental Health Services

Every society influences mental health treatment by how it organizes, delivers, and pays for mental health services. In the United States, services are financed and delivered in vastly different ways than in other nations. That organization was shaped by and reflects a unique set of historical, economic, political, and social forces, which were summarized in the SGR ( DHHS, 1999). The mental health service system is a fragmented patchwork, often referred to as the " de factomental health system" because of its lack of a single set of organizing principles ( Regier et al., 1993). While this hybrid system serves a range of functions for many people, it has not successfully addressed the problem that people with the most complex needs and the fewest financial resources often find it difficult to use. This problem is magnified for minority groups. To understand the obstacles that minorities face, this section provides background on mental health service settings, financing, and the concept of culturally competent services.

Service Settings and Sectors

Mental health services are provided by numerous types of practitioners in a diverse array of environments, variously called settings and sectors. Settings range from home and community to institutions, and sectors include public or private primary care and specialty care. This section provides a broad overview of mental health services, patterns of use, and trends in financing. Interested readers are referred to the SGR, which covers these topics in greater detail.

The burgeoning types of community services available today stand in sharp contrast to the institutional orientation of the past. Propelled by reform movements, advocacy, and the advent of managed care, today's best mental health services extend beyond diagnosis and treatment to cover prevention and the fulfillment of broader needs, including housing and employment. Services are formal (provided by professionals) or informal (provided by lay volunteers). The most fundamental shift has been in the setting for service delivery, from the institution to the community.

There are four major sectors for receiving mental health care:

1. The specialty mental health sector is designed solely for the provision of mental health services. It refers to mental hospitals, residential treatment facilities, and psychiatric units of general hospitals. It also refers to specialized agencies and programs in the community, such as community mental health centers, day treatment programs, and rehabilitation programs. Within these settings, services are furnished by specialized mental health professionals, such as psychologists, psychiatric nurses, psychiatrists, and psychiatric social workers;

2. The general medical and primary care sector offers a comprehensive range of health care services including, but not limited to, mental health services. Primary care physicians, nurse practitioners, internists, and pediatricians are the general types of professionals who practice in a range of settings that include clinics, offices, community health centers, and hospitals;

3. The human services sector is made up of social welfare (housing, transportation, and employment), criminal justice, educational, religious, and charitable services. These services are delivered in a full range of settings - home, community, and institutions;

4. The voluntary support network refers to self-help groups and organizations devoted to education, communication, and support. Services provided by the voluntary support network are largely found in the community. Typically informal in nature, they often help patients and families increase knowledge, reduce feelings of isolation, obtain referrals to formal treatment, and cope with mental health problems and illnesses.

Consumers can exercise choice in treatment largely because of the range of effective treatments for mental illness and the diversity of settings and sectors in which these treatments are offered. Consumers can choose, too, between distinct treatment modalities, such as psychotherapy, counseling, pharmacotherapy (medications), or rehabilitation. For severe mental illnesses, however, all types are usually essential, as are delivery systems to integrate their services ( DHHS, 1999).

Consumer preferences cannot necessarily be inferred from the types of treatment they actually use because costs, reimbursement, or availability of services - rather than preferences - may drive their utilization. For example, minority patients who wish to see mental health professionals of similar racial or ethnic backgrounds may often find it difficult or impossible, because most mental health practitioners are white. Because there are only 1.5 American Indian/Alaska Native psychiatrists per 100,000 American Indians/Alaska Natives in this country, and only 2.0 Hispanic psychiatrists per 100,000 Hispanics, the chance of an ethnic match between Native or Hispanic American patient and provider is highly unlikely ( Manderscheid & Henderson, 1999).

Financing of Mental Health Services and Managed Care

Mental health services are financed from many funding streams that originate in the public and private sectors. In 1996, slightly more than half of the $69 billion in mental health spending was by public payers, including Medicaid and Medicare. The remainder came mostly from either private insurance (27%) or out-of-pocket payments (17%) by patients and their families ( DHHS, 1999).

One of the most significant changes affecting both privately and publicly funded services has been the striking shift to managed care. Relatively uncommon two decades ago, managed care in some form now covers the majority of Americans, regardless of whether their care is paid for through the public or the private sector ( Levit & Lundy, 1998). The term "managed care" technically refers to a variety of mechanisms for organizing, delivering, and paying for health services. It is attractive to purchasers because it holds the promise of containing costs, increasing access to care, improving coordination of care, promoting evidence-based quality care, and emphasizing prevention. Attainment of these goals for all racial and ethnic groups is difficult to verify through research because of the breathtaking pace of change in the health care marketplace. Study in this area is also challenging because claims data are closely held by private companies and thus are often unavailable to researchers, and because insurers and providers often do not collect information about ethnicity or race ( Fraser, 1997).

Almost 72 percent of Americans with health insurance in 1999 were enrolled in managed behavioral health organizations for mental or addictive disorders ( OPEN MINDS, 1999). Managed care has far-reaching implications for mental health services in terms of access, utilization, and quality, yet there has been only a limited body of research on its effectiveness in these areas ( DHHS, 1999).

Through lower costs, managed care was expected to boost access to care, which is especially critical for racial and ethnic minorities. However, there is preliminary evidence that managed care is perceived by some racial and ethnic minorities as imposing more barriers to treatment than does fee-for-service care Scholle & Kelleher, 1997; Provan & Carle, 2000. Yet, improved access alone will not eliminate disparities ( Chapter 3). Other compelling factors curtail utilization of services by racial and ethnic minorities, and they need to be addressed to reduce the gap between minorities and whites ( Chapter 7).

In terms of quality of care, the SGR noted ongoing efforts within behavioral health care to develop quality reporting systems. It also pointed out that existing incentives within and outside managed care do not encourage an emphasis on quality of care ( DHHS, 1999). While the SGR concluded that there is little direct evidence of problems with quality in well implemented managed care programs, it cautioned that "the risk for more impaired populations and children remains a serious concern."

Finally, managed care has been coupled with legislative proposals to impose parity in financing of mental health services. Intended to reverse decades of inequity, parity seeks coverage for mental health services on a par with that for somatic (physical) illness. Managed care's potential to control costs through various management strategies that prevent overuse of services makes parity more economically feasible ( DHHS, 1999). Studies described in the SGR found negligible cost increases under existing parity programs within several States. Further, several studies have shown that racial and ethnic disparities in access to health care and in treatment outcomes are reduced or eliminated under equal access systems such as the Department of Defense health care system Optenberg et al., 1995; Taylor et al., 1997, the VA medical system for some disease conditions, and in some health maintenance organizations Tambor et al., 1994; Martin, Shelby, & Zhang, 1995; Clancy & Franks, 1997.

Evidence-Based Treatment and Minorities

The SGR documented a comprehensive range of effective treatments for many mental disorders ( DHHS, 1999). These evidence-based treatments rely on consistent scientific evidence, from controlled clinical trials, that they significantly improve patients' outcomes ( Drake et al., 2001). Despite strong and consistent evidence of efficacy, the SGR spotlighted the problem that evidence-based treatments are not being translated into community settings and are not being provided to everyone who comes in for care.

Many reasons have been cited as underlying the gap between research and practice. The most significant are practitioners' lack of knowledge of research results, the lag time between reporting of results and their translation into the practice setting, and the cost of introducing innovative services into health systems, most of which are operating within a highly competitive marketplace. There are also fundamental differences in the health characteristics of patients studied in academic settings where the research is conducted versus practice settings where patients are much more heterogeneous and often disabled by more than one disorder ( DHHS, 1999).

The gap between research and practice is even worse for racial and ethnic minorities. Problems span both research and practice settings. A special analysis performed for this Supplement reveals that controlled clinical trials used to generate professional treatment guidelines did not conduct specific analyses for any minority group (See Appendix A for complete analysis). Controlled clinical trials offer the highest level of scientific rigor for establishing that a given treatment works.

Several professional associations and government agencies have formulated treatment guidelines or evidence-based reports on treatment outcomes for certain disorders on the basis of consistent scientific evidence, across multiple controlled clinical trials. Since 1986, nearly 10,000 participants have been included in randomized clinical trials evaluating the efficacy of treatments for bipolar disorder, major depression, schizophrenia, and attention-deficit/hyperactivity disorder. However, for nearly half of these participants (4,991), no information on race or ethnicity is available. For another 7 percent of participants (N = 656), studies only reported the designation "non-white," without indicating a specific minority group. For the remaining 47 percent of participants (N = 4,335), Table 2-1 shows the breakdown by ethnicity. In all clinical trials reporting data on ethnicity, very few minorities were included and not a single study analyzed the efficacy of the treatment by ethnicity or race. A similar conclusion was reached by the American Psychological Association in a careful analysis of all empirically validated psychotherapies: "We know of no psychotherapy treatment research that meets basic criteria important for demonstrating treatment efficacy for ethnic minority populations..." ( Chambless et al., 1996).

The failure to conduct ethnic-specific analyses in clinical research is a problem that must be addressed the health characteristics of patients ( Chapter 7). This problem is not unique to the mental health field; it affects all areas of health research. In 1993, Congress passed legislation creating the National Institute of Health's Office of Research on Minority Health to increase the representation of minorities in all aspects of biomedical and behavioral research ( National Institutes of Health, 2001). In November 2000, the Minority Health Disparities Research and Education Act elevated the Office of Research on Minority Health to the National Center on Minority Health and Health Disparities. This gave NIH increased programmatic and budget authority for research on minority health issues and health disparities. The law also promotes more training and education of health professionals, the evaluation of data collection systems, and a national public awareness campaign.

Even though the treatment guidelines are extrapolated from largely white populations, they are, as a matter of public health prudence, the best available treatments for everyone, regardless of race or ethnicity. Yet evidence suggests that in clinical practice settings, minorities are less likely than whites to receive treatment that adheres to treatment guidelines ( Chapters 3- 6; see also Lehman & Steinwachs, 1998; Sclar et al., 1999; Blazer et al., 2000; Young et al., 2001). Existing treatment guidelines should be used for all people with mental disorders, regardless of ethnicity or race. But to be most effective, treatments need to be tailored and delivered appropriately for individuals according to age, gender, race, ethnicity, and culture ( DHHS, 1999).

Culturally Competent Services

The last four decades have witnessed tremendous changes in mental health service delivery. The civil rights movement, the expansion of mental health services into the community, and the demographic shift toward greater population diversity led to a growing awareness of inadequacies of the mental health system in meeting the needs of ethnic and racial minorities Rogler et al., 1987; Takeuchi & Uehara, 1996. Research documented huge variations in utilization between minorities and whites, and it began to uncover the influence of culture on mental health and mental illness Snowden & Cheung, 1990; Sue et al., 1991. Major differences were found in some manifestations of mental disorders, idioms for communicating distress, and patterns of help-seeking. The natural outgrowth of research and public awareness was self-examination by the mental health field and the advent of consumer and family advocacy. As noted in Chapter 1, major recognition was given to the importance of culture in the assessment of mental illness with the publication of the " Outline for Culture Formulation" in DSM-IV ( APA, 1994).

Another innovation was to take stock of the mental health treatment setting. This setting is arguably unique in terms of its strong reliance on language, communication, and trust between patients and providers. Key elements of therapeutic success depend on rapport and on the clinicians' understanding of patients' cultural identity, social supports, self-esteem, and reticence about treatment due to societal stigma. Advocates, practitioners, and policymakers, driven by widespread awareness of treatment inadequacies for minorities, began to press for a new treatment approach: the delivery of services responsive to the cultural concerns of racial and ethnic minority groups, including their languages, histories, traditions, beliefs, and values. This approach to service delivery, often referred to as cultural competence, has been promoted largely on the basis of humanistic values and intuitive sensibility rather than empirical evidence. Nevertheless, substantive data from consumer and family self-reports, ethnic match, and ethnic-specific services outcome studies suggest that tailoring services to the specific needs of these groups will improve utilization and outcomes.

Cultural competence underscores the recognition of patients' cultures and then develops a set of skills, knowledge, and policies to deliver effective treatments ( Sue & Sue, 1999). Underlying cultural competence is the conviction that services tailored to culture would be more inviting, would encourage minorities to get treatment, and would improve their outcome once in treatment. Cultural competence represents a fundamental shift in ethnic and race relations ( Sue et al., 1998). The term competence places the responsibility on mental health services organizations and practitioners - most of whom are white ( Peterson et al., 1996) - and challenges them to deliver culturally appropriate services. Yet the participation of consumers, families, and communities helping service systems design and carry out culturally appropriate services is also essential ( Chapter 7).

Many models of cultural competence have been proposed. One of the most frequently cited models was developed in the context of care for children and adolescents with serious emotional disturbance ( Cross et al., 1989). At the Federal level, efforts have begun to operationalize cultural competence for applied behavioral healthcare settings ( CMHS, 2000). Though these and many other models have been proposed, few if any have been subject to empirical test. No empirical data are yet available as to what the key ingredients of cultural competence are and what influence, if any, they have on clinical outcomes for racial and ethnic minorities e.g., Sue & Zane, 1987; Ramirez, 1991; Pedersen & Ivey, 1993; Ridley et al., 1994; Lopez, 1997; Szapocznik et al. 1997; Falicov, 1998; Koss-Chioino & Vargas, 1999; Sue & Sue, 1999. A common theme across models of cultural competence, however, is that they make treatment effectiveness for a culturally diverse clientele the responsibility of the system, not of the people seeking treatment.

Later chapters of this Supplement describe the findings to date in relation to each ethnic or racial group. The main point is that cultural competence is more than the sum of its parts: It is a broad-based approach to transform the organization and delivery of all mental health services to meet the diverse needs of all patients.

Medications and Minorities

The introductory chapter of this Supplement emphasized the overall genetic similarities across ethnic groups and noted that while there may be some genetic polymorphisms that show mean differences between groups, these variations cannot be used to distinguish one population from another. Observed group differences are outweighed by shared genetic variation and may be correlates of lifestyle rather than genetic factors ( Paabo, 2001). For example, researchers are finding some racial and ethnic differences in response to a heart medication ( Exner et al., 2001) that appear to reflect both genetic and environmental factors. It is nevertheless reasonable to assume that medications for mental disorders, in the absence of data to the contrary, are as effective for racial and ethnic minority groups as they are for whites.

Therefore, this Supplement encourages people with mental illness, regardless of race or ethnicity, to take advantage of scientific advances and seek effective pharmacological treatments for mental illness. As part of the standard practice of delivering medicine, clinicians always need to individualize therapies according to the age, gender, culture, ethnicity, and other life circumstances of the patient.

There is a growing body of research on subtle genetic differences in how medications are metabolized across certain ethnic populations. Similarly, this body of research also focuses on how lifestyles that are more common to a given ethnic group affect drug metabolism. Lifestyle factors include diet, rates of smoking, alcohol consumption, and use of alternative or complementary treatments. These factors can interact with drugs to alter their safety or effectiveness.

The relatively new field known as ethnopsychopharmacology investigates ethnic variations that affect medication dosing and other aspects of pharmacology. Most research in this field has focused on gene polymorphisms (DNA variations) affecting drug metabolizing enzymes. After drugs are taken by mouth, they enter the blood and are circulated to the liver, where they are metabolized by enzymes (proteins encoded by genes). Certain genetic variations affecting the functions of these enzymes are more common to particular racial or ethnic groups. The variations can affect the pace of drug metabolism: A faster rate of metabolism leaves less drug in the circulation, whereas a slower rate allows more drug to be recirculated to other parts of the body. For example, African Americans and Asians are, on average, more likely than whites to be slow metabolizers of several medications for psychosis and depression Lin et al., 1997). Clinicians who are unaware of these differences may inadvertently prescribe doses that are too high for minority patients by giving them the dose normally prescribed for whites. This would lead to more medication side effects, patient nonadherence, and possibly greater risk of long-term, severe side effects such as tardive dyskinesia (Lin et al., 1997; Lin & Cheung, 1999.

A key point is that this area of research looks for frequency differences across populations, rather than between individuals. For example, one research study reported on population frequencies for a polymorphism linked to the breakdown of neurotransmitters. It found the particular polymorphism in 15 to 31 percent of East Asians, compared with 7 to 40 percent of Africans, and 33 to 62 percent of Europeans and Southwest Asians ( Palmatier et al., 1999). It is important to note that these differences become apparent across populations, but do not apply to an individual seeking treatment (unless the clinician has specific knowledge about that person's genetic makeup, or genotype, or their medication blood levels). The concern about applying research regarding ethnically based differences in population frequencies of gene polymorphisms is that it will lead to stereotyping and racial profiling of individuals based on their physical appearance ( Schwartz, 2001). For any individual, genetic variation in response to medications cannot be inferred from racial or ethnic group membership alone.

Racism, Discrimination, and Mental Health

Since its inception, America has struggled with its handling of matters related to race, ethnicity, and immigration. The histories of each racial and ethnic minority group attest to long periods of legalized discrimination - and more subtle forms of discrimination - within U.S. borders ( Takaki, 1993). Ancestors of many of today's African Americans were forcibly brought to the United States as slaves. The Indian Removal Act of 1830 forced American Indians off their land and onto reservations in remote areas of the country that lacked natural resources and economic opportunities. The Chinese Exclusion Act of 1882 barred immigration from China to the U.S. and denied citizenship to Chinese Americans until it was repealed in 1952. Over 100,000 Japanese Americans were unconstitutionally incarcerated during World War II, yet none was ever shown to be disloyal. Many Mexican Americans, Puerto Ricans, and Pacific Islanders became U.S. citizens through conquest, not choice. Although racial and ethnic minorities cannot lay claim to being the sole recipients of maltreatment in the United States, legally sanctioned discrimination and exclusion of racial and ethnic minorities have been the rule, rather than the exception, for much of the history of this country. Each of the later chapters of this Supplement describes some of the key historical events that helped shape the contemporary mental health status of each group.

Racism and discrimination are umbrella terms referring to beliefs, attitudes, and practices that denigrate individuals or groups because of phenotypic characteristics (e.g., skin color and facial features) or ethnic group affiliation. Despite improvements over the last three decades, research continues to document racial discrimination in housing rentals and sales ( Yinger, 1995) and in hiring practices ( Kirschenman & Neckerman, 1991). Racism and discrimination also have been documented in the administration of medical care. They are manifest, for example, in fewer diagnostic and treatment procedures for African Americans versus whites Giles et al., 1995; Shiefer et al., 2000. More generally, racism and discrimination take forms from demeaning daily insults to more severe events, such as hate crimes and other violence ( Krieger et al., 1999). Racism and discrimination can be perpetrated by institutions or individuals, acting intentionally or unintentionally.

Public attitudes underlying discriminatory practices have been studied in several national surveys conducted over many decades. One of the most respected and nationally representative surveys is the General Social Survey, which in 1990 found that a significant percentage of whites held disparaging stereotypes of African Americans, Hispanics, and Asians. The most extreme findings were that 40 to 56 percent of whites endorsed the view that African Americans and Hispanics "prefer to live off welfare" and "are prone to violence" ( Davis & Smith, 1990).

Minority groups commonly report experiences with racism and discrimination, and they consider these experiences to be stressful ( Clark et al., 1999). In a national probability sample of minority groups and whites, African Americans and Hispanic Americans reported experiencing higher overall levels of global stress than did whites ( Williams, 2000). The differences were greatest for two specific types: financial stress and stress from racial bias. Asian Americans also reported higher overall levels of stress and higher levels of stress from racial bias, but sampling methods did not permit statistical comparisons with other groups. American Indians and Alaska Natives were not studied ( Williams, 2000).

Recent studies link the experience of racism to poorer mental and physical health. For example, racial inequalities may be the primary cause of differences in reported quality of life between African Americans and whites ( Hughes & Thomas, 1998). Experiences of racism have been linked with hypertension among African Americans Krieger & Sidney, 1996; Krieger et al., 1999. A study of African Americans found perceived discrimination to be associated with psychological distress, lower well-being, self-reported ill health, and number of days confined to bed Williams et al., 1997; Ren et al., 1999.

A recent, nationally representative telephone survey looked more closely at two overall types of racism, their prevalence, and how they may differentially affect mental health ( Kessler et al., 1999). One type of racism was termed "major discrimination" in reference to dramatic events like being "hassled by police" or "fired from a job." This form of discrimination was reported with a lifetime prevalence of 50 percent of African Americans, in contrast to 31 percent of whites. Major discrimination was associated with psychological distress and major depression in both groups. The other form of discrimination, termed "day-to-day perceived discrimination," was reported to be experienced "often" by almost 25 percent of African Americans and only 3 percent of whites. This form of discrimination was related to the development of distress and diagnoses of generalized anxiety and depression in African Americans and whites. The magnitude of the association between these two forms of discrimination and poorer mental health was similar to other commonly studied stressful life events, such as death of a loved one, divorce, or job loss.

While this line of research is largely focused on African Americans, there are a few studies of racism's impact on other racial and ethnic minorities. Perceived discrimination was linked to symptoms of depression in a large sample of 5,000 children of Asian, Latin American, and Caribbean immigrants ( Rumbaut, 1994). Two recent studies found that perceived discrimination was highly related to depressive symptoms among adults of Mexican origin ( Finch et al., 2000) and among Asians ( Noh et al., 1999).

In summary, the findings indicate that racism and discrimination are clearly stressful events ( see also Clark et al., 1999). Racism and discrimination adversely affect health and mental health, and they place minorities at risk for mental disorders such as depression and anxiety. Whether racism and discrimination can by themselves cause these disorders is less clear, yet deserves research attention.

These and related findings have prompted researchers to ask how racism may jeopardize the mental health of minorities. Three general ways are proposed:

1. Racial stereotypes and negative images can be internalized, denigrating individuals' self-worth and adversely affecting their social and psychological functioning;

2. Racism and discrimination by societal institutions have resulted in minorities' lower socioeconomic status and poorer living conditions in which poverty, crime, and violence are persistent stressors that can affect mental health (see next section); and

3. Racism and discrimination are stressful events that can directly lead to psychological distress and physiological changes affecting mental health ( Williams & Williams-Morris, 2000).

Poverty, Marginal Neighborhoods, and Community Violence

Poverty disproportionately affects racial and ethnic minorities. The overall rate of poverty in the United States, 12 percent in 1999, masks great variation. While 8 percent of whites are poor, rates are much higher among racial and ethnic minorities: 11 percent of Asian Americans and Pacific Islanders, 23 percent of Hispanic Americans, 24 percent of African Americans, and 26 percent of American Indians and Alaska Natives ( U. S. Census Bureau, 1999). Measured another way, the per capita income for racial and ethnic minority groups is much lower than that for whites ( Table 2-2).

Table 2-2 gives Per Capita Income averages by ethnicity in 1999.

For centuries, it has been known that people living in poverty, whatever their race or ethnicity, have the poorest overall health see reviews by Krieger, 1993; Adler et al., 1994; Yen & Syme, 1999. It comes as no surprise then that poverty is also linked to poorer mental health ( Adler et al., 1994). Studies have consistently shown that people in the lowest strata of income, education, and occupation (known as socioeconomic status, or SES) are about two to three times more likely than those in the highest strata to have a mental disorder Holzer et al., 1986; Regier et al., 1993; Muntaner et al., 1998. They also are more likely to have higher levels of psychological distress ( Eaton & Muntaner, 1999).

Poverty in the United States has become concentrated in urban areas ( Herbers, 1986). Poor neighborhoods have few resources and suffer from considerable distress and disadvantage in terms of high unemployment rates, homelessness, substance abuse, and crime. A disadvantaged community marked by economic and social flux, high turnover of residents, and low levels of supervision of teenagers and young adults creates an environment conducive to violence. Young racial and ethnic minority men from such environments are often perceived as being especially prone to violent behavior, and indeed they are disproportionately arrested for violent crimes. However, the recent Surgeon General's Report on Youth Violence cites self-reports of youth from both majority and minority populations that indicate that differences in violent acts committed may not be as large as arrest records suggest. The Report on Youth Violence concludes that race and ethnicity, considered in isolation from other life circumstances, shed little light on a given child's or adolescent's propensity for engaging in violence ( DHHS, 2001).

How is poverty so clearly related to poorer mental health? This question can be answered in two ways. People who are poor are more likely to be exposed to stressful social environments (e.g., violence and unemployment) and to be cushioned less by social or material resources Dohrenwend, 1973; McLeod & Kessler, 1990. In this way, poverty among whites and nonwhites is a risk factor for poor mental health. Also, having a mental disorder, such as schizophrenia, takes such a toll on individual functioning and productivity that it can lead to poverty. In this way, poverty is a consequence of mental illness ( Dohrenwend et al., 1992). Both are plausible explanations for the robust relationship between poverty and mental illness ( DHHS, 1999).

Scholars have debated whether low SES alone can explain cultural differences in health or health care utilization e.g. Lillie-Blanton et al., 1996; Williams, 1996; Stolley, 1999, 2000; LaVeist, 2000; Krieger, 2000. Most scholars agree that poverty and socioeconomic status do play a strong role, but the question is whether they play an exclusive role. The answer to this question is "no." Evidence contained within this Supplement is clearly contrary to the simple assertion that lower SES by itself explains ethnic and racial disparities. An excellent example is presented in Chapter 6. Mexican American immigrants to the United States, although quite impoverished, enjoy excellent mental health ( Vega et al., 1998). In this study, immigrants' culture was interpreted as protecting them against the impact of poverty. In other studies of African Americans and Hispanics (cited in Chapters 3 and 6), more generous mental health coverage for minorities did not eliminate disparities in their utilization of mental health services. Minorities of the same SES as whites still used fewer mental health services, despite good access.

The debate separates poverty from other factors that might influence the outcome - such as experiences with racism, help-seeking behavior, or attitudes - as if they were isolated or independent from one another. In fact, poverty is caused in part by a historical legacy of racism and discrimination against minorities. And minority groups have developed coping skills to help them endure generations of poverty. In other words, poverty and other factors are overlapping and interdependent for different ethnic groups and different individuals. As but one example, the experience of poverty for immigrants who previously had been wealthy in their homeland cannot be equated with the experience of poverty for immigrants coming from economically disadvantaged backgrounds.

An important caveat in reviewing this evidence is that while most researchers measure and control for SES they do not carefully define and measure aspects of culture. Many studies report the ethnic or racial backgrounds of study participants as a shorthand for their culture, without systematically examining more specific information about their living circumstances, social class, attitudes, beliefs, and behavior. In the future, defining and measuring different aspects of culture will strengthen our understanding ethnic differences that occur, beyond those explained by poverty and socioeconomic status.

Demographic Trends

The United States is undergoing a major demographic transformation in racial and ethnic composition of its population. In 1990, 23 percent of U.S. adults and 31 percent of children were from racial and ethnic minority groups ( Hollmann, 1993). In 25 years, it is projected that about 40 percent of adults and 48 percent of children will be from racial and ethnic minority groups U.S. Census Bureau, 2000; Lewit & Baker, 1994. While these changes bring with them the enormous richness of diverse cultures, significant changes are needed in the mental health system to meet the associated challenges, a topic addressed in Chapter 7.

Diversity within Racial and Ethnic Groups

The four most recognized racial and ethnic minority groups are themselves quite diverse. For instance, Asian Americans and Pacific Islanders include at least 43 separate subgroups who speak over 100 languages. Hispanics are of Mexican, Puerto Rican, Cuban, Central and South American, or other Hispanic heritage (U.S. Census Bureau, 2000). American Indian/Alaskan Natives consist of more than 500 tribes with different cultural traditions, languages, and ancestry. Even among African Americans, diversity has recently increased as black immigrants arrive from the Caribbean, South America, and Africa. Some members of these subgroups have largely acculturated or assimilated into mainstream U.S. culture, whereas others speak English with difficulty and interact almost exclusively with members of their own ethnic group.

Growth Rates

African Americans had long been the country's largest ethnic minority group. However, over the past decade, they have grown by just 13 percent to 34.7 million people. In contrast, higher birth and immigration rates led Hispanics to grow by 56 percent, to 35.3 million people, while the whites grew just 1 percent from 209 million to 212 million. According to 2000 census figures, Hispanics have replaced African Americans as the second largest ethnic group after whites ( U.S. Census Bureau, 2001).

Hispanics grew faster than any other ethnic minority group in terms of the actual number of individuals and the rate of population growth. The group with the second highest rate of population growth was Asian Americans, who in the 2000 census were counted separately from Native Hawaiians and Other Pacific Islanders. Because of immigration, the Asian American population grew 40.7 percent to 10.6 million people, and this growth is projected to continue throughout the century ( U.S. Census Bureau, 2001).

American Indians and Alaska Natives surged between 38 and 50 percent over each of the decades from the 1960s through the 1980s. However, during the 1990s, the rate of growth was slightly slower (19%). Even so, the rate is still greater than that for the general population. One factor accounting for this higher-than-average growth rate is an increase in the number of people who now identify themselves as American Indian or Alaska Native. The current size of the American Indian and Alaska Native population is just under 1 percent of the total U.S. population, or about 2.5 million people. This number nearly doubles, however, when including individuals who identify as being American Indian and Alaska Native as well as one or more other races ( U.S. Census Bureau, 2001).

The numbers of ethnic minority children and youth are increasing most rapidly. Between 1995 and 2015, the numbers of black youth are expected to increase by 19 percent, American Indian and Alaska Native youth by 17 percent, Hispanic youth by 59 percent, and Asian and Pacific Islander youth by 74 percent. During the same period, the white youth population is expected to increase by 3 percent ( Snyder & Sickmund, 1999).

Geographic Distribution

Until the 1960s, American Indians, Asian Americans, and Hispanic Americans were geographically isolated. Before then, American Indians lived primarily on reservations to which the government assigned them. Few Asian Americans lived outside California, Hawaii, Washington, and New York City. Latinos resided primarily in the southwestern border States, New York City, and a few midwestern industrial cities ( Harrison & Bennett, 1995).

Today, although they are not evenly distributed, members of each of the four major racial and ethnic minority groups reside throughout the United States. The western States are the most ethnically diverse in the United States, and they are home to many Latinos, Asian Americans, and American Indians. In the Midwest, which is less ethnically diverse, over 85 percent of the population is white, and most of the remainder is black. This proportion has remained relatively unchanged since the 1970s.

Although the Nation as a whole is becoming more ethnically diverse, this diversity remains relatively concentrated in a few States and large metropolitan areas. In general, minorities are more likely than whites to live in urban areas. In 1997, 88 percent of minorities lived in cities and their surrounding areas, compared to 77 percent of whites. American Indians/Alaska Natives and African Americans are the only minority groups with any considerable rural population. ( U.S. Census Bureau, 1999).

Impact of Immigration Laws

During the last century, U.S. immigration laws alternately closed and opened the doors of immigration to different foreign populations. For example, the 1924 Immigration Act established the National Origins System, which restricted annual immigration from any foreign country to 2 percent of that country's population living in the United States, as counted in the census of 1890. Since most of the foreign-born counted in the 1890 census were from northern and western European countries, the 1924 Immigration Act reinforced patterns of white immigration and staved off immigration from other areas, including Asia, Latin America, and Africa.

Until the 1960s, approximately two-thirds of all legal immigrants to the United States were from Europe and Canada. The Immigration Act of 1965 replaced the National Origins System and allowed an annual immigration quota of 20,000 individuals from each country in the Eastern Hemisphere. The Act also gave preference to individuals in certain occupations. The effect was striking: Immigration from Asia skyrocketed from 6 percent of all immigrants in the 1950s to 37 percent by the 1980s. Yet another provision of the Act supported family reunification and gave preference to people with relatives in the United States, one factor behind the growth in immigration from Mexico and other Latin American countries ( U.S. Census Bureau, 1999). Over this same period of time, the percentage of immigrants from Europe and Canada fell from 68 percent to 12 percent ( U.S. Immigration and Naturalization Service, 1999).

In the past 20 years, immigration has led to a shift in the racial and ethnic composition of the United States not witnessed since the late 17th century, when black slaves became part of the labor force in the South ( Muller, 1993). Though this wave of immigration is similar to the surge of immigration that occurred in the early part of this century, a critical difference is in the countries of origin. In the early 1900s, immigrants primarily came from Europe and Canada, while recent immigration is primarily from Asian and Latin American countries.

Overall, the racial and ethnic makeup of the United States has changed more rapidly since 1965 than during any other period in history. The reform in immigration policy in 1965, the increase in self-identification by ethnic minorities, and the slowing of the country's birth rates, especially among non-Hispanic white Americans, have all led to an increasing, and increasingly diverse, racial and ethnic minority population in the United States.

Conclusions

1. Culture influences many aspects of mental illness, including how patients from a given culture express and manifest their symptoms, their style of coping, their family and community supports, and their willingness to seek treatment. Likewise, the cultures of the clinician and the service system influence diagnosis, treatment, and service delivery. Cultural and social influences are not the only determinants of mental illness and patterns of service utilization for racial and ethnic minorities, but they do play important roles.

2. Mental disorders are highly prevalent across all populations, regardless of race or ethnicity. Cultural and social factors contribute to the causation of mental illness, yet that contribution varies by disorder. Mental illness is considered the product of a complex interaction among biological, psychological, social, and cultural factors. The role of any one of these major factors can be stronger or weaker depending on the specific disorder.

3. Within the United States, overall rates of mental disorders for most minority groups are largely similar to those for whites. This general conclusion does not apply to vulnerable, high-need sub-groups, who have higher rates and are often not captured in community surveys. The overall rates of mental disorder for many smaller racial and ethnic groups, most notably American Indians, Alaska Natives, Asian Americans and Pacific Islanders are not sufficiently studied to permit definitive conclusions.

4. Ethnic and racial minorities in the United States face a social and economic environment of inequality that includes greater exposure to racism and discrimination, violence, and poverty, all of which take a toll on mental health. Living in poverty has the most measurable impact on rates of mental illness. People in the lowest stratum of income, education, and occupation are about two to three times more likely than those in the highest stratum to have a mental disorder.

5. Racism and discrimination are stressful events that adversely affect health and mental health. They place minorities at risk for mental disorders such as depression and anxiety. Whether racism and discrimination can by themselves cause these disorders is less clear, yet deserves research attention.

6. Stigma discourages major segments of the population, majority and minority alike, from seeking help. Attitudes toward mental illness held by minorities are as unfavorable, or even more unfavorable, than attitudes held by whites.

7. Mistrust of mental health services is an important reason deterring minorities from seeking treatment. Their concerns are reinforced by evidence, both direct and indirect, of clinician bias and stereotyping. The extent to which clinician bias and stereotyping explain disparities in mental health services is not known.

8. The cultures of ethnic and racial minorities alter the types of mental health services they use. Cultural misunderstandings or communication problems between patients and clinicians may prevent minorities from using services and receiving appropriate care.

References

1. American Psychiatric Association. (1994)Diagnostic and statistical manual of mental disorders (4th ed.), Washington,, DC. Author.

2. Blazer, D. G., Hybels, C. F., Simonsick, E. G., et al. (2000) Marked differences in antidepressant use by race in an elderly community sample: 1986-1996American Journal of Psychiatry. 157, [ PubMed: 10873916 ]

3. Eaton, W. W., & Muntaner, C. (1999)In A. V. Horwitz & T. K. Scheid (Eds.), A handbook for the study of mental health: Social contexts, theories, and systems (pp. 259-283)., New York Cambridge University Press.

4. Falicov, C. J. (1998) Latino families in therapy: A guide to multicultural practice. , New York Guilford Press.

5. Hurh, W. M., & Kim, K. C. (1988)Uprooting and adjustment: A sociological study of Korean immigrants' mental health (Final report to the National Institute of Mental Health), Macomb, IL. Western Illinois University, Department of Sociology and Anthropology.

6. Jenkins, J. H. (1993) Ethnopsychiatry (pp. 203-221)., Albany, NY. State University of New York Press.

7. Kleinman, A. (1988) Rethinking psychiatry: From cultural category to personal experience. , New York Free Press.

8. LaVeist, T. A., Diala, C., & Jarrett, N. C. (2000) Minority health in America (pp. 194-208)., Baltimore, MD. Johns Hopkins University Press.

9. Levit, L., & Lundy, J. (1998)Trends and indicators in the changing health care market place: Chartbook, Menlo Park, CA. Henry J. Kaiser Family Foundation.

10. Lopez, S. R., Nelson, K. A., Polo, J. A., Jenkins, J., Karno, M., & Snyder, K. (1998, August) Family warmth and the course of schizophrenia of Mexican Americans and Anglo Americans. Paper presented at the International Congress of Applied Psychology, San Francisco, CA.

11. Manderscheid, R. W., & Henderson, M. J., Eds. (1999)Mental Health, United States: 1998, Rockville, MD. Center for Mental Health Services.

12. Muller, T. (1993) Immigrants and the American city. , New York New York University Press.

13. National Institutes of Health. Strategic research plan to reduce and ultimately eliminate health disparities, fiscal years 2002-2006. Draft, October 6, 2000. (2000)

14. Neal-Barnett, A. M., & Smith, J. (1997) Cultural issues in the treatment of anxiety (pp. 154-174)., New York Guilford Press.

15. Portes, A., & Rumbaut, R. G. (1990) Immigrant America: A portrait. , Berkeley, CA. University of California Press.

16. Prudhomme, C., & Musto, D. F. (1973)In C. V. Willie, B. M. Kramer, & B. S. Brown (Eds.), Racism and mental health (pp. 25-57)., Pittsburgh,, PA. University of Pittsburgh Press.

17. Ramirez, M. (1991) Psychotherapy and counseling with minorities: A cognitive approach to individual and cultural differences. , New York Pergamon Press.

18. Rumbaut, R. G. (1989) Portraits, patterns, and predictors of the refugee adaptation process In D.W. Haines (Ed.) Refugees as immigrants: Cambodians, Laotians and Vietnamese in America (pp. 138-182)., Totowa, NG. Rowman and Littlefield.

19. Scholle, S., & Kelleher, K. (1998) Managed care for seriously emotionally disturbed children. Paper presented at a Substance Abuse and Mental Health Services Administration Managed Care Seminar, Washington, DC.

20. Sue, D. W., & Sue, D. (1999) Counseling the culturally different: Theory and practice (3rd edition). , New York Wiley.

21. Sue, S., Kurasaki, K. S., & Srinivasan, S. (1998)In P. C. Kendall, J. N. Butcher, & G. N. Holmbeck (Eds.). Handbook of research methods in clinical psychology (2nd ed., pp. 51-71)., New York Wiley.

22. Takeuchi, D. T., & Uehara, E. S. (1996) In. B. L. Levin & J. Petrila (Eds.), Mental health services: A public health perspective (pp. 63-80)., New York Oxford University Press.

23. U.S. Department of Health and Human Services. (2000) Healthy People 2010 (2nd ed.).With Understanding and improving health and Objectives for improving health (2 vols.), Washington, DC.

24. Weisz, J. R., McCarty, C. A., Eastman, K.L., Chaiyasit, W., Suwanlert, S. (1997)In S. S. Luthar, J. A. Burack, D. Cicchetti, & J. R. Weisz (Eds.), Developmental psychopathology: Perspectives on adjustment, risk, and disorder (pp. 568-592)., Cambridge, England. Cambridge University Press.

25. Williams, D. R. (2000)In C.Hogue, M. Hargraves, & K. Scott-Collins (Eds.). Minority health in America (pp. 209-243)., Baltimore Johns Hopkins University Press.

26. World Health Organization. (1992)International statistical classification of diseases and related health problems (10th revision, ICD-10), Geneva.

1

In medicine, each disease or disorder is considered mutally exclusive from another ( WHO, 1992). Each disorder is presumed, but rarely proven, to have unique pathophysiology ( Scadding, 1996).

2

In very general terms, most other healing systems throughout history conceived of sickness and health in the context of understanding relations of human beings to the cosmos, including planets, stars, mountains, rivers, deities, spirits, and ancestors ( Porter 1997).

3

Defined in the next section of this chapter as "beliefs, attitudes, and practices that denigrate individuals or groups because of phenotypic characteristics or ethnic group affilliation...[which] can be perpetrated by institutions or individuals, acting intentionally or unintentionally."

4

Researchers may have collected this information but did not report it in their published studies.

5

One study of attention-deficit/hyperactivity disorder (AD/HD), the NIMH Multimodal Treatment Study of AD/HD, plans to conduct ethnic-specific analyses.

6

Perceived discrimination" is the term used by researchers in reference to the self-reports of individuals about being the target of discrimination or racism. The term is not meant to imply that racism did not take place.

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Chapter 2 Culture Counts: The Influence of Culture and Society on Mental Health

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To better understand what happens inside the clinical setting, this chapter looks outside. It reveals the diverse effects of culture and society on mental health, mental illness, and mental health services. This understanding is key to developing mental health services that are more responsive to the cultural and social contexts of racial and ethnic minorities.

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Poor African Americans distrust their medical examiners more than middle-class African Americans, but both trust their doctors less than middle-class white men (p 119 – 120).

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Abstract

Addressing differences in social class is critical to an examination of racial disparities in health care. Low socioeconomic status is an important determinant of access to health care.

Results from a qualitative, in-depth interview study of 60 African Americans who had one or more chronic illnesses found that low-income respondents expressed much greater dissatisfaction with health care than did middle-income respondents.

Low socioeconomic status has potentially deadly consequences for several reasons: its associations with other determinants of health status, its relationship to health insurance or the absence thereof, and the constraints on care at sites serving people who have low incomes.

Although there has recently been a growing tendency to disentangle ethnicity and socioeconomic status (SES) in studies of the health of African Americans 1, 2 (Thomas Denberg, written communication, January 2002), relatively few studies have examined African Americans' perceptions of health care, and even fewer have examined those perceptions in relation to SES. 3-5 Various authors have called attention to the simplistic ways in which SES is often used, 6-8 and the relative infrequency of studies of class-based differences in health within ethnic groups as opposed to studies that compare ethnic groups (T. Denberg, written communication, January 2002).

SES is intimately associated with racism, which has restricted socioeconomic attainment for members of minority groups. 9 Williams observes that SES is not just a confounder of racial differences in health but part of the causal pathway by which race affects health. 9 He also notes that race is an antecedent and determinant of SES and that racial differences in SES reflect, in part, the successful implementation of discriminatory policies premised on the inferiority of certain racial groups.

A recent Institute of Medicine report 6 documents the many studies that have demonstrated widespread racism in health care. One manifestation of racism is the finding that Whites are more likely than African Americans to receive a broad range of specific medical procedures, 10-12 and that African Americans are more likely to receive undesirable interventions such as amputations. 13-15 Research that indicates that physicians tend to perceive African Americans and members of low- and middle-SES groups more negatively than they do Whites and upper-SES patients 16 illustrates the effects of racism on the delivery of care.

National opinion surveys indicate that African Americans are more likely than Whites to rate the health services in their communities as fair or poor. 17 Blendon et al. found many more negative attitudes expressed by African Americans overall toward the nation's health and social institutions, and they suggest that these attitudes are at least partially grounded in the circumstances and experiences that fail to eliminate historical racial disparities. 17

Although life expectancy for African Americans has more than doubled during the 20th century, African Americans continue to bear a higher burden of death, disease, and disability than Whites. 18 African Americans have an overall death rate that is 1.6 times higher than that of the White population, and elevated mortality rates for African Americans compared with the White population exist for 8 of the 10 leading causes of death. 9 Moreover, health care facilities serving the poor in the segregated inner city are fraught with problems of decreasing and inferior services. 19 Dwindling health care resources for low-income people have provoked concern on the part of policy analysts without any significant action being taken. 20, 21

Low SES is an important determinant of access to health care. Persons with low incomes are more likely to be Medicaid recipients or uninsured, have poor-quality health care, and seek health care less often; when they do seek health care, it is more likely to be for an emergency. 22-26 Blendon et al. 27 found that 1 in 11 African Americans reported not receiving health care for economic reasons compared with 1 in 20 whites, and that 1 in 4 African Americans who reported that they had a chronic or serious illness did not have an ambulatory visit in the year preceding the survey, compared with 1 in 6 White persons who were surveyed. Not only were African Americans less likely to be covered by a private insurance carrier, they were less likely to have any insurance. In a separate study, 17 they found that 1 in 4 African Americans reported problems paying for medical bills, including paying for physicians, hospitals, and prescription drugs.

The question has been raised of whether financial resources may be more relevant to policy interventions than considerations related to race and ethnicity. 28 But ethnicity, or cultural background, is extremely important as well. Expressed through interpersonal interactions, culture is constantly redefined and renegotiated, and it must be interpreted within the context of individual history, family constellation, and SES. 8 Ethnicity is not simply a demographic variable. Without acknowledging both cultural background and social class, analyses of specific cultural groups are incomplete and may overlook important factors that profoundly affect people's health. The health care experiences of African Americans are affected by their awareness of the long history of racism in American health care 29 that resulted in such infamous episodes as the Tuskegee experiments, 30 the barring of African Americans from entering the medical profession until recently, 31 and various other overt expressions of racism. The cultural history of health care for African Americans in the United States is thus a critical factor in analyzing the current state of health care delivery.

In this article, we report on findings from a study of middle-income and low-income African Americans who had one or more chronic illnesses. The main objective of this analysis was to compare satisfaction with health care by persons categorized as low income with those categorized as middle income. This analysis yielded distinct differences between how middle-income and low-income African Americans in this study viewed their health care.

METHODS

Our findings are based on 2 large qualitative studies that examined the same questions about the daily management of chronic illness but included different age groups. They are combined here to illustrate the issues African Americans experience with health care. Respondents were African Americans aged 21 to 63 who had one or more chronic illnesses. The most common illnesses were diabetes mellitus, asthma, and heart disease or hypertension. The total number of African Americans included in the study was 111. Persons who were Medicare recipients were omitted from this analysis because Medicare enables low-income people to seek care in sectors of the health care system that would otherwise be unavailable to them, which leads to another level of analysis that is beyond the scope of this article. The total number of African Americans discussed here, therefore, is 60.

Respondents were recruited from a variety of sources in 2 urban counties in California between June 1994 and June 2001. This was primarily a community study, with few respondents being recruited directly from clinics: 39% from flyers, 32% from contacts in social service agencies, 15% from clinics and home care services, 10% from religious organizations, and 4% from participant referrals. The criterion for entry into the studies was the presence of one or more chronic illnesses. The sample reflected a range of illness severity from mild to severe.

In addition to African Americans, 3 other ethnic groups were studied: Latinos, Filipino Americans, and Cambodian Americans. They are omitted from this analysis in order to focus on patterns particular to African Americans.

Following key tenets of the in-depth interview approach, 32-34 all respondents were interviewed 3 times in a 1-year period by the second author, who was of the same ethnicity as the respondents. Gender-based distrust was not observed among men, all of whom knew they would be interviewed by a woman prior to being interviewed. Interviews were semistructured with many open-ended questions, lasted for approximately 1 to 2 hours, and focused on respondents' health, experiences with their illnesses, economic situation, and use of and access to health care. Each interview was tape-recorded and transcribed verbatim. All but 2 respondents were born in the United States, and all were interviewed in English.

The first step in the analysis for this article was to divide the data into low-income and middle-income groups. Krieger and colleagues 7 propose a multifaceted analysis of social class for public health research that includes individual, household, neighborhood, and poverty-area levels, and this approach was adapted to this primarily qualitative study. In differentiating persons categorized as low income from those categorized as middle income, we examined the following categories: income history, occupation and employment history, medical insurance history and current status, and living arrangements. The socioeconomic data were also analyzed by age and gender.

Each group was analyzed separately, and cross-group comparisons were then made. A specific data analytic procedure was followed. Core categories that reappeared in the data repeatedly (e.g., health insurance) were identified and compared with other emergent categories. Codes were developed, generated from meanings in the data. The entire data set was coded for specific topics with NUD*IST (QSR International Pty Ltd, Melbourne, Australia), a data-sorting software program, which resulted in over 100 discrete codes.

A case-by-case narrative analysis was also conducted. Narratives are the stories people tell about their experiences; they provide important insights into their perspectives on those experiences. Narrative analysis, which emphasizes the topics that dominate respondents' reports and the way they are addressed, leads to the identification of themes across the data set. For this analysis, transcripts were sorted into privately insured, Medicaid, and uninsured, and then analyzed by group. The coded data and the narrative analysis yielded the same themes regarding satisfaction with health care and served as a cross-check on each other.

RESULTS

Demographics

The 60 respondents ranged in age from 21 to 63. Respondents reflected diversity in SES, ranging from those who were middle class, worked as professionals, were home owners, and had medical insurance to those who were poor and unemployed, lived in public housing, and had no medical insurance. All respondents were living in the community at the time of the study. See Table 1 ▶ for demographic characteristics.

TABLE 1

Private (n = 28)

Medicaid (n = 18)

Uninsured (n = 14)

Other a

9

32.1

6

33.3

2

14.3

Other a

1

3.6

0

0

1

7.1

Relationship Between SES and Insurance Status

Using selected markers of SES, 7 we divided the sample into low income and middle income. Of the total sample of 60 persons, 32 were categorized as low income and 28 as middle income. Persons categorized as low income had a history of unsteady income, with significant periods of unemployment and public assistance that often carried into the present. Middle-income persons had long, steady work histories, a concomitant steady income, and had seldom or never received public assistance.

Type of housing was also indicative of income level. In this study, neighborhood or poverty area was not a useful descriptor of income level, but subsidized housing was. Persons categorized as low income most often lived in subsidized housing, and none were homeowners. In contrast, middle-income persons were often homeowners, and none lived in subsidized housing. Eighty percent of respondents lived in neighborhoods that were primarily African American, and 20% lived in integrated neighborhoods.

In this study, SES translated directly into health insurance status: persons categorized as low income had a history of being uninsured or Medicaid recipients, while middle-income persons reported a history of private insurance. At the time of the study, all those who were currently uninsured or who were Medicaid recipients met the other criteria for categorization as low income; that is, there were no uninsured people in this study who were experiencing a temporary economic setback. Twenty-eight were privately insured, 18 Medicaid recipients, and 14 completely uninsured.

The type of insurance that respondents had dictated the sector of the health care system in which they were seen. At least 15 different sites were used by the 60 respondents. These sites encompassed a wide spectrum of health care delivery. Middle-income persons went to private physicians or had health plans that provided comprehensive care through a health maintenance organization (HMO). Persons who had Medicaid coverage were seen primarily in hospital low-income clinics. Those who were completely uninsured primarily used emergency rooms and free clinics.

SES and Perceptions of Health Care

Level of satisfaction with health care was strongly related to the sector of the health care system in which people were seen. The primary finding to emerge from this research was that low-income respondents reported higher levels of dissatisfaction with health care than middle-income respondents. No differences were found in responses relative to respondent age, however.

Middle-income persons received their health care through private practices and HMOs. They seldom complained about the sector of the health care system in which they were seen. For example, a 49-year-old woman who was an administrator in a university had high blood pressure as well as lifelong respiratory and vision problems. She said, "I've always had good medical care. They like to experiment, and I've never minded being experimented on. So if they say, 'Just to be on the safe side, let's make sure it's not something,' I've never minded that."

When middle-income respondents did complain about the sector of the health care system in which they were seen, their complaints were usually mild. Another woman, a 40-year-old loan specialist who had asthma, upon being given a new physician in her HMO, said, "He's the new doctor, he probably doesn't have any patients, I hadn't been in in a couple of years, so they tossed me over to him. My old doctor, she knows how to treat my asthma. His treatment of my asthma is less aggressive than hers is, so if this keeps up [difficulty breathing without relief], I will request her again."

Middle-income respondents reported lengthy periods of being seen by one physician, sometimes for many years. Almost without exception, middle-income persons reported that their physicians knew about their health problems in detail and reported ongoing dialogues between themselves and their physicians about the management of their chronic illnesses. Reports of satisfaction with health care were widespread. Middle-income respondents reported frequent routine visits. They reported having trust in, and good rapport with, their physician. They believed their physician was knowledgeable and seldom questioned the treatment plans their physician had developed for them.

For example, a 48-year-old man who had diabetes and multiple sclerosis took an early retirement from his civil service job at a nearby naval base. When asked about his relationship with his physician, he said, "He's young, so we talk, and you know, he listens." Rare were comments such as that by a 29-year-old woman who worked in health care administration and had asthma: "Sadly, I've had [a particular HMO] all my life, and I've never really had a primary physician, just because they change so much. So I really cannot say that I've ever had anyone take a real personal interest in my health."

Dissatisfaction With Health Care Among Low-Income Persons

In contrast to middle-income respondents, expressions of dissatisfaction with the health care system by low-income respondents were common. Although middle-income respondents sometimes reported problems with the health care system, such as getting their insurance to cover a medication or approve a treatment, those efforts were never of the same magnitude as for low-income persons, who reported fighting to receive basic health care.

Low-income persons spent much greater portions of time dealing with the health care bureaucracy. They were preoccupied with how to access the system and what to do in an emergency. They reported that dealing with the health care system was an ongoing challenge and drain on their energies. For example, a 42-year-old unemployed woman who had asthma and heart disease said, "If you miss an appointment [arrive late] at their clinic, or with their doctors, you have to wait in line for another appointment. And weeks go by. I be forever not seein' the doctor. Yeah, I be sick, and I be sayin' the only way that you get seen out there be if you dyin'." Few low-income respondents reported routine visits to a physician, in contrast to middleincome respondents, most of whom saw their physicians routinely. Low-income respondents were much more likely to see physicians only when a new health problem arose.

Low-income respondents made frequent comments about the deficiencies of the health care system. All but 8% saw their health care as being second-rate. Despite their sustained efforts to use the system effectively, few reported satisfaction with the overall system. Instead, they reported dissatisfaction with its inefficiency, as one unemployed 40-year-old woman did who had asthma and high blood pressure and had had a stroke: "You know, this is the hospital, and this is where your doctors are. But you can't see your doctor. If you call in there and say, 'Oh, I'm sick,' you have to go into emergency and be there 10 hours instead of just havin' a general practitioner or somethin' up there."

Being turned away was also reported. Another woman, 35 years old, who had asthma and was unemployed, described how she was refused care at a community clinic when she sought urgent care for an episode of asthma: "I said, 'You can't see me?' He says, 'No, you have a doctor, you have to go there.' I'm sayin' 'But I'm sick, and the whole point is you're close, they're farther.' And he wouldn't see me."

One source of dissatisfaction was the rapid turnover of physicians in public hospitals and low-income clinics, which made it difficult for low-income respondents to form relationships with physicians who were treating them. Low-income respondents seldom reported having a regular physician for any length of time. While 15% of low-income respondents reported being followed by a specific physician for a period of a year, the remainder reported not seeing the same physician twice. Those who did see the same physician over a period of time reported more positive feelings about their health care than did those who seldom saw the same physician again. Low-income persons also reported reluctance to become attached to physicians who treated them in these settings because they anticipated that their physician would move on before long and they would be given a new physician.

Low-income respondents who did have a regular physician usually reported high satisfaction with their health care. For example, a 49-year-old unemployed man who had diabetes and heart disease reported how he had finally acquired a regular physician and how it positively affected his attitude: "I didn't have a primary doctor, so they sent me to [clinic]. And I bounce and bounce about. Then I got a good doctor. She works in a private practice too, but she was my doctor. That was the first doctor that I ever had any trust and faith in."

Low-income respondents without regular physicians frequently reported that they felt that physicians were inattentive to their problems. They said that physicians did not listen to them, were condescending, did not explain things thoroughly, and brushed off their queries. Low-income respondents who did not have a regular physician questioned physician knowledge and wondered whether they were receiving good health care.

Those who were patients in public hospitals and clinics where the need to train medical students and residents existed side by side with the need to provide care were especially likely to be doubtful of the knowledge level of practitioners. For example, a 60-year-old former home health aide who had had multiple strokes described her experiences with physicians when she was recovering from a stroke: "I know this one [an attending physician], I call him 'Goofy.' He acts like it. Him and this lady doctor. She has just started internin'. I guess she don't know nothin'." Asked how it made her feel, she responded, "It makes you mad."

Questioning Whether Discrimination Is Present

Although middle-income persons occasionally described specific medical encounters in the past as racist, they rarely reported discrimination by their current physician. An exception was a 63-year-old minister who had diabetes and was on renal dialysis, having been refused a renal transplant. He reflected on his experiences with physicians, acknowledging that while there were numerous physicians who had treated him with concern, there were nevertheless many he had encountered who did not: "They don't expect you to ask questions, and when you do, it frustrates them. They don't know that you and I are different from them. We don't even react the same way. And they haven't thought of how you should be, but you should conform to their way of thinking. And that's not the way it is. And they know nothing about your culture, period. So my confidence is small."

Low-income persons were likely to suspect or identify behavior they viewed as discriminatory or racist. A high level of mistrust was reported by low-income respondents who questioned whether various health encounters were signs of discrimination; these included seeing White people who arrived for appointments after they did being called first, physician reluctance to try different medications or treat a condition more aggressively, indifferent care, and waiting for hours in emergency rooms to be seen. In addition, some respondents reported that they felt they were treated like second-class citizens. For example, a 45-year-old unemployed and uninsured man who had asthma said, "Some of the people there [at the clinic] got a funky attitude. You know, you're payin' for this, somebody payin'. They ain't got a right to treat you like garbage in the first place. That is wrong. Period."

Changes in Health Care Coverage

During the course of the study, 5 people experienced changes in their health care coverage. In all but one case, these changes represented a change for the worse-from private insurance to Medicaid, or from Medicaid to no insurance at all. For example, a 36-year-old unemployed woman who had asthma lost her Medicaid and became uninsured when her son moved out to live with his father. Asked why she switched to a different provider, she said, "I have no Medi-Cal [Medicaid]. My son moved away. So I started going to [county hospital]." Fears about losing Medicaid and becoming uninsured were ever-present. Another woman, 40 years old and unemployed, who had asthma and high blood pressure and had had a stroke, described her struggle to retain her Medicaid: "I'm on appeal. So while I'm on appeal, they haven't taken my Medi-Cal. I'm goin' to fight for my Medi-Cal."

DISCUSSION

Despite recent survey research that suggests that African Americans as a group are relatively well satisfied with the quality of their health care, 35 this research demonstrates that satisfaction is likely to be very different for low-income than for middle-income African Americans, with respect to both quality and quantity of health care. Research has found that satisfaction is linked to a range of factors, including ethnic group, patient education, hospital identity, registration expediency and wait times, perceived competence and attitudes of providers, and resolution of the problem, 36 as well as patients' perception of a relationship of trust, providers' answering of questions and provision of adequate information, and patients' feeling of being involved in decisions about their care. 37

But health insurance status is also important. In one study, those who were privately insured were significantly more satisfied than those who received Medicaid or were uninsured on 8 dimensions of patient satisfaction, 38 and in another study, women of lower SES had poorer primary care experiences than women who had higher incomes. 39

Taken together, the research to date suggests that, although multiple factors affect patient satisfaction, SES is among the most significant because it dictates the sector of the health care system in which people receive care. In this research, while low-income respondents had many complaints about their health care, middle-income respondents had few. This research thus underscores the importance of considering both ethnicity and social class. Lumping together on the basis of SES people who have vastly different experiences of health and health care may be highly misleading.

In conjunction with social class, the health care setting that is used may be a particular focus for questions of satisfaction, as some settings are more highly bureaucratized than others, which may differentially affect patient satisfaction. A recent survey by the Commonwealth Fund 35 found that of the various ethnic groups surveyed, African Americans were the most likely to rely on hospital-based services: 11% relied on emergency rooms and 9% on ambulatory clinics. In our study, low-income respondents also tended to use hospital-based services, and they generally found them wanting. Those who have low incomes may particularly experience problems in access and in the receipt of quality health care, which reinforces their mistrust. The continual aggravation of trying to gain access and get their health care needs met leads them to view themselves as receiving inadequate health care.

Mistrust of the system fostered mistrust of individual practitioners among these respondents. The great frustration experienced by low-income persons in dealing with the health care system apparently affects interactions with individual providers. They view themselves as receiving second-rate health care, and this leads them to be more suspicious of practitioners' skills and intentions. Moreover, long experience of receiving medical treatment in public hospitals and clinics has led to a recognition that they are often being treated by physicians-in-training. They know that such physicians are learning medicine and are often not yet expert at what they do. Accordingly, they question physician knowledge, especially when medications appear to have little effect and they continue to feel ill. But they also hesitate to form bonds with physicians-in-training because, if they are followed by the same physician for a period of months, they know that, given the training system, such physicians will move on and they will be assigned someone new.

Dissatisfaction with health care is a deterrent to seeking care. Because of the difficulties low-income persons often encounter in gaining access to care, they may seek health care only when they feel it is absolutely necessary. When they do seek medical care, it is often for an emergency. Because many do not have any regular health care, they seek medical care through emergency rooms and free drop-in clinics. They do not have consistent follow-up for health problems. 23

In this study, low-income persons were infrequently seen for routine checkups compared with middle-income persons. Routine checkups are a primary teaching vehicle for helping patients to understand and manage their chronic illnesses. Moreover, they facilitate the building of rapport between patient and practitioner. It is therefore not surprising that middle-income persons in this research expressed positive regard for their physicians in most cases, while low-income persons did not.

Class-based discrimination apparently interacts with racism in complex ways. In Ren et al.'s study of African Americans, 4 they found that those with more education were more likely to report racial discrimination than those who were less educated, leading them to hypothesize that more highly educated African Americans may be better able to articulate, rather than internalize, their experiences of discrimination, while those with less education may be bothered by racial discrimination but more adversely affected by the day-to-day struggles of economic hardship.

This study, however, suggests that low-income African Americans are fully able to articulate their experiences of discrimination and that they view not only individual interactions as discriminatory but the overall system in which they receive care as a testament to ongoing discrimination as well. T. Denberg (written communication, January 2002) observes that social stratification is not necessarily restricted to income, education, and occupation, but to how individuals are perceived or valued in society. The comments of respondents in this study suggest that they interpreted their treatment in this system to be an indicator of their low value to society, which resulted in resentment, anger, and efforts to fight for their rights.

Undoubtedly, a significant underlying problem is the structure of the health care delivery system itself. Williams observes, "Institutional policies have played a major role in creating large racial differences in SES. Because of the persistence of the institutional mechanisms underlying racial inequality, there has been remarkable stability in the racial gap in SES over time." 9 The long-term and short-term effects of the US history of underfunding health care programs for the poor are well-known. 6, 19-21, 40, 41 Although there have been improvements in access to health care for children in many states, the recent past has been a particularly stagnant period with respect to implementing new policies to rectify the problems of equity in the health care system for adults.

Persons who have low incomes are at the greatest risk of death and disability. They are seen in the sectors of the health care system that are most seriously underfunded, and consequently their access to routine health care is fraught with limitations. 41 While reducing poverty and altering SES in everyday life may be a challenging long-term process, providing everyone with equal access to quality health care would clearly have a major, and positive, effect in reducing health disparities.

This study had several limitations. The sample size was small and was drawn from one geographic location. Also, the sample was drawn from volunteers who were recruited through a variety of means such as flyers and referrals. Nevertheless, these qualitative findings suggest specific directions for further research. First, the research clearly suggests that studies of satisfaction with health care should encompass both ethnicity and social class. Second, the research suggests that satisfaction comprises a variety of elements, including satisfaction with individual providers, with a particular health care setting, and with discrete components within that setting such as rate of provider turnover. Third, perceptions of racism and discrimination as well as perceived attitudes of providers appear to significantly affect satisfaction level. Finally, satisfaction is apparently heavily influenced by health insurance status.

In conclusion, despite the current emphasis on eliminating health disparities, this goal cannot be achieved without concomitant reductions in disparities by social class, as racial disparities hinge, in part, on social class disparities. Low SES has potentially deadly consequences for several reasons: its associations with other determinants of health status, its relationship to health insurance or the absence thereof, and the constraints on care in sites serving people who have low incomes. To reduce health disparities, it is necessary not only to overcome the present policy inertia and develop universal health insurance that is equitable but also to undermine racist and class biases in the health care system. Only by addressing these 2 different, but interrelated, problems will it be possible to effect changes in the health of low-income African Americans and reduce health disparities.

Acknowledgments

This research was supported by grants from the National Institutes of Health, National Institute on Aging (R37 AG11144 and RO1 AG14152), G. Becker, principal investigator.

Many thanks to Kumiko Shimizu for her work on these projects.

G. Becker designed the research, developed the interview schedule, led the data analysis, and drafted the manuscript. E. Newsom conducted the interviews, participated in data analysis, and edited the manuscript.

Human Participant Protection
The study protocol and consent form were approved by the institutional review board of the University of California, San Francisco.

References

1. Dressler WW. Health in the African American community: accounting for health inequalities. Med Anthropol Q. 1993;7:325-345. [ Google Scholar]

6. Smedley BD, Stith AY, Nelson, AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academy Press; 2002.

29. Byrd WM, Clayton LA. Background paper: racial and ethnic disparities in health care: a background and history. In: Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academy Press; 2002.

30. Jones JH. Bad Blood: The Tuskegee Syphilis Experiment. New York, NY: The Free Press; 1993.

31. Byrd WM, Clayton LA. An American Health Care Dilemma: Race, Medicine, and Health Care in the United States, 1900-2000. New York, NY: Routledge; 2002

32. Hammersley M, Atkinson P. Ethnographic Principles in Practice. London, England: Tavistock; 1986.

33. Rubinstein RL. In-depth interviewing and the structure of its insights. In: Reinharz, S, Rowles G, eds. Qualitative Gerontology. New York, NY: Springer; 1987.

34. Mishler E. Research Interviewing. Cambridge, Mass: Harvard University Press; 1986.

35. Collins KS, Hughes DL, Doty MM, Ives BL, Edwards NJ, Tenney K. Diverse Communities, Common Concerns: Assessing Health Care Quality for Minority Americans: Findings From the Commonwealth Fund 2001 Health Care Quality Survey. New York, NY: Commonwealth Fund; 2002.

41. Altman SH, Reinhardt UE, Shields AE. The Future US Healthcare System: Who Will Care for the Poor and Uninsured? Chicago, Ill: Health Care Administration Press; 1998.

Articles from American Journal of Public Health are provided here courtesy of American Public Health Association

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Socioeconomic Status and Dissatisfaction With Health Care Among Chronically Ill African Americans

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Addressing differences in social class is critical to an examination of racial disparities in health care. Low socioeconomic status is an important determinant of access to health care.Results from a qualitative, in-depth interview study of 60 African ...

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Trans women of color have a much higher murder rate than the general public, especially young trans women of color (p 120 – 122).

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In 2015, official records show 23 transgender people were murdered. In reality, though, that number was probably much higher. Even without the actual numbers in place, 2015 was the most violent year for transgender people on record, and black transgender women were most often the target. What's worse is when transgender people are murdered, not very many people notice. Names aren't right, gender pronouns are misreported, killers aren't found and statistics aren't kept.

On Thursday, Mic announced its project Unerased: Counting Transgender Lives, an effort to document the growing violence against transgender people since 2010. For many, the numbers Mic reported might be shocking. But for others, those numbers are sadly expected.

In 2016, Mic reports there have already been 23 transgender people killed, matching last year's numbers with a month still left until 2017. When you consider that transgender people are the most targeted LGBTQ-identified group for hate crimes, it becomes clear that transgender people bear a disproportionate rate of violence. As of now, many transgender people have no legal protection from discrimination, and some of our law makers are actually telling us that's OK.

While all transgender people are susceptible to violence, black transgender women are most at risk.

According to Mic's numbers, the murder rate for the general population is 1 out of every 19,000. For young people, that number becomes 1 in every 12,000 murdered, but when it comes to black transgender women, 1 in every 2,600 is killed. If everyone in the country were as at risk for life-ending violence as black transgender women, Mic reports the country's murder rate would leap from 15,696 in 2015 to a whopping 120,087. Think about that for a minute.

It's something writer and activist Raquel Willis previously told Teen Vogue she thinks about all the time.

"This isn't something we just think about when it's in the news or think about it when someone writes an article about a trans woman slain," Raquel said. "It's something we think about daily. We have to constantly have to watch our surroundings."

"If you don't fit this limited stereotypical script of what a woman is supposed to look like...it's almost having a target on your back," she added.

Part of the problem, the Mic investigation found, is our legal system is not set up to handle transgender victims. Law enforcement doesn't have the proper knowledge or tools to identify transgender victims using the correct name or gender identity and it's often expensive for a transgender person to get the legal documents that would lead to their correct identification. But because transgender people are historically ignored and devalued, that system has continued.

"It is un-American that 5 states do not have laws against hate crimes. Hate crimes are committed to instill fear into a community because of a particular identity," activist Precious Davis has told Teen Vogue. "Safety is a human right and if someone commits a crime based upon someone's gender, sexual orientation, ethnicity, etc., they deserve to be brought to justice. This is about protecting human dignity and the sanctity of all Americans being given the right to be their authentic selves without the fear of being harmed."

Mic's project is intended to work as a resource for activists, journalists and academics as a central place to gather information, but we hope it also serves to educate the general public on the violent crisis transgender people face. It's time we know the names of the transgender people murdered, and it's time we unerase their identities.

Related: Black Transgender Women React to Dee Whigham's Murder

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Trans People Experience So Much Violence That There Is Now a Database Tracking It

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In 2015, official records show 23 transgender people were murdered. In reality, though, that number was probably much higher. Even without the actual numbers in place, 2015 was the most violent year for transgender people on record, and black transgender women were most often the target.

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Explanation of chosen articles.

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Emma Watson faces backlash for being a "bad feminist" for posing topless for Vanity Fair (p 87 – 88, 101).

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British actress Emma Watson hit back at critics who said she betrayed her feminist ideals by posing for a revealing picture in Vanity Fair magazine where parts of her breasts were exposed.

Watson, the "Harry Potter" movie series co-star and pioneer of the HeForShe campaign to make men advocate for feminism, talked about the photo shoot for the magazine while promoting her latest film, the Disney live action "Beauty and the Beast."

"It just always reveals to me how many misconceptions and what a misunderstanding there is about what feminism is," she said in an interview with Reuters.

"Feminism is about giving women choice. Feminism is not a stick with which to beat other women with. It's about freedom, it's about liberation, it's about equality. I really don't know what my tits have to do with it. It's very confusing.

"I'm confused. Most people are confused. No, I'm just always just quietly stunned," she said.

The magazine's photo shoot by acclaimed fashion photographer Tim Walker showed Watson in an open, white crocheted bolero jacket with no bra or shirt underneath.

"We'd been doing so many crazy things on that shoot but it felt incredibly artistic and I've been so creatively involved and engaged with Tim and I'm so thrilled about how interesting and beautiful the photographs were," she said.

(Editing by Nick Zieminski)

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Actress Emma Watson says revealing photo does not undermine feminism

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British actress Emma Watson hit back at critics who said she betrayed her feminist ideals by posing for a revealing picture in Vanity Fair magazine where parts of her breasts were exposed.

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Trump adds new commission, VOICE, to strictly track violence committed by immigrants (p 78 – 81).

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As mandated by Trump's executive order signed last month, the Department of Homeland Security announced in implementation guidance issued last week that it would create the Victims Of Immigration Crime Engagement office, or VOICE.

"I have ordered the Department of Homeland Security to create an office to serve American victims," Trump said Tuesday night. "We are providing a voice to those who have been ignored by our media, and silenced by special interests."

What did Trump order?

In establishing the office as called for in Trump's January 25 executive order, DHS Secretary John Kelly ordered the reallocation of any department resources currently going to advocating for undocumented immigrants that can be re-routed to fund the office.

VOICE's job will be to work with victims of crimes committed by undocumented immigrants.

Trump called in his order for the office to issue reports once a quarter "studying the effects of the victimization by criminal aliens present in the United States."

How did he make his case?

Trump invited three guests whose family members were allegedly killed by criminals living in the US illegally, acknowledging them individually as he described his recent crime reporting initiative.

To make his point, Trump in his speech recognized Jamiel Shaw, Susan Oliver, her daughter, Jenna Oliver, and Jessica Davis.

Shaw's teen son, Jamiel Shaw Jr., was murdered by a gang member living in the US illegally.

Susan Oliver and Davis' husbands were Deputy Sheriff Danny Oliver and Detective Michael Davis, who were killed in the line of duty in California. An undocumented immigrant is charged with their murders.

"To Jamiel, Jenna, Susan and Jessica: I want you to know -- we will never stop fighting for justice," Trump said. "Your loved ones will never be forgotten, we will always honor their memory."

Why is it controversial?

The line about creating VOICE in Trump's speech elicited some audible groans from Democrats in the chamber.

Along with a similar provision in the executive order requiring weekly reports about crimes committed by undocumented immigrants designed to name and shame sanctuary cities, critics fear the measures are designed to skew public opinion unfavorably toward immigrants. Studies conducted by organizations that support pro-immigration policies have found that immigrants commit crimes at a lower rate than the general public, findings that supporters of hardline immigration policies say don't matter.

"The point is that every crime that is committed by someone who is here illegally is a crime that would not occur if they weren't in the country," said Hans von Spakovsky, a legal expert at the conservative Heritage Foundation.

Illinois Democratic Sen. Tammy Duckworth, on the other hand, called the initiative "horrifying" and said Trump was exploiting his guests.

"Especially this VOICE program, I find horrifying," Duckworth told CNN. "And for him to bring guests who suffered such tragedies, but to use it as a political point when it comes to undocumented immigrants, is sad. I wish he would have -- he touched on DREAMers a little bit -- but really no real discussion about he was going to go about doing this other than build more walls."

Latino Partnership for Conservative Principles President Alfonso Aguilar, a one-time Trump supporter and conservative immigration activist who has been back and forth on his feelings on Trump's agenda, said he liked the rest of the President's statements in the speech on immigration but not VOICE.

"The majority of undocumented immigrants are good hard working people," Aguilar told CNN's John Berman on "Newsroom" Wednesday. "A small minority, and you're absolutely right, smaller than those in the general population, engage in criminal activity. So it is blown out of proportion. I don't know -- I think the office is just going to keep statistics and things like that, but I think if they do the research (they'd) realize that the majority of undocumented immigrants are really not involved in criminal activity."

Vermont Sen. Bernie Sanders criticized Trump's use of victims of tragedy to promote his agenda.

"The murder of anyone is a tragedy, and our hearts go out to all families who lose a loved one to violence," Sanders said in a Facebook post. "But let's be clear about what Donald Trump is doing tonight in inviting family members who saw a loved one murdered by an undocumented immigrant. He is stirring up fear and hatred against immigrants and trying to divide our nation."

Sanders also mentioned victims of hate crimes by non-immigrant perpetrators, wondering why Trump did not mention them.

"President Trump, any murder is a tragedy. Don't use these tragedies to stir up divisions by race and nationality," Sanders said.

"The obvious intent of a provision like that is to provide a misleading view of what sanctuary jurisdictions are really doing," Omar Jadwat, director of the American Civil Liberties Union's Immigrants' Rights Project, told CNN in January.

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What is VOICE? Trump highlights crimes by undocumented immigrants

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As mandated by Trump's executive order signed last month, the Department of Homeland Security announced in implementation guidance issued last week that it would create the Victims Of Immigration Crime Engagement office, or VOICE. "I have ordered the Department of Homeland Security to create an office to serve American victims," Trump said Tuesday night.

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Man in Washington shot in his driveway after being told to leave the country and "go back where [he was] from" (p 105 – 106).

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The gunman allegedly told the man "Go back to your country." Police are investigating the shooting in Kent as a possible hate crime, according to CNN affiliate KIRO.

The victim is a US citizen, originally from India's Punjab province, Seattle-area Sikh community leader Jasmit Singh told CNN.

Singh said the man's family told him that he had been in his driveway Friday when a 6-foot man approached, asking something along the lines of "why are you cleaning your car?"

The conversation became heated and the man threatened the victim, calling him names and yelling "go home to your country," before he pushed him to the ground and pulled out a gun.

The victim lost consciousness, only realizing he had been shot when he regained consciousness, Singh said. He was discharged from hospital Saturday and doctors expected him to make a complete recovery, Singh said.

Police respond

"We're early on in our investigation and the shot resulted in non life-threatening injuries, however we are treating this as a very serious incident," Kent police chief Ken Thomas said in a news conference broadcast by KIRO.

Thomas said police were investigating the shooting as a possible hate crime, KIRO reported.

"To think that this could happen in our community was very surprising and extremely disappointing," Thomas said. "This is the first incident of this magnitude that I'm aware of in the city of Kent.

The FBI's Seattle office said it was investigating alongside Kent police.

"The FBI remains committed​ to investigating c​rimes that are potentially hate-motivated and we continue to work with all our community partners in the Seattle area," a spokesperson said in a statement.

India reacts

India's Minister of External Affairs, Sushma Swaraj, tweeted that she was sorry to hear of the attack.

Swaraj said she had spoken to the victim's father, who told her his son had suffered a bullet injury to the arm and was "out of danger" and recovering in a private hospital.

He told me that his son had a bullet injury on his arm. He is out of danger and is recovering in a private hospital. /2
- Sushma Swaraj (@SushmaSwaraj) March 5, 2017

India's Foreign Ministry said it was in touch with local authorities and had offered assistance.

"What we heard from the victim himself is that the shooter asked him when are you going back to your own country?" spokesman Gopal Baglay said.

MaryKay Loss Carlson, the top diplomat at the US Embassy in New Delhi, tweeted her thoughts as well.

"Saddened by shooting in WA. Wishes for a quick and full recovery. As @POTUS said we condemn "hate and evil in all its forms," she said.

Witness to attack

A tenant at the property where the shooting took place told KIRO she witnessed her landlord being shot before the gunman ran away.

"The guy told him to go back home," Susan Livie told the station.

The Sikh Coalition said members of its community were at heightened risk of hate crime attacks -- partially because their faith required the wearing of turbans and beards.

In a statement, spokesman Rajdeep Singh said it's important the Kent shooting be investigated as a hate crime.

"While we appreciate the efforts of state and local officials to respond to attacks like this, we need our national leaders to make hate crime prevention a top priority," he said. "Tone matters in our political discourse, because this a matter of life or death for millions of Americans who are worried about losing loved ones to hate."

The coalition said the Kent attack had similarities with the shooting of two Indian immigrants in Kansas in February.

The coalition said violence against minorities had increased since the presidential election and hate crimes needed to be identified as such.

Stigma of racism 'erased'

"Investigating this as an anti-Sikh hate crime is critical, because without our government agencies recognizing hatred for what it is, we can't combat the problem," Jasmit Singh said.

"The Sikh community is shaken and very frustrated at the hate and rhetoric that is being spread today about anyone that looks different, who looks like an immigrant."

Jasmit Singh said approximately 50,000 Sikhs lived in Washington, -- 30,000 of them in the Kent-Renton area.

"Based on anecdotal evidence, more and more people are saying inappropriate things to Sikh men, the stigma attached to being a racist has been erased from the community," he said.

Rep. Ami Bera, the longest currently serving Indian-American member of Congress, on Sunday denounced the attack.

"This disturbing crime is an outrage that goes against everything we stand for as a nation of immigrants," Bera said in a statement. "Xenophobia and racisim have no place in America, and we as a nation need to stand up to these hate crimes -- starting with the President."

Jasmit Singh also said the White House needs to speak out against racism and bigotry.

"In the past -- in Bush, Obama time -- there was swift action and communication saying that this is unacceptable," he said. "We aren't seeing any response from this administration."

But Kent Police Department and City Council have provided a lot of feedback and met with the community, he said.

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Artemis Moshtaghian, Huizhong Wu and Susannah Cullinane, CNN

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Sikh man's shooting in Washington investigated as hate crime

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The gunman allegedly told the man "Go back to your country." Police are investigating the shooting in Kent as a possible hate crime, according to CNN affiliate KIRO. The victim is a US citizen, originally from India's Punjab province, Seattle-area Sikh community leader Jasmit Singh told CNN.

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Transgender boy forced to wrestle in women's championship due to "the gender on [his] birth certificate". He won and is now facing backlash for having an advantage from hormone therapy (p 98).

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In the wake of winning a controversial Texas state girls' wrestling title over the weekend, Mack Beggs, a 17-year-old transgender wrestler, spoke to the need to "stay strong" while also calling on state policymakers to "change the laws and then watch me wrestle the boys."

Beggs, who identifies as male, was dogged throughout the tournament by questions about whether his testosterone treatments made him too strong to wrestle fairly against girls. In an interview with ESPN's Outside the Lines on Wednesday, Beggs said he was unfazed by the boos that rained down on him en route to the 110-pound championship, which capped an undefeated season for the Euless Trinity junior.

"I just heard the boos, but I heard more cheering," Beggs told OTL. "Honestly, I was like, 'You know what? Boo all you want, because you're just hating. You hating ain't going to get me and you nowhere, and I'm just going to keep on doing what I've got to do.'

"That's why I've always had that mentality. If you're going to be negative, you know, whatever, that's not going to faze me."

Beggs, who says he has been taunted with slurs such as "f----t" and "it," cited the testosterone as a reason for the boos, as well as ignorance and a lack of understanding on the part of his critics.

"I mean, I've been winning before when I didn't have testosterone, but now that, you know, I'm actually winning winning, people want to go crazy," Beggs said. He added that some people "just automatically want to call me a cheater."

"Like that kind of makes me feel like they don't care about my training or the work that I put in," he continued. "Because I've been to [state] twice. And it's not like I'm just doing this because I want to like call myself a boy and just dominate all these girls. What do I get out of that? I don't get anything out of that."

Given the choice, Beggs said he would "definitely" want to wrestle boys, "because I'm a guy. It just makes more sense."

The University Interscholastic League, which oversees athletics in Texas public schools, enacted a rule on Aug. 1 that required students to wrestle against the gender listed on their birth certificates. So Beggs faced Chelsea Sanchez for the 110-pound weight class title on Saturday, beating her 12-2 to improve to 56-0 and earn the championship.

In the event the UIL were to amend its rules and allow him to wrestle against boys next year, Beggs said he is not concerned by a step up in competition.

"Boy's wrestling is hard. It's really, really hard. But I'll do it. If it means wrestling with the guys, I'll do it," he said. "It doesn't invalidate how I wrestle and how my technique is. If I get beat, I get beat. I just didn't train hard enough. I didn't work hard enough."

Beggs reached this year's state tournament after two of his opponents at regionals forfeited, including one who bowed out in the finals. Beggs said he spoke to the girls afterward and "they didn't want to forfeit."

"Their parents made them forfeit," he explained. "And I was like, 'Are you being serious?' Like you're going to let ignorance take over your daughter wrestling no matter who it is?"

In light of the forfeits, Beggs said that given the opportunity to repeat any of his wrestling tournaments this season, he would go back to regionals, "because I would want it to be way different. I feel like I did not earn that regional medal."

Beggs said there were moments during his teenage years that "got pretty dark," including in seventh grade, when he contemplated suicide.

"I don't think I've ever told anyone, but I would feel like I need to kill myself sometimes. But I was like, 'No, nah, I can't do that.'"

His advice to those who might be afraid to go through what he has gone through: "Don't give up. Because as soon as you feel like you're going to give up, you've already lost."

"You just have to stay strong," Beggs added. "There's going to be sucky days. There is going to be sucky days, believe me. ... There's always going to be another day. There's always going to be another week. You've just got to keep on rolling."

Asked if he has found his purpose, Beggs replied that he wants to be an advocate for kids who are transgender and "live my life how I want to."
Information from The Associated Press was used in this report.

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Transgender wrestler: Negativity won't faze me

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In the wake of winning a controversial Texas state girls' wrestling title over the weekend, Mack Beggs, a 17-year-old transgender wrestler, spoke to the need to "stay strong" while also calling on state policymakers to "change the laws and then watch me wrestle the boys."

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Sexually-active gay men are still not allowed to donate blood in the United States due to fear from HIV/AIDS, even though blood tests for these diseases have been available for years. The discriminatory rule also neglects to address heterosexual couples who engage in anal sex, the reason for denying gay men (79 – 80).

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Gay or bisexual men who have had sex with another man in the past 12 months are not allowed to donate blood, according to official rules from the U.S. Food and Drug Administration.

The ban has caused outrage among some in the gay community who say they are being stopped from helping their LGBT "brothers and sisters" targeted in Sunday's shooting at the Pulse nightclub.

Forty-nine people were killed when Omar Mateen, 29, opened fire in the gay bar. At least 53 more were wounded in the worst mass shooting in U.S. history.

Easier to buy a gun than donate blood?

After the attack, the OneBlood donation center immediately put out an urgent call for donors to help hospitals deal with the massive influx of injured people.

The center's website crashed from online traffic, and more than 5,300 people donated blood through the OneBlood statewide network on Sunday -- a single-day record, according to Susan Forbes, OneBlood's vice president of of marketing and communications.

Though response from the public has been huge, sexually active gay and bisexual men are still barred from donating.

Many hit back at the ban online, saying it's easier to buy a gun than for a gay man to donate blood in the United States.

Temporary lifting of ban?

There have been conflicting reports over whether the ban had been temporarily lifted, with Orlando City Commissioner Patty Sheehan telling CNN: "They lifted the ban on gay men giving blood yesterday."

"They've been able to test for HIV in the blood system for years, and this is what it took to allow gay men to finally be able to give blood. And they lined up. There were 1,500 people in line yesterday," she said.

However, the OneBlood donation center said in a tweet Sunday that all FDA guidelines remained in place.

There are no plans on the part of the White House to change the guidelines, press secretary Josh Earnest said Tuesday, noting that they are based on guidance from the FDA.

Origins of the ban

The FDA implemented a near-lifetime ban of blood donations from gay and bisexual men in 1985 at the start of the AIDS epidemic, when little was known about the spread of the disease.

Since the ban was introduced, screening technologies have vastly improved, and the FDA updated its guidance on the issue in 2015.

Under the latest rules, gay and bisexual men may donate blood, provided it has been 12 months since their last sexual encounter with another man.

At the time of the rules revision, the Human Rights Campaign said that the change was a "step in the right direction" but that the new policy "still falls short of a fully acceptable solution because it continues to stigmatize gay and bisexual men."

Rep. Sean Maloney, D-New York, said Tuesday on MSNBC that the hypocritical policy needs to be changed. "We can have these discriminatory practices in simple things like donating blood or profound things like whether you can be fired from your job, and it's wrong," he said.

Other countries that have implemented a one-year deferral policy include Argentina, Australia, Brazil, Hungary, Japan, Sweden and the United Kingdom.

How safe is American blood?

Every unit of blood donated in the United States must undergo 13 tests, including 10 for infectious diseases (such as HIV, hepatitis and syphilis).

The use of donor education material, specific deferral questions and advances in donor testing have reduced the risk of HIV transmission from a blood transfusion to about 1 in 1.5 million to 2 million blood units, according to the National Institutes of Health.

While it is possible to detect HIV in a unit of blood nine to 11 days after infection, the NIH says that once a person is infected with HIV, it generally takes about three months for the body to produce enough antibodies to be detected by an HIV antibody test. For some people, it can take up to six months.

So who can donate blood? All donors must be in good general health, be at least 17 years old -- in most states, including Florida -- and weigh at least 110 pounds, according to the Red Cross.

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Gay men outraged over ban on blood donation

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Gay or bisexual men who have had sex with another man in the past 12 months are not allowed to donate blood, according to official rules from the U.S. Food and Drug Administration. The ban has caused outrage among some in the gay community who say they are being stopped from helping their LGBT "brothers and sisters" targeted in Sunday's shooting at the Pulse nightclub.

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Man, and his mother, detained at Florida airport returning from Jamaica and asked if they was Muslim (p 79 – 80).

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Muhammad Ali's Son Detained at Airport and Was Asked 'Are you Muslim?'

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"It's quite clear that what triggered his detention was his Arabic name and his religion," a family friend and lawyer said

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Man detained at JFK airport for "not looking like an engineer" (p 73, 79 – 80.

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"What is an abstract class and why do you need it?"

"Write a function to check if a Binary Search Tree is balanced."

Those are the questions that Celestine Omin says he was asked by border officials at JFK Airport to prove that he was an engineer.

The 28-year-old was traveling from Lagos, Nigeria, last weekend on a work trip for his employer, startup Andela.

He was told that he didn't look like an engineer and needed to take the test to prove it, according to Andela. He was handed a white sheet of paper and two incredibly difficult computer science questions.

Andela is backed by Mark Zuckerberg and Priscilla Chan's fund, the Chan Zuckerberg Initiative, and it is incredibly selective. It trains software developers in Africa and gives them full-time roles at international companies. It has over 215 developers in Lagos and Nairobi who work with more than 60 companies.

After three hours -- and a call between U.S. Customs and Border Protection and Andela cofounder Christina Sass -- he was let go.

In a statement to CNNTech, CBP wrote that it "does not administer written tests to verify a traveler's purpose of travel."

"[Our] officers strive to treat all people arriving in the country with dignity and respect," the statement read.

Related: 'I'm terrified to leave the country'

Sass told CNNTech that its developers are frequently traveling in and out of the U.S. for short-term work visits. She estimated that in 2016, there were more than 70 trips taken. Nothing of this nature has ever happened.

"We absolutely want to be play by the rules -- we just need to know what they are," said Sass.

This comes at a time when foreigners and immigrants are feeling the effects of the new administration's stance on increased border patrolling. When President Trump took office, he signed an executive order for "extreme vetting" of people from seven majority Muslim countries. The order has since been blocked in the courts, but Trump is expected to issue a revised one next week. He's also considering an executive order to reevaluate and revamp various work visas.

After the incident, Andela said it followed up via phone and email to Customs to better understand what sort of information it needs to ensure something like what happened to Omin doesn't happen again. It has not heard back.

"If we want to maintain our position in the world or, better yet, enhance it, we need to do better," wrote Sass and cofounder Jeremy Johnson in a post about the incident on Thursday.

"The technologists of tomorrow will be every race, gender and religion, and they will hail from every corner of the globe." wrote Sass and Johnson.

CNN Politics' Tal Kopan contributed to this report.

CNNMoney (New York) First published March 2, 2017: 6:45 PM ET

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Tech startup questions why Nigerian engineer was detained at JFK

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"Write a function to check if a Binary Search Tree is balanced." Those are the questions that Celestine Omin says he was asked by border officials at JFK Airport to prove that he was an engineer. The 28-year-old was traveling from Lagos, Nigeria, last weekend on a work trip for his employer, startup Andela.

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Female lawmaker stands up after an older, male lawmaker argues that women should be paid less (p 78).

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Lawmaker told off after sexist comments - CNN Video

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An argument over sexism erupted in European Parliament when a lawmaker described women as smaller, weaker and less intelligent in a debate about equal pay.

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Bomb threats on Jewish centers or synogogues since January 1, 2017 (79 – 80).

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This map shows just how widespread the Jewish center bomb threats are

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We mapped the 101 bomb threats at 81 different Jewish institutions. The threats cover 33 states, from Florida to Maine to Washington state, as well as two Canadian provinces.

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The feminist who coined the term "intersectionality", Kimberlé Crenshaw, talks specifically about the intersection of police violence against black people and violence against women (p 118 – 119).

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The urgency of intersectionality | Kimberlé Crenshaw | TED

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Transgenders are no longer allowed to use the bathroom of the gender that they identify with, as Trump rolls back an Obama-era protection (p 98).

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In a period when being a woman, especially a black woman, in STEM fields was taboo, Katherine Johnson helped put a person into orbit for the first time (p 79 – 81, 95 – 97, 115 – 117).

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Katherine Johnson, one of the NASA research mathematicians portrayed in the Oscar-nominated film "Hidden Figures," received a standing ovation at the Academy Awards on Sunday.

Johnson, portrayed in the movie by Taraji P. Henson, worked for NASA as a research mathematician for more than 30 years, according to NASA's website. Appearing at the Dolby Theatre, Johnson, now 98 years old, thanked the crowd for their support.

Johnson was instrumental in Alan Shepard's journey to become the first American in space and in John Glenn's mission to become the first American to orbit the Earth. She, along with the other women of color in the program, dealt with segregation in Jim Crow-era Virginia where NASA's Langley Research Center was located. Johnson didn't anticipate the success she would find at NASA, telling the Los Angeles Times that she "did what we were asked to do to the best of the ability."

"I was just excited to have challenging work to do and smart people to work with," she said.

Johnson has said she approves of her portrayal in the film.

"Go see 'Hidden Figures,' and take a young person," she told the Los Angeles Times last month when asked how to get more women and people of color involved in STEM careers. "It will give a more positive outlook on what is possible if you work hard, do your best and are prepared."

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Real-life subject of 'Hidden Figures' receives standing ovation at Oscars

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Katherine Johnson, one of the NASA research mathematicians portrayed in the Oscar-nominated film "Hidden Figures," received a standing ovation at the Academy Awards on Sunday. Johnson, portrayed in the movie by Taraji P. Henson, worked for NASA as a research mathematician for more than 30 years, according to NASA's website.

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Finally, in 2017, the first Muslim actor won an Oscar. Mahershala Ali won the Oscar for Best Supporting Actor (p 79 – 81).

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There's no Muslim ban at this year's Academy Awards.

Mahershala Ali, accepting the best supporting actor trophy on Sunday for his turn in "Moonlight," became the first-ever Muslim actor to take home an Oscar.

The Oakland native closed out his acceptance speech with a shoutout to his wife, Amatus Sami-Karim, who spent awards season in her third trimester.

"We just had our daughter four days ago," Ali said. "So I just want to thank her for being such a soldier through this process and helping really carry me through it all."

The Oakland native's breakthrough - coming on the heels of President Trump's travel ban on seven majority-Muslim nations currently stayed by a federal appeals court - didn't go unnoticed on social media.

"The first #Oscars winner is a Muslim. America is already great, Donald," tweeted author Anand Giridharadas.

Ali, who converted to Islam 17 years ago, spoke about faith and persecution while accepting a Screen Actors Guild award last month for "Moonlight."

"When we get caught up in the minutia, the details that make us all different, there are two ways of seeing that," he said.

"It's an opportunity to see the texture of that person, to see what makes them unique. Or it's an opportunity to go to war about it. To say that that person's different than me and I don't like it, so let's battle."
Send a Letter to the Editor

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Mahershala Ali becomes the first Muslim actor to win an Oscar

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There's no Muslim ban at this year's Academy Awards. Mahershala Ali, accepting the best supporting actor trophy on Sunday for his turn in "Moonlight," became the first-ever Muslim actor to take home an Oscar. The Oakland native closed out his acceptance speech with a shoutout to his wife, Amatus Sami-Karim, who spent awards season in her third trimester.

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Homeless women express the struggles of remaining sanitary during menstruation (p 132 – 134).

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Homeless women typically know where to find a safe place to sleep or a hot meal to eat. But when it comes to taking care of their feminine hygiene needs, they often have nowhere to turn.

Tampons and sanitary pads usually top the list of needs at shelters, since they’re pricey and supporters don’t often donate them, social workers told Al Jazeera. Compounding the issue is the fact that clean showers are also scarce, and not washing during menstruation can lead to infections.

It’s a desperate situation that many homeless women feel resigned to accept.

"I’ll never be clean," a young woman living on the streets of San Francisco once told Doniece Sandoval, the entrepreneur behind Lava Mae, a mobile shower program, according to Nation Swell.

Maribel Guillet, 36, is all too familiar with that despondent feeling.

Guillet, who lives in a Bronx, New York, homeless shelter, typically menstruates for about 10 days and experiences heavy bleeding, she told Al Jazeera. But because of the shelter’s strict restrictions, she can’t always use the restroom as often as she needs to.

The fact that menstruation is a taboo topic to begin with, means that people who are able help, often aren’t even aware that such a vast need exists.

While donating clothes to a homeless day center in Camden, New Jersey, back in 2009, Joanie Balderstone and her partner, Rebecca McIntire, asked the women there what else they really needed.

The overwhelming consensus was pads and tampons, the couple wrote on their organization’s website.

That interaction is what spurred the pair to found Distributing Dignity, a nonprofit that donates bras and feminine hygiene products to women in need.

A few months later, they hosted their first "Mardi Bra" party, according to Philly.com.
Guests donated 80 new bras and hundreds of feminine products that the founders distributed to shelters in Camden.

They’ve since expanded to help shelters throughout South Jersey and Philadelphia.

Gaining access to such an everyday item has proved to be invaluable to the women Distributing Dignity helps.

When residents at Camden County Women's Center, which supports survivors of domestic abuse, recently got shipment of sanitary napkins, they were thrilled to see that the box contained pads of varying sizes.

"It sounds silly," Jeen Moncayo, a case worker at the center, told Philly.com, "but the choice is empowering."

See how you can help at Distributing Dignity.

Sexist Vintage Ads

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For Homeless Women, Getting Their Period Is One Of The Most Difficult Challenges

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Homeless women typically know where to find a safe place to sleep or a hot meal to eat. But when it comes to taking care of their feminine hygiene needs, they often have nowhere to turn.

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Indian man told to "get out of my country" before being shot and killed (p 105 – 106).

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KANSAS CITY/NEW DELHI A white U.S. Navy veteran has been charged with killing an engineer from India and wounding two other men when he opened fire in a Kansas bar in what federal authorities were investigating on Friday as a possible hate crime that shocked the victim's home country.

The shooting on Wednesday night led news bulletins in India and triggered outrage on social media, where people voiced concern that U.S. President Donald Trump's "America First" position on immigration and jobs has fueled a climate of intolerance.

White House spokesman Sean Spicer said Friday that any loss of life was tragic, but it would be absurd to link the killing to Trump's rhetoric.

Pratik Mathur, spokesman for the Indian embassy in Washington, said India had expressed "our deep concern over the incident" to the U.S. government and requested a "thorough and speedy investigation."

Adam Purinton, 51, was charged on Thursday in Johnson County, Kansas, with one count of premeditated first-degree murder and two counts of attempted premeditated first-degree murder, District Attorney Stephen Howe told reporters.

He declined to elaborate on the details of the incident or the gunman's motive. Local media reports said Purinton often complained about his ill health and was mourning the death of his father.

The Federal Bureau of Investigation was looking at whether it was a hate crime, the official term for crimes motivated by bias or prejudice.

If convicted of the state murder charges, Purinton faces a life sentence without eligibility for parole for 50 years, Howe said.

Purinton is accused of killing Srinivas Kuchibhotla, 32, and wounding Alok Madasani, also 32, in Austins Bar and Grill in Olathe, Kansas, on Wednesday evening, police said. At least one bystander told the Kansas City Star the gunman shouted "get out of my country" before shooting the Indian victims.

Purinton is also accused of wounding American Ian Grillot, 24, who was shot as he tried to intervene.

"People call me a hero," Grillot said in a video released by the hospital where he was undergoing treatment for gunshot wounds to the hand and chest. "I was just doing what anyone should have done for any other human being."

Kuchibhotla was married but had no children. His wife, identified by media as Sunayana Dumala, told reporters on Friday that the gunman "has taken a life, a very lovable soul, from everyone."

Kuchibhotla received a master's in electronics from the University of Texas in El Paso in 2007, according to LinkedIn. His Facebook page, where he called himself "Srinu," said that in 2014 he joined the Kansas office of Switzerland-based navigation device maker Garmin Ltd from Rockwell Collins Inc.

Flags at Garmin's offices flew at half-staff on Friday. The company said it was "devastated by the senseless tragedy."

Dozens of people attended a candle-light vigil Friday evening at the First Baptist Church of Olathe, across the road from the bar. Hundreds of thousands of dollars has been raised through crowdfunding sites for the three victims.

The suspect fled on foot and was arrested five hours after the shooting at an Applebee's restaurant in Clinton, Missouri. He reportedly told an employee there he needed a place to hide because he had killed two Middle Eastern men, the Star reported.

Purinton, a former Federal Aviation Administration employee, was transferred back to Kansas on Friday and was being held with bond set at $2 million, according to jail records.

He is scheduled to appear in court on Monday. It was not immediately known whether he had hired a lawyer.

"I don't want people to think of him as a monster or racist man because that's not who he is," Adele Mathews, Purinton's niece, said in a statement released to local media.

Police did not say whether Purinton has faced charges in the past. However, he was not generally known to police in Olathe, a city of 134,000 people about 25 miles (40 km) southwest of Kansas City, Sergeant Logan Bonney said Friday.

At Kuchibhotla's family home near the Indian tech hub of Hyderabad, relatives backed government calls to ensure the safety of Indians living in the United States.

"The government should voice out this strongly because our brothers, sisters and our relatives are there," the victim's brother, Venu Madhav, told Reuters Television.

Many Indians initially welcomed Trump's election, seeing his calls to restrict Muslim immigration as support for their Hindu-majority country. India has been at odds for decades with Pakistan, its mainly Muslim neighbor.

But the Trump administration may also have skilled Indian workers like Kuchibhotla in mind as it considers curbing the H-1B visa program, worrying both India's $150 billion IT services industry and Prime Minister Narendra Modi's government.

"Don't be shocked! Be angry!" Siddharth, a well-known South Indian actor who uses one name, tweeted to his 2.6 million followers in remarks echoed across social media. "Trump is spreading hate. This is a hate crime! RIP #SrinivasKuchibhotla."

(Reporting by Dave Kaup in Kansas City and Aditya Kalra in New Delhi; Additional reporting by David Ingram in New York, Brendan O'Brien in Milwaukee and Ayesha Rascoe and David Brunnstrom in Washington, Alex Dobuzinskis in Los Angeles and Timothy McLaughlin in Chicago; Editing by Grant McCool and Lisa Shumaker)

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Kansas man charged with killing Indian in possible hate crime

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A white U.S. Navy veteran has been charged with killing an engineer from India and wounding two other men when he opened fire in a Kansas bar in what federal authorities were investigating on Friday as a possible hate crime that shocked the victim's home country.

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Black parents explain to children how to interact with police due to racial profiling (p 75 – 76, 104).

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Black Parents Explain How to Deal with the Police | Cut

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Explanation of chosen articles.

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Suicide rates among men are greater, occurring 3.5 times more often (p 44 – 46).

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American Foundation for Suicide Prevention

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Are you in a crisis? Call 800-273-8255 or text TALK to 741741.

Learn the latest statistics on suicide. Data on suicide are taken from the Centers for Disease Control and Prevention (CDC) Data & Statistics Fatal Injury Report for 2018, as of March 1, 2020. Suicide rates listed are Age-Adjusted Rates.

Suicide is the

10th

leading cause of death in the US

In 2018,

48,344

Americans died by suicide

In 2018, there were an estimated

1.4M

suicide attempts

In 2015, suicide and self-injury cost the US

$69B

Become an advocate to help prevent suicide Learn more

Additional facts about suicide in the US

The age-adjusted suicide rate in 2018 was 14.2 per 100,000 individuals.

The rate of suicide is highest in middle-aged white men.

In 2018, men died by suicide 3.56x more often than women.

On average, there are 132 suicides per day.

White males accounted for 69.67% of suicide deaths in 2018.

In 2018, firearms accounted for 50.57% of all suicide deaths.

More resources

Suicide research videos

Short and easy-to-understand, these new research-themed videos make suicide prevention research accessible, and are perfect for sharing on social media, helping to spread the word that through research, we can #StopSuicide.
Learn more about research

Suicide Rates in the United States

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Years 11.8 12 12.2 12.4 12.6 12.8 13 13.2 13.4 13.6 13.8 14 14.2 Rate per 100,000 Individuals

Suicide rates by race/ethnicity

Suicide methods

Suicide rates by age

Suicide rates by race/ethnicity

Suicide methods

In 2018, the suicide rates were higher among adults ages 45 to 54 years (20.04 per 100,000) and 55 to 64 years (20.20 per 100,000), with the rate highest among adults ages 52 to 59 years (21.56 per 100,000). Younger groups have had consistently lower suicide rates than middle-aged and older adults. In 2018, adolescents and young adults aged 15 to 24 had a suicide rate of 14.45.

Suicide rates by age

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Years 2 4 6 8 10 12 14 16 18 20 Rate per 100,000 Individuals

Public policy priorities

Learn more about our top Federal and State policy priorities for suicide prevention.
Learn more

Suicide attempts

When it comes to suicide and suicide attempts there are rate differences depending on demographic characteristics such as age, gender, ethnicity and race. Nonetheless, suicide occurs in all demographic groups.

In the U.S., no complete count of suicide attempt data are available. The CDC gathers data from hospitals on non-fatal injuries from self-harm as well as survey data.

In 2015, (the most recent year for which data are available), approximately 575,000 people visited a hospital for injuries due to self-harm.

Based on the 2018 National Survey of Drug Use and Mental Health it is estimated that 0.5 percent of the adults aged 18 or older made at least one suicide attempt. This translates to approximately 1.4 million adults. Adult females reported a suicide attempt 1.5 times as often as males. Further breakdown by gender and race are not available.

Based on the most recent Youth Risk Behaviors Survey from 2017, 7.4 percent of youth in grades 9-12 reported that they had made at least one suicide attempt in the past 12 months. Female students attempted almost twice as often as male students (9.3% vs. 5.1%). Black students reported the highest rate of attempt (9.8%) with white students at 6.1 percent. Approximately 2.4 percent of all students reported making a suicide attempt that required treatment by a doctor or nurse. For those requiring treatment, rates were highest for Black students (3.4%).

About AFSP

Learn about the American Foundation for Suicide Prevention, and our mission to save lives and bring hope to those affected by suicide.
Learn more

Become an advocate for suicide prevention

By signing up as an AFSP Field Advocate, you will become a vital part of a large grassroots movement of people across the U.S. who are speaking out for suicide prevention and mental health policies at all levels of government.
Learn more

Boards, commitees and councils

The American Foundation for Suicide Prevention's National Board, Councils and Committees are dedicated to the fight to stop suicide.
Learn more

Action Center

Visit our Action Center to stay up to date on the federal and state bills that need your support.
Take action

Sign up for email alerts

Receive updates from the American Foundation for Suicide Prevention

© 2020 American Foundation for Suicide Prevention. All rights reserved.

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Are you in a crisis? Call 800-273-8255 or text TALK to 741741. Learn the latest statistics on suicide. Data on suicide are taken from the Centers for Disease Control and Prevention (CDC) Data & Statistics Fatal Injury Report for 2018, as of March 1, 2020. Suicide rates listed are Age-Adjusted Rates.

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Numerous infographics show the disparities between career choices and pay between genders (p 31 – 33, 49 – 54).

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BBC states that girls lose confidence in their abilities as early as 6 years-old
(p 42 – 44).

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Girls start to see themselves as less innately talented than boys do when they are only six years old, a group of US researchers has said.

They said the "disheartening" results suggested the problem could snowball to affect future careers.

The study on 400 children, in the journal Science, initially found both five-year-old boys and girls thought their own gender was "brilliant".

But then only one year later, gender differences had emerged.
Girl Power: How can books empower young girls?
The team from Princeton University, New York University and the University of Illinois said it appeared stereotypes were starting to show.

Suspected influences include exposure to media, teachers, parents and other children.

The study put sets of five, six and seven-year-olds through different experiments.

In one, the children were read a story about someone who is "really, really smart" but it is not clear who the story is about.

They then had to guess the protagonist from four pictures - two of men and two of women.

At age five, boys pick men and girls pick women around 75% of the time. But fast-forward a year to age six and boys are still picking men while girls are now slightly more likely to pick men too.

In another scenario, groups of children played a new board game.

But for some it was branded as "for children who are really, really smart" and for others it was described as "for children who try really, really hard".

Six and seven-year old girls were as likely as boys to enjoy the game for those who try, but much less likely to say they enjoy the game for smart children.

Prof Andrei Cimpian, one of the researchers, told the BBC News website: "The message that comes out of these data is that young kids are exposed to the cultural notion that genius is more likely a male than a female quality.

"It's disheartening to see these effects emerge so early. When you see them, you realise how much of an uphill battle it's going to be."

His research has previously looked at academic careers associated with needing innate brilliance in order to succeed.

It argued that the higher people rated the need for genius - such as in physics or philosophy - the lower the number of women involved.

Prof Cimpian added: "Early on, society's stereotypes can create differences in trajectory.

"At five, six or seven you're not thinking about a career, but soon you're making decisions about what courses to take and what extracurriculars to take part in.

"Even if the difference starts small it can snowball into something a lot bigger."

Fellow researcher Dr Lin Bian advised parents and teachers to emphasise the importance of hard work.

She told the BBC: "[Studies suggest] that everyone does better when hard work is believed as the key to success.

"In our studies, girls might be particularly impacted by the messages focusing on 'hard work' - they became equally interested in playing the game as boys.

"Thus conveying the importance of hard work to success could protect and even promote young girls' interests."

The UK's Fawcett Society campaigns on the gender pay gap and argues early differences - blue and superheroes versus pink and princesses - is part of the problem.

Sam Smethers, the organisation's chief executive, said: "This is a massive issue and it is holding us all, but particularly girls, back.

" Our research found that young women experienced gender stereotypes at school and from an early age."

Follow James on Twitter.

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Girls start to see themselves as less innately talented than boys do when they are only six years old, a group of US researchers has said. They said the "disheartening" results suggested the problem could snowball to affect future careers.

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ND House Representatives discuss reasons to keep ND's Blue Laws. Two lawmakers cite sexist reasons to keep them
(p 32 – 33).

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Repeal of the Blue Laws in North Dakota has hit another roadblock. The House of Representatives voted against getting rid of them.

But, what's coming to light now are the comments made by male house members on the chamber floor. Their argument for keeping the law? So wives can use that time to make their husbands breakfast in bed.

It was only by a thin margin repealing North Dakota's Sunday closing law failed in the house.

One lawmaker in favor of keeping the law in place feels Sunday mornings should be used for your wife to make you breakfast in bed.

"Spending time with your wife, your husband. Making him breakfast, bringing it to him in bed and then after that go take your kids for a walk," says Representative Bernie Satrom.

Another feels his wife spends all his hard earned money the rest of the week and his wallet needs a day off. "I don't know about you but my wife has no problem spending everything I earn in 6 and a half days. And I don't think it hurts at all to have a half day off," says Representative Vernon Laning.

"I don't see what's so frustrating about it. If that's the way they want to live, that's their choice," says Vonnie Flute from Fargo. "But you don't find it degrading or anything like that?" asks Valley News Team's Bradford Arick. "No, I don't see why you should," Flute responds.

Sarah Cramer, from Fargo has a different point of view. "I really, I hadn't heard the comments. I hadn't heard how outright the comments were. It's frustrating personally because when you know those are the people representing you and you don't feel like you're being represented and those kind of backwards ways of thinking are still present, it's really, it's upsetting."

Valley News Live reached out to the North Dakota Women's Network, a spokesperson called this "regrettable humor." They add that it was sad to do this at the expense of women and perhaps these legislators are not taking policy-making for their women constituents seriously because of their personal biases.

We also called Representative Bernie Satrom, but got no answer. We called Representative Laning, and he laughed when we confronted him about the comments.

Representative Laning says it was only intended to be a humorous note, and he's not sure why some people have taken it personally. He adds that maybe those people lack a sense of humor. He said it's not indicative of how he feels about women or his wife.

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ND lawmakers say Blue Laws should remain so wives can make breakfast in bed

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Repeal of the Blue Laws in North Dakota has hit another roadblock. The House of Representatives voted against getting rid of them. But, what's coming to light now are the comments made by male house members on the chamber floor.

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Hannah Witton shares her hatred of the idea of "looking like a slut" and the related rape culture insinuations (p 40 – 44, 62).

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No-one wants to look like a slut. But what does a slut look like? What is a slut? Spoiler alert: there's no such thing as a slut. Do I Look Like A Slut? Posters!

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Guante challenges the phrase "Man Up" in his slam poetry (p 44 – 46).

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Guante - "Ten Responses to the Phrase 'Man Up'"

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While OECD countries have made great progress in narrowing gender gaps in education, new gender disparities in school performance are opening. Six out of ten students who do not even achieve the baseline level of proficiency in reading, mathematics and science are boys.

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While OECD countries have made great progress in narrowing gender gaps in education, new gender disparities in school performance are opening. Six out of ten students who do not even achieve the baseline level of proficiency in reading, mathematics and science are boys.

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ElleUK photoshops men out of politics, news shows, and other high-profile jobs to show the lack of women "at the top", sparking the hashtag #MoreWomen. The campaign was met with social backlash amid support (p 38 – 40, 49 – 54).

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Red carpet looks from the 2017 Grammy Awards show the difference between female and male dress (p 35 – 36, 58 – 62).

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All The Red Carpet Looks At The 2017 GRAMMY Awards

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American Psychological Association discusses the hurdles that therapists must overcome to reach men (p 44 – 46).

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Try to imagine the Marlboro man in therapy. The image just doesn't compute, does it? The Marlboro man wouldn't admit to needing help. The Marlboro man wouldn't talk about his emotions. For that matter, the Marlboro man might not even recognize that he has emotions.

That, in a nutshell, is the problem with convincing men to seek help of any kind, including therapy, according to Jill Berger, PhD, a recent psychology graduate of Nova Southeastern University who studies the psychology of masculinity. Traditionally, she says, society demands that men emulate a Marlboro man ideal--tough, independent and unemotional--that just isn't compatible with therapy.

Indeed, dozens of studies and surveys over the past several decades have shown that men of all ages and ethnicities are less likely than women to seek help for all sorts of problems--including depression, substance abuse and stressful life events--even though they encounter those problems at the same or greater rates as women. In a 1993 study published in Psychotherapy (Vol. 30, No. 4, pages 546-553), for example, psychologist John Vessey, PhD, reviewed several epidemiologic surveys and found that a full two-thirds of mental health outpatient visits were made by women. This inability, reluctance or straight-up unwillingness to get help can harm men's own mental and physical health, and can make life more difficult for their friends and families, says Berger.

Of course, not all men are the same. And recently, some researchers have begun to delve more deeply into men's help-seeking behavior, to try to parse the societal and personal factors that make some men, in some situations, more likely to reach out to a psychologist or other source of aid.

"I don't think that it's biologically determined that men will seek less help than women," says University of Missouri Counseling Psychology Professor Glenn Good, PhD, who studies men and masculinity and also has a private practice that focuses on men. "So if that's true, then it must mean that it's socialization and upbringing: Men learn to seek less help."

He and other researchers hope that by understanding what drives men toward or away from therapy and other types of help, they'll be able to encourage more men to get help when needed, and to make that help more effective. Their research so far suggests two key solutions: Make men understand that many other men face mental health issues like depression, and adjust the description of therapy itself to make it more appealing to men.

Why men don't seek help

The first hurdle some men face is that they may be so out of touch with their emotions that they do not even realize that they are, for example, depressed. APA President and Nova Southeastern University psychologist Ronald F. Levant, EdD, has coined the term "normative male alexithymia"--literally "without words for emotions" ( see page 60)--to describe this phenomenon.

Many boys, he says, learn from their parents and from other children that they are not supposed to express vulnerability or caring. They learn to suppress their emotional responses--like crying or even sad facial expressions--so much that, by the time they are adults, they are genuinely unaware of their emotions and how to describe them in words.

In his book "New Psychotherapies for Men" (Wiley, 1997), Levant gives the example of a father stood up by his son for a father-son hockey game. When asked his feelings on the subject, the father said "He shouldn't have done it!" It wasn't until the therapist prompted him again that he managed to say he was upset.

Even when men do realize that they are depressed, abusing alcohol or have some other problem, they are still less likely than women to see a psychologist or other mental health professional, says psychologist and masculinity researcher James Mahalik, PhD, of Boston College, who gives a thorough overview of the evidence in a 2003 article in the American Psychologist (Vol. 58, No. 1, pages 5-14). In the article, he and co-author Michael Addis, PhD, also outline some of the factors underlying men's reluctance:

Masculine role socialization. To benefit from counseling, a man must admit that he needs help, must rely on the counselor and must openly discuss and express emotion. These requirements, says Mahalik, conflict with traditional ideals of what it means to be male: toughness, independence and emotional control.

"What we're finding is that the more men 'do their gender' and define themselves by traditional roles in our society, the less they tend to get help," Mahalik says.

In a study published this January in the Psychology of Men and Masculinity (Vol. 6, No. 1, pages 73-78), for example, Berger, Levant and their colleagues found that men with higher levels of traditional masculinity ideology also tended to have a more negative opinion of seeking psychological help.

And in a 1995 study in the Journal of Counseling and Development (Vol. 74, No. 1, pages 70-75), Good found that men who scored higher on a test of male gender role conflict--a conflict between rigid learned gender roles and the healthy expression of emotion--were more likely to be depressed and more likely to have a negative opinion of psychological counseling.

Social Norms. Some men may also worry that society will look down on a man who can't "tough it out" on his own, and that seeking--or even needing--help is not "normal" male behavior. Even men who do seek counseling may worry about what others think of their choice, including Tim (a pseudonym), a client of Good's in his 50s who began therapy after he ended an extramarital affair.

"I was not afraid of counseling," he says, "maybe because I'm not a very typical male--I tend to be pretty open with my emotions."

He did, however, have one concern--telling his boss why he needed to take time off work. Although his boss ended up being relatively understanding, Tim says, he's not sure that would be the case with everyone.

"I have to be very careful with whom I discuss the issue of being in therapy--I think there is a stigma," he says. "People expect men to be 'strong.'"

And indeed, Mahalik notes, a man who is surrounded by a supportive group of other men--say, a church group that encouraged members to share problems and seek support--might be more likely to seek help than a man whose only social network discouraged such sharing.

In general, Mahalik says, men are more likely to seek help for problems that they think are normative--that is, problems that many other men share.

"If men perceive that being depressed is not 'normal,' then if they do try to get help they may feel dysfunctional and aberrant," Mahalik explains. "So instead they might try to keep the depression quiet, and maybe self-medicate with drugs or alcohol."

What can be done?

One way to convince more men to seek help, then, is to convince them that the things they need help with are "normal." In this regard, Mahalik says, psychology could take a cue from the erectile dysfunction drug industry.

"Men are going in to see their doctors much more about erectile dysfunction now, after the ads for Viagra and other drugs, because there's so much more awareness," he explains.

And in fact, psychology is beginning to do just that. In 2003, for example, the National Institute of Mental Health launched a national media campaign called "Real Men. Real Depression." to raise awareness that depression affects more than 6 million men annually ( see page 66). And the National Football League's "Tackling Men's Health" campaign--which aims to convince men to visit their doctors and proactively manage their health--includes a Web site section on mental health, with a link to a depression self-screening test (see www.nfl.com/tacklingmenshealth).

Psychologists can also work to make the terminology they use to describe therapy more palatable to men, says John Robertson, PhD, an emeritus professor at Kansas State University. In a 1992 study in the Journal of Counseling Psychology (Vol. 39, No. 2, pages 240-246), for example, he created two brochures for a campus counseling center and distributed them to community college students in auto mechanics, welding and other mostly male areas. One of the brochures described the center's counseling services in traditional terms, the other used terms like "consultations" rather than "therapy" and emphasized self-help and achievement. He found that the men who received the second brochure were more likely to say they'd seek assistance at the center than men who received the traditional one.

Robertson also has a private practice that focuses almost entirely on men, and he says that in his advertising he emphasizes skills--like parenting skills or anger control skills--much more than, say, personal development.

"It's not a particularly surprising or brilliant notion," he says, "that you want to match the client to the service."

And as psychologists continue to study men and help-seeking, they'll be better able to do just that.

"What are the contexts that may influence men to seek help, and why?" asks Mahalik. "That's the challenge for us to figure out, in terms of both clinical research and outreach. Right now we have some beginnings of the answers."

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University of Missouri Counseling Psychology

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Try to imagine the Marlboro man in therapy. The image just doesn't compute, does it? The Marlboro man wouldn't admit to needing help. The Marlboro man wouldn't talk about his emotions. For that matter, the Marlboro man might not even recognize that he has emotions.

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Decked out in a gold-sequined gown, 24-year-old dental surgery student Iris Mittenaere beat 12 other finalists to take the crown. As Miss Universe, she will be campaigning for dental and oral care around the world.

"This sash is not only a sash," said Mittenaere, who is from Northern France, in a Miss Universe interview after the pageant. "This is something to help people, to understand people."

First and second runner-ups were Miss Haiti (Raquel Pelissier) and Miss Colombia (Andrea Tovar). The top finalists hailed from Kenya, Indonesia, Mexico, Peru, Panama, Colombia, Phillippines, Canada, Brazil, France, Haiti, Thailand and the U.S.

The pageant changed its format this year; it had 12 instead of 13 finalists, and counted online votes from the Miss Universe app and Twitter.

This was the first time Sierra Leone entered the competition and was represented by Hawa Kamara, 2013 Miss West Africa. Miss Canada, Siera Bearchell, also made headlines for taking on trolls who body-shamed her for her size.

The annual pageant was held on Monday at the Mall of Asia Arena in Metro Manila, Philippines. Host Steve Harvey joked on the show that he got the winner right this year, after last year's snafu of getting it wrong. Rapper Flo Rida and R&B group Boys II Men provided entertainment.

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Decked out in a gold-sequined gown, 24-year-old dental surgery student Iris Mittenaere beat 12 other finalists to take the crown. As Miss Universe, she will be campaigning for dental and oral care around the world. "This sash is not only a sash," said Mittenaere, who is from Northern France, in a Miss Universe interview after the pageant.

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Miss Universe has made leaps and bounds as far as diversity and acceptance, with body positivity and talk of strong female leaders; however, the contestants are still judged on their looks before they can reach the question rounds (p 58 – 62).

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Miss Universe 2017: Top 10 Bikini Bodies

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See the final 9 contestants in the bikini portion of the Miss Universe pageant, held on January 29, 2017, in Manila, Philippines.

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CoverGirl's first CoverBoy, James Charles faces backlash amidst support from fans (p 58 – 62).

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In the course of a year, teen makeup artist James Charles has gone from starting an Instagram account showing off his impressive work to getting shoutouts from Katy Perry for making history.

On Tuesday, the pop star helped announce that Charles has become the first male to represent the CoverGirl brand.

"All CoverGirls are role models and boundary-breakers, fearlessly expressing themselves, standing up for what they believe, and redefining what it means to be beautiful,'' the company said in a statement to TODAY. "James Charles is no exception. One year ago, he boldly chose to launch his Instagram to the world, using transformative, dynamic makeup looks to showcase the many facets of his personality, serving as an inspiration to anyone who might have been afraid to do the same.

"We support anyone and everyone who wants to express themselves with makeup. CoverGirl believes in beauty for all, and we're proud to welcome James Charles to the family."

RELATED: 15 drugstore mascaras celebrity makeup artists can't live without

Charles, 17, now has more than 525,000 Instagram followers and 77,000 YouTube subscribers who come to check out his stylish creations.

He also is known for taking his high school senior picture to another level at Bethlehem Central High School in Delmar, New York.

The CoverGirl partnership with Charles began Tuesday and will include a new mascara coming out later this month.

RELATED: Get your pumpkin spice fix with these 29 pumpkin beauty products

"I am so beyond excited and overwhelmed and happy and astonished and of course, SHOOK, to announce that I am the newest face of CoverGirl,'' Charles wrote on Instagram. "First ever male ambassador for the brand and I am so honored and excited to be working with such an iconic brand.

"I started my Instagram one year ago to inspire others and as an artistic outlet to challenge myself creatively. I truly hope that this shows that anyone and everyone can wear makeup and can do anything if you work hard."

Follow TODAY.com writer Scott Stump on Twitter.

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Meet CoverGirl's first 'CoverBoy': Teen makeup artist breaks beauty barriers

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In the course of a year, teen makeup artist James Charles has gone from starting an Instagram account showing off his impressive work to getting shoutouts from Katy Perry for making history. On Tuesday, the pop star helped announce that Charles has become the first male to represent the CoverGirl brand.

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A high-profile, peer-reviewed, scientific journal discusses the science supporting a gender and sex spectrum (p 24, 48 – 49).

"... sex [is] assigned by anatomy, hormones, [individual] cells, and chromosomes...

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Illustration by Jonny Wan

As a clinical geneticist, Paul James is accustomed to discussing some of the most delicate issues with his patients. But in early 2010, he found himself having a particularly awkward conversation about sex.

A 46-year-old pregnant woman had visited his clinic at the Royal Melbourne Hospital in Australia to hear the results of an amniocentesis test to screen her baby's chromosomes for abnormalities. The baby was fine - but follow-up tests had revealed something astonishing about the mother. Her body was built of cells from two individuals, probably from twin embryos that had merged in her own mother's womb. And there was more. One set of cells carried two X chromosomes, the complement that typically makes a person female; the other had an X and a Y. Halfway through her fifth decade and pregnant with her third child, the woman learned for the first time that a large part of her body was chromosomally male. "That's kind of science-fiction material for someone who just came in for an amniocentesis," says James.

Sex can be much more complicated than it at first seems. According to the simple scenario, the presence or absence of a Y chromosome is what counts: with it, you are male, and without it, you are female. But doctors have long known that some people straddle the boundary - their sex chromosomes say one thing, but their gonads (ovaries or testes) or sexual anatomy say another. Parents of children with these kinds of conditions - known as intersex conditions, or differences or disorders of sex development (DSDs) - often face difficult decisions about whether to bring up their child as a boy or a girl. Some researchers now say that as many as 1 person in 100 has some form of DSD.

When genetics is taken into consideration, the boundary between the sexes becomes even blurrier. Scientists have identified many of the genes involved in the main forms of DSD, and have uncovered variations in these genes that have subtle effects on a person's anatomical or physiological sex. What's more, new technologies in DNA sequencing and cell biology are revealing that almost everyone is, to varying degrees, a patchwork of genetically distinct cells, some with a sex that might not match that of the rest of their body. Some studies even suggest that the sex of each cell drives its behaviour, through a complicated network of molecular interactions. "I think there's much greater diversity within male or female, and there is certainly an area of overlap where some people can't easily define themselves within the binary structure," says John Achermann, who studies sex development and endocrinology at University College London's Institute of Child Health.

These discoveries do not sit well in a world in which sex is still defined in binary terms. Few legal systems allow for any ambiguity in biological sex, and a person's legal rights and social status can be heavily influenced by whether their birth certificate says male or female.

"The main problem with a strong dichotomy is that there are intermediate cases that push the limits and ask us to figure out exactly where the dividing line is between males and females," says Arthur Arnold at the University of California, Los Angeles, who studies biological sex differences. "And that's often a very difficult problem, because sex can be defined a number of ways."

The start of sex

That the two sexes are physically different is obvious, but at the start of life, it is not. Five weeks into development, a human embryo has the potential to form both male and female anatomy. Next to the developing kidneys, two bulges known as the gonadal ridges emerge alongside two pairs of ducts, one of which can form the uterus and Fallopian tubes, and the other the male internal genital plumbing: the epididymes, vas deferentia and seminal vesicles. At six weeks, the gonad switches on the developmental pathway to become an ovary or a testis. If a testis develops, it secretes testosterone, which supports the development of the male ducts. It also makes other hormones that force the presumptive uterus and Fallopian tubes to shrink away. If the gonad becomes an ovary, it makes oestrogen, and the lack of testosterone causes the male plumbing to wither. The sex hormones also dictate the development of the external genitalia, and they come into play once more at puberty, triggering the development of secondary sexual characteristics such as breasts or facial hair.

Changes to any of these processes can have dramatic effects on an individual's sex. Gene mutations affecting gonad development can result in a person with XY chromosomes developing typically female characteristics, whereas alterations in hormone signalling can cause XX individuals to develop along male lines.

For many years, scientists believed that female development was the default programme, and that male development was actively switched on by the presence of a particular gene on the Y chromosome. In 1990, researchers made headlines when they uncovered the identity of this gene, which they called SRY. Just by itself, this gene can switch the gonad from ovarian to testicular development. For example, XX individuals who carry a fragment of the Y chromosome that contains SRY develop as males.

By the turn of the millennium, however, the idea of femaleness being a passive default option had been toppled by the discovery of genes that actively promote ovarian development and suppress the testicular programme - such as one called WNT4. XY individuals with extra copies of this gene can develop atypical genitals and gonads, and a rudimentary uterus and Fallopian tubes. In 2011, researchers showed that if another key ovarian gene, RSPO1, is not working normally, it causes XX people to develop an ovotestis - a gonad with areas of both ovarian and testicular development.

These discoveries have pointed to a complex process of sex determination, in which the identity of the gonad emerges from a contest between two opposing networks of gene activity. Changes in the activity or amounts of molecules (such as WNT4) in the networks can tip the balance towards or away from the sex seemingly spelled out by the chromosomes. "It has been, in a sense, a philosophical change in our way of looking at sex; that it's a balance," says Eric Vilain, a clinician and the director of the Center for Gender-Based Biology at the University of California, Los Angeles. "It's more of a systems-biology view of the world of sex."

Battle of the sexes

According to some scientists, that balance can shift long after development is over. Studies in mice suggest that the gonad teeters between being male and female throughout life, its identity requiring constant maintenance. In 2009, researchers reported deactivating an ovarian gene called Foxl2 in adult female mice; they found that the granulosa cells that support the development of eggs transformed into Sertoli cells, which support sperm development. Two years later, a separate team showed the opposite: that inactivating a gene called Dmrt1 could turn adult testicular cells into ovarian ones. "That was the big shock, the fact that it was going on post-natally," says Vincent Harley, a geneticist who studies gonad development at the MIMR-PHI Institute for Medical Research in Melbourne.

The gonad is not the only source of diversity in sex. A number of DSDs are caused by changes in the machinery that responds to hormonal signals from the gonads and other glands. Complete androgen insensitivity syndrome, or CAIS, for example, arises when a person's cells are deaf to male sex hormones, usually because the receptors that respond to the hormones are not working. People with CAIS have Y chromosomes and internal testes, but their external genitalia are female, and they develop as females at puberty.

Conditions such as these meet the medical definition of DSDs, in which an individual's anatomical sex seems to be at odds with their chromosomal or gonadal sex. But they are rare - affecting about 1 in 4,500 people. Some researchers now say that the definition should be widened to include subtle variations of anatomy such as mild hypospadias, in which a man's urethral opening is on the underside of his penis rather than at the tip. The most inclusive definitions point to the figure of 1 in 100 people having some form of DSD, says Vilain (see 'The sex spectrum').

But beyond this, there could be even more variation. Since the 1990s, researchers have identified more than 25 genes involved in DSDs, and next-generation DNA sequencing in the past few years has uncovered a wide range of variations in these genes that have mild effects on individuals, rather than causing DSDs. "Biologically, it's a spectrum," says Vilain.

A DSD called congenital adrenal hyperplasia (CAH), for example, causes the body to produce excessive amounts of male sex hormones; XX individuals with this condition are born with ambiguous genitalia (an enlarged clitoris and fused labia that resemble a scrotum). It is usually caused by a severe deficiency in an enzyme called 21-hydroxylase. But women carrying mutations that result in a milder deficiency develop a 'non-classical' form of CAH, which affects about 1 in 1,000 individuals; they may have male-like facial and body hair, irregular periods or fertility problems - or they might have no obvious symptoms at all. Another gene, NR5A1, is currently fascinating researchers because variations in it cause a wide range of effects, from underdeveloped gonads to mild hypospadias in men, and premature menopause in women.

Many people never discover their condition unless they seek help for infertility, or discover it through some other brush with medicine. Last year, for example, surgeons reported that they had been operating on a hernia in a man, when they discovered that he had a womb. The man was 70, and had fathered four children.

Cellular sex

Studies of DSDs have shown that sex is no simple dichotomy. But things become even more complex when scientists zoom in to look at individual cells. The common assumption that every cell contains the same set of genes is untrue. Some people have mosaicism: they develop from a single fertilized egg but become a patchwork of cells with different genetic make-ups. This can happen when sex chromosomes are doled out unevenly between dividing cells during early embryonic development. For example, an embryo that starts off as XY can lose a Y chromosome from a subset of its cells. If most cells end up as XY, the result is a physically typical male, but if most cells are X, the result is a female with a condition called Turner's syndrome, which tends to result in restricted height and underdeveloped ovaries. This kind of mosaicism is rare, affecting about 1 in 15,000 people.

The effects of sex-chromosome mosaicism range from the prosaic to the extraordinary. A few cases have been documented in which a mosaic XXY embryo became a mix of two cell types - some with two X chromosomes and some with two Xs and a Y - and then split early in development. This results in 'identical' twins of different sexes.

There is a second way in which a person can end up with cells of different chromosomal sexes. James's patient was a chimaera: a person who develops from a mixture of two fertilized eggs, usually owing to a merger between embryonic twins in the womb. This kind of chimaerism resulting in a DSD is extremely rare, representing about 1% of all DSD cases.

"Surgeons discovered that the man had a womb. He was 70."

Another form of chimaerism, however, is now known to be widespread. Termed microchimaerism, it happens when stem cells from a fetus cross the placenta into the mother's body, and vice versa. It was first identified in the early 1970s - but the big surprise came more than two decades later, when researchers discovered how long these crossover cells survive, even though they are foreign tissue that the body should, in theory, reject. A study in 1996 recorded women with fetal cells in their blood as many as 27 years after giving birth; another found that maternal cells remain in children up to adulthood. This type of work has further blurred the sex divide, because it means that men often carry cells from their mothers, and women who have been pregnant with a male fetus can carry a smattering of its discarded cells.

Microchimaeric cells have been found in many tissues. In 2012, for example, immunologist Lee Nelson and her team at the University of Washington in Seattle found XY cells in post-mortem samples of women's brains. The oldest woman carrying male DNA was 94 years old. Other studies have shown that these immigrant cells are not idle; they integrate into their new environment and acquire specialized functions, including (in mice at least) forming neurons in the brain. But what is not known is how a peppering of male cells in a female, or vice versa, affects the health or characteristics of a tissue - for example, whether it makes the tissue more susceptible to diseases more common in the opposite sex. "I think that's a great question," says Nelson, "and it is essentially entirely unaddressed." In terms of human behaviour, the consensus is that a few male microchimaeric cells in the brain seem unlikely to have a major effect on a woman.

Scientists are now finding that XX and XY cells behave in different ways, and that this can be independent of the action of sex hormones. "To tell you the truth, it's actually kind of surprising how big an effect of sex chromosomes we've been able to see," says Arnold. He and his colleagues have shown that the dose of X chromosomes in a mouse's body can affect its metabolism, and studies in a lab dish suggest that XX and XY cells behave differently on a molecular level, for example with different metabolic responses to stress. The next challenge, says Arnold, is to uncover the mechanisms. His team is studying the handful of X-chromosome genes now known to be more active in females than in males. "I actually think that there are more sex differences than we know of," says Arnold.

Beyond the binary

Biologists may have been building a more nuanced view of sex, but society has yet to catch up. True, more than half a century of activism from members of the lesbian, gay, bisexual and transgender community has softened social attitudes to sexual orientation and gender. Many societies are now comfortable with men and women crossing conventional societal boundaries in their choice of appearance, career and sexual partner. But when it comes to sex, there is still intense social pressure to conform to the binary model.

This pressure has meant that people born with clear DSDs often undergo surgery to 'normalize' their genitals. Such surgery is controversial because it is usually performed on babies, who are too young to consent, and risks assigning a sex at odds with the child's ultimate gender identity - their sense of their own gender. Intersex advocacy groups have therefore argued that doctors and parents should at least wait until a child is old enough to communicate their gender identity, which typically manifests around the age of three, or old enough to decide whether they want surgery at all.

This issue was brought into focus by a lawsuit filed in South Carolina in May 2013 by the adoptive parents of a child known as MC, who was born with ovotesticular DSD, a condition that produces ambiguous genitalia and gonads with both ovarian and testicular tissue. When MC was 16 months old, doctors performed surgery to assign the child as female - but MC, who is now eight years old, went on to develop a male gender identity. Because he was in state care at the time of his treatment, the lawsuit alleged not only that the surgery constituted medical malpractice, but also that the state denied him his constitutional right to bodily integrity and his right to reproduce. Last month, a court decision prevented the federal case from going to trial, but a state case is ongoing.

"This is potentially a critically important decision for children born with intersex traits," says Julie Greenberg, a specialist in legal issues relating to gender and sex at Thomas Jefferson School of Law in San Diego, California. The suit will hopefully encourage doctors in the United States to refrain from performing operations on infants with DSDs when there are questions about their medical necessity, she says. It could raise awareness about "the emotional and physical struggles intersex people are forced to endure because doctors wanted to 'help' us fit in," says Georgiann Davis, a sociologist who studies issues surrounding intersex traits and gender at the University of Nevada, Las Vegas, who was born with CAIS.

Doctors and scientists are sympathetic to these concerns, but the MC case also makes some uneasy - because they know how much is still to be learned about the biology of sex. They think that changing medical practice by legal ruling is not ideal, and would like to see more data collected on outcomes such as quality of life and sexual function to help decide the best course of action for people with DSDs - something that researchers are starting to do.

Diagnoses of DSDs once relied on hormone tests, anatomical inspections and imaging, followed by painstaking tests of one gene at a time. Now, advances in genetic techniques mean that teams can analyse multiple genes at once, aiming straight for a genetic diagnosis and making the process less stressful for families. Vilain, for example, is using whole-exome sequencing - which sequences the protein-coding regions of a person's entire genome - on XY people with DSDs. Last year, his team showed that exome sequencing could offer a probable diagnosis in 35% of the study participants whose genetic cause had been unknown.

Vilain, Harley and Achermann say that doctors are taking an increasingly circumspect attitude to genital surgery. Children with DSDs are treated by multidisciplinary teams that aim to tailor management and support to each individual and their family, but this usually involves raising a child as male or female even if no surgery is done. Scientists and advocacy groups mostly agree on this, says Vilain: "It might be difficult for children to be raised in a gender that just does not exist out there." In most countries, it is legally impossible to be anything but male or female.

Yet if biologists continue to show that sex is a spectrum, then society and state will have to grapple with the consequences, and work out where and how to draw the line. Many transgender and intersex activists dream of a world where a person's sex or gender is irrelevant. Although some governments are moving in this direction, Greenberg is pessimistic about the prospects of realizing this dream - in the United States, at least. "I think to get rid of gender markers altogether or to allow a third, indeterminate marker, is going to be difficult."

So if the law requires that a person is male or female, should that sex be assigned by anatomy, hormones, cells or chromosomes, and what should be done if they clash? "My feeling is that since there is not one biological parameter that takes over every other parameter, at the end of the day, gender identity seems to be the most reasonable parameter," says Vilain. In other words, if you want to know whether someone is male or female, it may be best just to ask.

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University College London 's Institute of Child Health

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Illustration by Jonny Wan As a clinical geneticist, Paul James is accustomed to discussing some of the most delicate issues with his patients. But in early 2010, he found himself having a particularly awkward conversation about sex.