Cross-Cultural Aspects of Contraceptive Counseling

email: loejet@wxs.nl

Introduction:
Who has not had the experience as a practical provider of contraception and counseling in reproductive matters that the help, offered to a person of another culture does not seem to reach the patient:

  For instance, she has had three unwanted pregnancies in the course of two years, or
        there were repeated consultations for side effects of contraception you have never heard 
        of or an apparent dislike for all kinds of contraception for unclear reasons.

It makes the provider helpless and uncomfortable and more often than not he or she gives up. 'If the help I can offer is not appreciated, so be it'. With the greater mobility of this era voluntary and involuntary migration is increasing and a growing number of clients from another culture comes for consultation so it is necessary to improve our communication in this respect. 

The big problem is that most health care providers want this in a small neat package: give me 'three golden tips', or 'ten rules of do's and don'ts'. This is impossible, as for every rule there is an exception, the truth often lies in the grey area and is not a matter of black and white. Generally speaking one can say: when in doubt ask the patient and ask again if you do not understand. This is why the motto for my presentation is so important: Do not judge thy neighbor until thou hast come into his place (Talmud).

This contribution will deal with:

• the formulation of sexual and reproductive rights
• theoretical aspects of cross-cultural communication
• education and change in behavior
• cultural aspects of sexual and reproductive health
• some differences in ideas and misconceptions towards contraception
• aspects and pitfalls of cross-cultural counseling

Sexual and Reproductive Rights
The sexual and reproductive rights are worded in a charter by the IPPF, produced in the wake of the UN International Conference on Population and Development in 1994 in Cairo. They are formulated in terms of human rights. In short they boil down to: sexuality without force or violence, wanted pregnancies and healthy deliveries.
 
These rights have been accepted by all participating countries. One wonders then where the problem is. If all governments agree and put these rights into practice most reproductive problems would be solved.

In practice though there are still many problems: - in some countries demographic goals are still pursued and incentives and disincentives are being used to reach the number of children the government wants. - access to contraceptive counseling is in many countries restricted to married women In these countries husbands often may forbid their wives to use contraception. - in many countries there is a limited choice of contraceptives available, the diaphragm and morning after pill are often not available. - sexual education for adolescents and education on the prevention of STD is limited or non existing and when an unwanted pregnancy occurs there is no place where adolescent can go for counseling or help.
 
The main reason for these problems are poverty, cultural and religious traditions and the lack of political aim. The solutions proposed are in the empowerment of women, male involvement and the building of holistic models of women's healthcare.  

Theoretical Aspects of Cross-Cultural Communication
In the theory of communication there are the following starting points:
     1. one cannot not communicate
     2. communication has a verbal and a nonverbal message
     3. communication has a contents- aspect and a relation- aspect
     4. In a chain of communication different interpretations can be attributed to cause and     
         consequences, due to differences between the two communicating persons.

There is a sender, a receiver and a message. The message has to be coded to be transmitted. The contents as well as the code of the message are culturally determined. The receiver decodes the message and reacts to the sender and so forth. This goes on till consensus as to the contents is reached. As soon as communication is colored by cultural or language differences distortion of the contents happens: the code is not directly decipherable because of differences in language, culture and power. For instance a woman uses the progestagen-only injectable and comes to you complaining of amenorrhea. Then it is important to know what she fears or dislikes about it and this could very well be different if she were from your own country. Or, a couple uses condoms as contraception but the husband has erection problems. Imagine how difficult it can be to explain this in a foreign language to a strange doctor. 

        1.   In cross-cultural communication one can try to solve these problems by:

a. realization of one's own norms, values and traditions
b. knowledge of the norms, values and traditions of the other culture
c. ability to handle the differences.

2.   In cross-cultural communication the verbal and nonverbal signs can easily be misinterpreted. By not having a common language at all and so having to communicate through interpreters, or by not mastering one and the same language and so blunder along. Also the way one uses a language: in a metaphorical or concrete sense, direct or indirect. The way one sits and looks or avoids looking at the other, shake hands. They all have certain cultural implications which can be misunderstood. For instance: A couple comes for contraception. The wife says nothing and looks down at her hands, while the husband speaks with the male doctor. This can be interpreted very differently in different cultures.

3.   On the relation-level of communication, implicit messages are exchanged dealing with the emotional impact of the complaint. (For instance: if the injectable causes the menstruation to stop, does this mean I will become permanently infertile?) Ideas and expectations that are associated with a certain tradition. What are the unspoken expectations of the client? These messages are often even more important than the contents of the complaint.

Cultural Aspects of Sexual and Reproductive Health
Before saying anything about this I would like to emphasize once more that the individual differences are much greater than the cultural similarities and for each statement there can be an individual exception. It makes a lot of difference how long the person has been living in a certain cultural background, there are large variations inside one country depending on religion, wealth and power of the individual. The only way one can be sure of an interpretation is to check and double check. Otherwise you for instance may conclude from one picture in a book that all Dutchmen wear wooden shoes! With this in mind one can say a couple of general things. In a society reproductive health matters are decided according to certain traditions, for instance the position of men and women in this society. Are they equal, who decides the number of children, who earns the family income? Is there a free choice of partners? What are the opinions on premarital sex? Are extra-matrimonial relationships openly or silently accepted? Is there a double standard towards the behavior of boys and girls? And so on and so forth. Sexuality is a subject which is seldom openly discussed. Often sexual education is not given to adolescents because of the fear this will only lead to more sexual activity on their part.

• Religion
• Position man and woman in society
• Reproductive wishes of the couple
• Demographic goals of the government
• Attitude towards adolescent sexuality
• Is sexuality/ sexual education as a topic more or less a taboo
• Availability of and attitude towards contraceptive methods

I will give some examples on how differences in culture can be described. The examples given below are merely two of many examples possible. They are meant to illustrate the difference between two cultures and I realize that in doing it this way I oversimplify the matter. The oversimplification has the purpose to make the differences more explicit and one must realize that for every characteristic mentioned there are exceptions. One culture mentioned here is the one I myself am part of and the other is a tradition of many inhabitants of the Netherlands.
 
In great generalization one could say that in Western Europe the following is often correct: In the last 100 years a lot has changed: the economy has flourished, the influence of the Christian church has diminished in most countries, The individual is considered more important than the group to which he or she belongs. families have become smaller, the general education is higher than before. The emphasis is more on avoidance of guilt rather than shame, more on rights than on duties. There is more permissiveness of teenage sexuality and a lot of sexual education. In Roman Catholic countries there is greater resistance against abortion than against birth outside marriage.

• Relatively little influence of religion
• Individualistic society
• Small Families, many one- parent families
• More emphasis on rights than on duties
• Equal position of men and women
• Permissive attitude towards premarital sex and teenage sexuality
• Much information about reproductive health matters

Middle East, Islamic countries 
In these countries the rules of behavior are strongly influenced by religious teachings. This is also true in countries such as Indonesia, where a large part of the population is Islamic. There is more emphasis on the interests of the family or group than on those of the individual. The rules are dictated by avoidance of shame rather than guilt. The head of the family is responsible for the family. According to the Koran man and woman should reach consensus as to the sexual and reproductive matters, but in practice the man often has a dominant position. In many countries for instance he is the only one who can apply for a divorce.

• Strong religious influence
• Patriarchal structure
• Group/ family more important than individual
• Roles of men and women, girls and boys are strictly separate
• Often people have a double standard as to what is proper for men and women.
• Honor and shame are very important
• Sex before marriage is strictly forbidden, virginity is of utmost importance
• Sexual education sometimes given at home or in schools

Situation of Fugitives
In the situation of involuntary migration there are extra problems because of the situation in the country of origin. There was often war and violence in the history of the patient and sexual violence while in flight. This is a subject which is often impossible to talk about since it is far too traumatic. Often the husband has disappeared or is murdered or children are lost. In the Netherlands many of the fugitives are young, in 1994 almost 40% was younger than 19 years. Their view of the future is often very insecure. The rate of unwanted pregnancies is high among them for various reasons.  

Some differences in ideas and misconceptions towards contraception
In many countries only a limited choice of contraceptives is available, often there are restrictions according to age or marital status. Sometimes women do not know under which circumstances breastfeeding is reliable as contraception and almost everywhere male involvement can be improved. Many women stop using a certain form of contraception because they are afraid it is bad for their health or the return of fertility. Sometimes women make mistakes in the use of the contraceptive pill, sometimes the influence of certain hormonal contraceptives on the menstrual bleeding is unacceptable. In some countries vasectomy is mistaken for castration and therefore unacceptable, or a permanent form of contraception is not allowed on religious grounds. As I mentioned before: morning after methods and the diaphragm are often unknown. 

Education and Change in Behavior
The patient as well as the provider want to prevent unwanted pregnancies and therefore the correct use of reliable contraceptives is necessary in sexual relationships. Prevention is always difficult: you have to do something now to prevent something in the far future of which you are not certain it would happen if you did not do anything. 
If contraceptive behavior needs to be improved, this change involves several phases:
 
                                                          Attitude > Intention > Behavior Attitude means attention for a certain topic. This can be positive if the woman sees advantages in the use of contraception: a healthy mother gets healthy children. This attitude can be negative in fugitives, when there are too many other problems that need attention.
Intention means one is planning to use contraception. This can be positively influenced by the social group, mothers and girlfriends. The intention can be negative if the husband is against contraception or when there are fears concerning a certain form of contraception.
Behavior depends on the possibilities and impossibilities of the individual. Some women find it hard to use contraception effectively. Sometimes the preferred type of contraception is too expensive or not available.

Whether one succeeds in permanently altering a form of behavior also depends on the results and feedback the individual gets. Altogether this is not a simple procedure and involves much more time and effort than simply once prescribing a form of contraception by the provider. It is very important when there are problems to find out what they are, so the real problem is solved and this might not the presented one.

Aspects and Pitfalls of Cross-Cultural Counseling
This is presented from my point of view as a Dutch provider with my Western European ideas and pitfalls. If you come from a different cultural background these ideas and pitfalls could be quite different or even reverse. What everybody will have in common is that time and again you have to ask the patient whether the help you provide is the help that is needed. You need to have and show an open attitude towards the verbal and non-verbal messages. The norms and values of the provider are sometimes not the same as those of the patient. In the West we think for instance somatization should be avoided. The doctor-patient relationship is equal, patients should come in the correct time and follow instructions. We are very direct in our use of the language and come directly to the point, are impatient and restrict ourselves to a clearly defined problem. In many other countries the expectations are different: there should be time to establish confidentiality. The use of language is often far more indirect or metaphorical, especially on sensitive topics such as sexuality and emotions. The patient will sometimes give a vague description of the problem and expects the provider to know what to do. The provider, in his opinion, should provide practical help in a broad area.

And in spite of the fact that one should refrain from thinking that a few simple rules will make the counseling perfect, as I mentioned in the introduction, here will follow at least some of the pitfalls and golden rules of cross-cultural counseling: 

Pitfalls:

• The illusion of colorblindness: there is no difference
• The irreversible mark of oppression; by lifelong oppression there will be permanent damage to 
  the personality
• The great white father syndrome; the provider thinks he is omnipotent and always knows what is best for the patient
• 'They are so different': the difference makes the client unapproachable for the provider
  stereotyping
• limiting care to technical acts
• role-conflict when family members act as interpreter
• use of double negations or figure of speech

Golden Rules:

• show respect, be open to the norms and values of your client
• take time for the building of confidentiality
• show you are the professional, but avoid ethnocentric behavior
• use of implicit but clear language
• first ask fact, then opinions then emotions
• check if the communication has been correct, be aware of possible socially accepted answers
• the nonverbal messages of the client can have a culturally different meaning