Case Scenario

I see a lot of Hispanic patients in my clinic, including adolescents who have just arrived from their home countries who need school physicals. The common adolescent topics—safety, drugs and sex—don't seem to apply to them. Early in my career I stumbled once when I tried to talk with a 15-year-old boy (in somewhat rudimentary Spanish) about safe sex. He didn't seem to know what I was talking about. In fact, I had the distinct impression that he didn't know any of the basics concerning intercourse or normal sexual feelings. How does a physician approach such adolescents? What topics are appropriate for the boys? For the girls? How can I prepare them for the information they will receive from their peers?

Commentary

Latinos are now the largest minority group in the United States, so this scenario is one that many physicians are likely to face in their practices. How, in the face of substantial cultural and language barriers, can we effectively address adolescent health issues in this high-risk population?

The usual adolescent topics—safety, illicit drug and alcohol use, and sex—are of particular importance in the health care of Latino adolescents. Among teens 13 to 19 years of age, Latinos have the highest motor vehicle occupant death rate per billion vehicle miles of travel (vmt) at 45, compared with 34 deaths per billion vmt in African-Americans and 30 deaths per billion vmt in whites.¹ The higher death rates in Latino teens may be associated with documented lower rates of safety belt use.

Multiple studies confirm high rates of illicit drug use, alcohol consumption and tobacco use among Latino adolescents. Almost one fourth of Latinos in 10th grade reported heavy drinking and illicit drug use in the past 30 days, a proportion comparable to that in whites and significantly higher than the proportion in African-Americans.² A 1997 national survey of adolescent girls found that Latinos and whites were more likely than African-Americans and Asian-Americans to engage in risk behaviors (smoking cigarettes, consuming alcohol, using illicit drugs, bingeing and purging, and not exercising).³

Latino adolescents have high rates of sexual activity, teen pregnancy and sexually transmitted diseases and low rates of condom use. Among U.S. high school students, 45 percent of whites have engaged in sexual intercourse. The figure for Latinos is 54 percent—a proportion exceeded only by that among African-Americans (71 percent).⁴ Recent national data reveal that Latinos have the highest birth rates among teens 15 to 19 years of age, at 94 per 1,000 girls, compared with 35 per 1,000 in whites and 85 per 1,000 in African-Americans.⁵ Among adolescents 15 to 19 years of age, Latinos have rates of chlamydia, gonorrhea and syphilis infection that are two to four times higher than rates in whites.⁶ Among high school girls, condom use during the most recent sexual intercourse was lowest among Latinos (43 percent), compared with whites (48 percent) and African-Americans (65 percent).⁴

In talking to a 15-year-old boy with limited English proficiency about safe sex, the physician in the case scenario mentioned “stumbling” because of “rudimentary Spanish.” Language problems can have a substantial impact on multiple aspects of health care, including access to care, health status, use of health services and health outcomes.⁷ Parents of Latino adolescents cite the language problem as the single most important barrier to obtaining health care for their children.⁸ Parents specifically report that the greatest obstacles are doctors and nurses who do not speak Spanish and the lack of medical interpreters.⁸

Trained interpreters should be requested when a physician is not completely fluent in a patient's language.⁹ Guidelines are available for the optimal use of medical interpreters during and after the office visit.⁷ Helpful hints include the following: (1) avoid using patients from the waiting room or untrained staff as interpreters because of potential problems with accuracy, confidentiality and medical terminology; (2) speak to and maintain eye contact with the patient and the parents, not the interpreter; (3) verify the quality and comprehension of translation by having the patient and parents repeat information through back-translation; and (4) ensure that the interpreter helps you by writing down prescriptions and instructions in Spanish and by accompanying the family to schedule follow-up appointments with the receptionist. It is extremely helpful to provide educational materials in both Spanish and English.

A routine psychosocial evaluation should be performed for the Latino teen, as with any adolescent patient. Use of psychosocial survey instruments can be helpful.¹⁰ To discuss such sensitive, confidential subjects, however, it is essential to first establish a rapport with adolescent patients and their families. Failure to understand certain normative cultural values can adversely affect the patient-physician relationship. For example, in “simpatía” (kindness, in Spanish), value is placed on politeness and pleasantness in the face of stress.⁷ A physician with a positive attitude is viewed as the norm by Latino adolescents and their families, so the relatively neutral attitude of many U.S. physicians is often viewed as negative. Lack of “simpatía” can result in decreased satisfaction with care, inaccurate histories, poor follow-up and nonadherence to therapy. “Simpatía” can be achieved by emphasizing courtesy, a positive attitude and social amenities. “Personalismo” can be translated as “formal friendliness.” Expectations include a warm, personal relationship with the physician, interactions at close distances and frequent contact.

With the normative cultural value, “respeto” (respect, in Spanish), appropriate deferential behavior is expected based on position of authority, age, gender, social position or economic status.⁷ The doctor is thus viewed as an authority figure to be awarded respect. For the Latino patient, an attempt to show the utmost respect may result in a hesitancy to ask questions. Another feature of “respeto” is that the parents expect to be shown reciprocal respect, especially if the doctor is younger than they are. The absence of “respeto” may lead to an inaccurate history, decreased satisfaction, nonadherence to therapy and inadequate follow-up. “Respeto” can be achieved by involving the teen and the parents in making medical decisions and by eliciting the family's concerns.

“Fatalismo,” or fatalism, is the belief that an individual can do little to alter fate. This view can lead to avoidance of effective therapy for chronic diseases (such as asthma and diabetes) and cancer, and less use of preventive screening.⁷ In one study,¹¹ for example, Latino adults were significantly more likely than whites to prefer not to know if they had incurable cancer; to believe that there is little one can do to prevent getting cancer; to believe that having cancer is like a death sentence; and to believe that cancer is God's punishment. Physicians can overcome the adverse aspects of “fatalismo” by emphasizing the efficacy of therapies for chronic disease and cancer, and the importance of screening and prevention.

Discussions of sexual issues with Latino adolescents and their families may be particularly difficult because of the premium placed on modesty that may derive from the salient influence of Catholicism and other traditional moral and religious forces in Latino culture. The physician should fully explain to the Latino teen the purpose of obtaining a comprehensive medical and psychosocial history and performing a physical examination. It is helpful to underscore the medical significance of such intensely personal questions, because they can be misinterpreted as insulting (i.e., lacking “respeto”). Given the priority placed on modesty, it is important to reassure the Latino teen of the confidentiality of the medical visit and to take extra care to use gowns to strategically cover private body regions.

Major conflicts may arise for first-generation immigrant Latino adolescents, who often try to maintain their culture of origin. Because adolescents naturally experiment with new behaviors to gain peer acceptance, immigrant Latino teens may be confronted by a clash between the culture of their parents and that of their American peers. The Latino adolescent who attempts to separate from immigrant parents and spends less time at home may be perceived as being “out of control.” He or she may be viewed by the parents as “too American,” for which the parents blame the new host environment and the new friends, thus creating even greater tension and conflict. The clinician can reduce this conflict by helping parents understand and anticipate normal and abnormal adolescent behaviors among American adolescents, by encouraging open discussion of family differences and by reviewing with families the relationship between adolescent risk-taking and Latinos' ethnic disparities in morbidity, mortality and health.

The physician can reassure parents that, despite appearances to the contrary, parents and grandparents can exert a tremendous influence on teens and help them avoid adolescent risk behaviors by providing early and ongoing anticipatory guidance and home sexuality education. For example, one study¹² of Latino adolescent girls revealed that the adjusted odds of teen pregnancy were more than three times lower when there was good communication between the teen and her mother. The physician should discuss with families the high prevalence of sexual activity among U.S. Latino adolescents, and the disproportionately high rates of teen pregnancy and sexually transmitted diseases (including human immunodeficiency virus) that are direct consequences. Reassure the adolescent that “not everyone is doing it” and that abstinence and safe sex are well known as the best tools for effective protection.

Data indicate that traditional Latino culture seems to be protective against adverse health outcomes, whereas greater acculturation increases health risks for Latino adolescents. A bi-national study of over 4,000 adolescents attending school in six Texan border cities and neighboring Tamaulipas, Mexico, showed that 48 percent of the U.S. Latino students scored above the critical level for depression compared with 39 percent of Mexican youths.¹³ About 23 percent of U.S. Latino adolescents reported current suicidal ideation, compared with 12 percent among Mexican students. In a study¹⁴ of high school students enrolled in a California bilingual program, acculturative stress was significantly associated with both depression and suicidal ideation. Two recent studies^15,16 have documented that less acculturated mothers are more likely to have better immunized children. Greater acculturation among Latino adolescents also is associated with an increased risk of cigarette smoking and illicit drug use.^17,18 In Latino girls, acculturation is associated with a significantly younger age at first sexual intercourse.¹⁹

We recommend that physicians discuss these findings with Latino teens and their families indicating the health risks of acculturation and the health benefits of traditional Latino culture.