Across healthcare organizations and educational institutions in the United States, an emphasis on the delivery of culturally competent healthcare, a term used to describe the provision of respectful healthcare for patients with diverse identities and beliefs, has raised important issues in a system charged with caring for an increasingly diverse population. While the term cultural competence suggests that this applies only to cultural diversity, in practice it has come to encompass the delivery of sensitive care to those belonging to traditionally marginalized identity groups, on the basis of gender, race, socioeconomic status or weight. The drive by universities and healthcare organizations to push for cultural competence in healthcare has raised the question of what cultural competency calls for, and, in doing so, has exposed some of its dangerous core tenets.
Cultural competency perhaps once expressed the basic and laudable notion that healthcare providers should respect patients’ autonomy to make their own decisions, based on their cultural values—even if such decisions are not the medically best decisions. More recently, however, cultural competency has morphed into the expectation that healthcare providers must defend the practices of marginalized groups, no matter how harmful these may be to their health, and show restraint in providing objective, scientific information, if this information is at odds with the patient’s cultural norms. This harms the health and well-being of the very marginalized groups the healthcare system aims to protect.
I recently spent three years at Emory University in Atlanta, Georgia, pursuing a graduate degree as a nurse practitioner. The student body was sincerely concerned with social justice: they organized lectures on race, reproductive health issues and on the delivery of culturally competent health care. I admired my classmates for their commitment to improving the status of minorities, women and those of low socioeconomic status, and for their willingness to challenge ideas they perceived as prejudiced. I myself am a woman, a feminist and a mixed race person, from a mixed-faith household, who decided to become a nurse practitioner to help the many people in the US who do not have access to affordable healthcare. My classmates were smart, ambitious, and caring. However, they did not see that their insistence on defending every practice and norm of those whom they considered to be from marginalized identity groups not only infantilized the members of these groups, but also laid the groundwork for a healthcare system in which potentially medically harmful practices and norms are either extoled, or considered off limits to criticism by healthcare professionals. The pressure to be culturally competent may also influence the healthcare provider to restrict or dishonestly reframe important information, if we anticipate that it may be misconstrued as culturally insensitive.
There is no unifying model of cultural competency. The model I refer to here is the one I observed in my classrooms. This may not be how it is practiced everywhere: however, when the most extreme forms of any ideology gain significant traction in educational institutions, they deserve reexamination.
We had many seminars on the need for cultural competence in healthcare. During these seminars, my classmates consistently defended the practices of other cultures. For example, they defended female genital mutilation (FGM) as a practice that we in the west simply do not understand, despite the fact that FGM has no health benefits and carries substantial risk of harms, including chronic pain, repeated infections, sexual health issues and obstetric complications. Also, despite substantial evidence showing links between obesity and poor health, many classmates argued against discussing patients’ weight with them, since weight is a marker of identity that cannot always be easily changed, so such discussions could be considered fat shaming. Clearly, in this setting, cultural competence meant that we, as non-bigoted healthcare providers, must consider any practice or norm of a marginalized group as either positive or above criticism. When a particular practice—such as FGM—cannot possibly be framed as anything other than negative from a health perspective, we have two choices, neither of which are beneficial to our patients’ health. The healthcare provider can either defend FGM as a misunderstood cultural practice or suggest that it is a negative stereotype and not widely practiced. But, if we are supposed to be culturally competent at recognizing positive or neutral practices within a cultural group, then we should also be able to recognize negative ones. In the case of FGM, for example, recognition of negative patterns is critical if we hope to safeguard at-risk children.
By contrast, many of my classmates were quick to make negative generalizations about whites, particularly white males. They were willing to criticize what they considered to be an assault on women’s reproductive health rights in western societies and made clear their disapproval of the anti-vaxxer movement among wealthy whites. I do not criticize them for speaking out against certain aspects of white culture. As future health care providers, their concerns about police brutality were appropriate, as was their criticism of the anti-vaxxer movement. However, this well-intentioned inconsistency has the potential for destructive outcomes, which may deepen already entrenched social, economic and racial health disparities. When we, as healthcare providers, are willing to criticize the unhealthy habits of non-marginalized groups, we can effect positive change in those groups and encourage healthy behaviors. When we are unwilling to criticize the unhealthy habits of marginalized groups—by, for example, tiptoeing around the subject of an obese patient’s need to lose weight, or tempering our discussion of the risks of teenage pregnancy when talking to a patient from a culture in which early pregnancy is acceptable or desirable—we enforce negative health behaviors with potentially devastating outcomes.
We must consider the reasons for this double standard. I fear that we think of the anti-vaxxer, anti- antibiotic, white, upper class patient as capable of processing objective medical information, even if it counters her beliefs. We view her as capable of reason, and strong enough to not crumble at the suggestion that her beliefs may be wrong. On the other hand, we view members of minorities and marginalized groups as too entrenched in their ideologies, and too weak to be able to consider objective health information as anything other than a threat to their identities. This double standard comes from a place of compassion, but it demeans marginalized groups and reinforces negative health behaviors that may exacerbate health disparities. It prioritizes the healthcare provider’s need to feel culturally sensitive over the patient’s need to be provided with the information necessary to make informed choices about her health. In this sense, the double standard bears witness to a paternalistic model of medicine, in which the will of the healthcare provider is valued over patient autonomy.
For almost two years, I have worked as a nurse practitioner at a small family practice clinic that serves the Hispanic community in Atlanta. My patients are mostly uninsured and poor. Many cannot speak English and cannot read, and, as a result, work at grueling, underpaid jobs, which few Americans would want to fill. I have a great deal of admiration and respect for many aspects of their culture. But, like any population, they have their share of misconceptions as to what practices are considered healthful. Black market antibiotics, which are easily purchased at local tiendas without a prescription, are regularly taken by my patients for normal aches and pains, the way one might take acetaminophen (paracetamol) or ibuprofen. Often, my patients come in requesting injections as cures for conditions for which no injection exists, antibiotics for non-infectious problems (such as back pain) or intravenous vitamin infusions for symptoms that are unlikely to be related to a vitamin deficiency. These beliefs about medicine and health are cultural. While many of my patients have little education and certain misguided cultural beliefs about health, they are more than capable of absorbing and understanding advice that contradicts their beliefs. Our differences can sometimes be a source of friction. However, it is my role to provide medical facts and make recommendations. To believe that my patients are incapable of valuing facts over their cultural norms is condescending at best and perpetuates harmful health behaviors, at worst.
Some may argue that all that culturally competent healthcare truly demands is that we respect the fact that a patient’s identity and belief system will influence her medical decisions, and attempt to accommodate that. But this is not what the cultural competency model, as I have seen it taught, ultimately achieves. This demand can be much better met by active rejection of the paternalistic model of healthcare and by returning decision-making power to the patient, without elevating the patient’s group identity above all else.
Awareness of cultural practices can help us understand both cultural strengths and weaknesses, and provide extra counseling or probe more deeply if necessary. For instance, I am aware that homosexuality can be more taboo among my patient population than among a liberal white population, so I attempt to establish trust with my patients before asking about sexual orientation. But this approach differs from a cultural competency model, which would urge us to either deny the prevalence of homophobia in the Hispanic community or to accept it without judgment.
Cultural competency encourages us to accept beliefs held by some groups and reject those held by others. It reassures us, for instance, that it is right to honor the norm that a Saudi male may be the primary decision maker about his wife’s health, but not to accept the intent of a rural white American Christian family to stop their daughter from having an abortion. In addition, a focus on marginalized identity often allows us to dismiss beliefs based on individual preference. It is common in healthcare to eyeroll the patient who refuses to take his prescribed medication because he just doesn’t like medication, when we would be ashamed to eyeroll a patient who refused to take a medication because doing so would run counter to his religious beliefs.
The cultural competency model attempts to push moral relativism into healthcare. It demands that we shield the beliefs and norms of people with marginalized identities, no matter how harmful, but offers no such protection to abhorrent or harmful beliefs held by the privileged or as a matter of individual preference. It grants us healthcare professionals a role as guardians of culture, somehow qualified to navigate the ever-changing societal currents that tell us whose beliefs and identities are acceptable and whose are not. Rather than teaching cultural competency in healthcare, with all its nuances and double standards, a simple commitment to rejecting paternalistic ideas and giving all patients the best advice, while respecting their autonomy, would encompass all that cultural competency attempts to achieve and encompass it more uniformly across individuals and groups.
As a healthcare professional who respects the ability and agency of members of racial, cultural and gender minorities, I will not regard such people as incapable, innocent parties with beliefs that need to be ferociously defended, even when those beliefs can do obvious harm. Healthcare workers who respect people and provide quality healthcare have to be able to view all patients as capable of forming both good and bad ideas. If we continue to pretend that members of marginalized groups are incapable of misguided thought, or that their cultural practices are by default innocent or good, then we disrespect their intricacy as humans and reduce them to simplistic creatures, mentally enslaved by identity norms, and without the ability to learn, make informed decisions and prosper.