Assessment And Treatment Of Anorexia In Latina Adolescents
When working with a Latino family, familialism may create a lack of trust towards anyone outside of the home, making it difficult to properly assess and obtain information. Not being able to fully understand the patient, their history of weight less and other features of the illness may result in under-diagnosis of AN. Gender roles within a Latino family influence help seeking behaviors and assessment.
Gender roles of Latinos are reflected through spatial distinctions of la casa, representing women’s space in the home, and la calle, a men’s place in the street. La casa is symbolic of traditional gender roles that emphasize subservience to males, self-sacrifice, and staying at home. Whereas, la calle is symbolic of a males role to provide for his family, authority, power and the freedom to do as he pleases. Females are regarded as “divine” and “morally strong”, and this glorification of the female role points to expectations that may serve as barriers for Latina adolescents in obtaining mental illness support. Latinas are expected to keep their personal problems private, put their needs last, and refrain from asking for support outside of the house.
It is unlikely that an individual with AN seeks help themselves and thus, gender roles would create an additional barrier for Latina adolescents struggling. It can be difficult to assess and diagnose a Latina adolescent due to the gender role expectations in particular, not discussing personal problems outside of the house. If clinicans do not recognize gender roles and the implications they hold, underdiagnosing AN in Latina adolescents may occur. Accurately identifying and diagnosing Latinas with AN is the first step to providing effective treatment. If a patient is not accurately diagnosed and continues with the suggested intervention for the misdiagnosis received, the likelihood of full recovery from AN is slim. In the Latino population, where outside help is commonly distrusted, a misdiagnosis may exacerbate preexisting negative feelings and opinions towards help seeking behaviors. Throughout America there has been a decrease in overt discrimination, however, cultural bias and implicit attitudes continue to influence clinician behavior and decisions made in practice. Historically, ethnicity was considered a protective factor against ED, in that it was believed that since the thin body ideal was a Western concept that only White women could be at risk.
The false stereotype that AN only occurs in affluent, White females may contribute to clinician bias. Unfortunately, cultural bias of clinicians may serve as a barrier to proper and timely identification of AN in Latina adolescents. Cultural bias that lives within the clinical population has been documented throughout research. When clinicians were presented with a passage regarding an adolescent experiencing eating disorder symptomatology, they were less likely to diagnose AN in Latinas than White women, even though ethnicity of the patient was the only variable. Consistent with these findings, Latinas were significantly less likely than White women to be asked about eating disorder symptomology, even when the severity of AN symptoms was controlled. White women were also far more likely to be referred for further evaluation than Latinas when they communicated eating concerns to a clinician. The diagnostic criteria outlined in the DSM V is the primary source of diagnosing guidelines for psychological problems. While the DSM V is useful in many ways, a Western institution, the American Psychological Association (APA), is responsible for the publication which is used by predominantly Western clinicians.
The diagnostic criteria doesn’t necessarily represent how Latinas experience ED and the disparity in prevalence may be explained by cultural differences in presentation of ED symptomology. The DSM V specifies “significantly low weight” as criteria for AN and that this assessment should be based off of BMI percentile when working with children and adolescence. The use of BMI percentile as one of three criteria is flawed, as it uses body weight to determine the extent to which someone may be struggling with AN. An individual with AN may classify as “normal” or even “overweight”, however this does not modify their experience or illness. On average, Latinas tend to have higher BMIs compared to White females. Thus, if a Latina seeks help she is more likely to be misdiagnosed because her ED may not be physically apparent and she may not be skinny enough to be identified. The World Health Organization endorses the need to develop “different BMI cut-off points for different ethnic groups due to the increasing evidence that the associations between BMI, percentage of body fat, and body fat distribution differ across populations".
The DSM V also specifies a fear or gaining weight and a fear of food, which may be uncommon within Latina adolescents experiencing AN, as Latino culture places value on food. Latino culture and American culture have differing views of food and what is considered normal, and the diagnostic material does not account for that. When assessing for AN, clinicians must consider varying presentations of AN, otherwise the mental illness may be overlooked, as it has been in the past. Thus far, this paper has proposed various explanations for disparities in prevalence and has examined cultural factors to consider when assessing a Latina adolescent with AN. Exposure to the emphasis American culture places on appearance as a determinant of self-worth and thinness as an ideal body type may promote AN symptology. Furthermore, the process of conforming to a culture that differs from an individuals country of origin, may result in acculturative stress. In addition, gender roles, and family dynamics may create barriers to accessing mental health care and can also make assessment challenging for clinicians.
Stereotypes of AN may contribute to cultural bias of clinicians, especially if they are practicing under the misconception that Latina adolescents are protected from ED. The diagnostic criteria used to asses for AN is also biased, as it does not adequately acknowledge the role culture plays in symptomology. The research conducted raises issues in relation to social justice, ethics and oppression. While the history of ED is one of female suffering, the current narrative only speaks to the experience of White women. Women from minority populations have continued to be ignored, dismissed and excluded from conversations around ED. A lack of representation, understanding and culturally competent diagnostic tools and assessments serves to further oppress marginalized populations. The basis that EDs and specifically AN are understood through the White experience maintains this oppression.
True social justice refuses to accept disparities in the distribution of social, economic and environmental resources. An in Latina adolescents raises social justice issues because it demonstrates While the failure to diagnose and treat AN within the Latina population reflects on the clinician, this situation reflects more so on an injustice within broader society. In order to avoid perpetuating bias and to apply diagnosis in a culturally sensitive manner, clinicians should begin with increasing their self-awareness in regard to their own identities, biases and stereotypes. While an individual may not be intentially racist or hold explicit bias, they are still able to perpetuate inequality through implicit bias. Without taking the time to question ones belief system it is impossible to alter behaviors and attitudes that may perpetuate bias. Implementing a client-centered commitment and starting where the client through utilizing a cognitive approach allows the client’s values, goals, and experiences to take precedence.
Attempting to understand the clients world and to share their experience without bias can help a clinician gain a true understanding of problems and their meanings. While the DSM V is a useful tool, additional self-report AN assessments that are available in a variety of languages should be used when applying diagnosis because the DSM V only accounts for one presentation of AN. In addition, asking the client and their family questions about their culture, norms, and values helps avoid clinical bias.
