Transcript Conceptualizing Native American Health: The Importance of Historical Context Jane M. Simoni, Ph.D. Department of Psychology Dr.

Conceptualizing Native American Health:
The Importance of Historical Context
Jane M. Simoni, Ph.D.
Department of Psychology
Dr. Jan Leu’s Undergraduate Course Cultural Psychology
November 17, 2008
Outline of Presentation
• Context
– Plight of Urban
Indians
• Consequences
(Results from the HONOR
Project)
– Historical Trauma
– Adverse Mental
Health Outcomes
– Discrimination &
Microaggressions
– Substance Use
– Physical and
Sexual Assault
– Colonial Trauma
Response
• Faces of the
Community
Context
Plight of Urban Indians
Historical Trauma
Discrimination &
Microaggressions
Physical and Sexual Assault
Plight of Urban Natives
 70% of AI/AN live off rez or tribal
lands with 65% living in cities
 Higher rates of most
communicable diseases
 Poverty rate is 3x that of any
other ethnic/racial group
 Relative to rural AI/ANs, urban
AI/ANs have higher infant
mortality rates, higher mortality
rates due to alcohol and injury,
and higher low birth weight
rates
 Economic vulnerability & ill
health suggest urban AI/ANs
are at risk for HIV and other
health related problems
Historical Trauma
• Collective and cumulative emotional
wounding that results from catastrophes
• Held personally and transmitted over
generations
• First observed in 1966 by clinicians alarmed by
the number of children of survivors of the Nazi
Holocaust seeking treatment
• Often discounted, leading to misunderstanding
and mistreatment of many children of survivors
Brave Heart (1995); Yellow Horse Brave Heart (2000)
Historically Traumatic Events:
Themes From TINWP Focus Groups
• History of genocide and ethnocide
– 1830s relocation “Trail of Tears”
– 1836 small pox-laden blankets to Mandans
– 1840s-1870s “Manifest Destiny” led to chain of
massacres-over 40 during Lincoln’s administration
• e.g., Sand Creek 1864 and Wounded Knee 1890
– 1890 bounties for Indian scalps in Texas, no
questions asked
"You will do well to inoculate the Indians
(with smallpox) by means of blankets, as
well as to try every other method that can
serve to extirpate this exorable race. I
should be very glad your scheme for
hunting them down by dogs could take
effect."
-General Amherst to Colonel Henry Bouquet, July 1763
Sand Creek Massacre of Cheyenne & Arapahos
“Of from five to six hundred
souls [who were killed], the
majority of which were
women and children…[they]
cut out woman’s private
parts and had them for
exhibition on a stick…[there]
were numerous instances in
which men had cut out the
private parts of females and
stretched them over the
saddle bows and wore them
over hats while riding in the
ranks…”
– Lieutenant from the New Mexico
Volunteer Cavalry in Testimony to
Congress
“Kill and scalp all,
little and big…nits make lice.”
- Colonel John Chivington
Environmental Trauma Examples
• 1979 largest nuclear accident in the U.S. at a United
Nuclear Co. milling plant on the Navajo reservation
in Church Rock, NM.
– 1,100 + tons of uranium waste gushed through a ruptured
tailings mill dam, releasing more than 100 million gallons of
water into Rio Puerco—and into groundwater
• 317 reservations are threatened by environmental
hazards/destruction
• 77 sacred sites disturbed or desecrated for resource
extraction
• Over the last 45 years, there have been over 1,000
atomic explosions on Western Shoshone land
Boarding School Period
• 1880s – 1930s: During this time, thousands of
Native children were forcefully removed from
their families and placed in Indian boarding
schools.
• The mission of the boarding schools was to
assimilate Native children into mainstream
culture. Tribes were effectively stripped of
their right to raise their children.
• The children were forced to learn English, cut
their hair, and were not allowed to practice
traditional ways. Many children were abused
and neglected in these settings.
Spiritual Trauma
• 500 years of conversion practices to eradicate Native
religious practices and ceremonies
• In 1883 the Court of Indian Offenses prohibited
ceremonial practices and enforced Christianity on
Indian populations
• By 1892 this policy was expanded to include
prohibition of dances, use of traditional medicines,
ceremonies, healing practices, and funerary rites
• Violations were met with withholding of food rations
and imprisonment for up to 6 months
Discrimination: Double Jeopardy
Stonewall Study Focus Group Findings
• Racism in non-Native LGBT communities
– Objectification and eroticization as partners (e.g,
NYC Pride float “Native” man)
– Denial of admittance to gay bars
– Asked for multiple pieces of identification
– Invisibility in LGBT settings
• Heterosexism in Native communities
– Denial of two-spirit existence and history
– Same-sex relations is a “white thing”
– Shunning or being kicked/harassed out of
communities or ceremonies (e.g., Native woman
and Sun Dance)
– Avoidance of the topic
– Cultural beliefs that same-sex relations are sinful,
immoral or against traditions (e.g., uninvited to
sweat)
Discrimination:
Microaggressions
Everyday injustices and daily hassles
• Appropriation of cultural and spiritual
customs – (e.g., some “New Age”
practices)
• Romanticization & eroticization of
images
• Invisibility – (e.g., being overlooked or
mistaken for different race)
Microaggressions Concepts
• Being asked if you are a “real
Indian” by a non-Native person?
• Teaching “Indian 101” to non-Natives
to make your point or be heard?
• Being asked to prove your
Indianness or authenticity by a
non-Native person (other than for
BIA purposes)?
• Being asked to change your Native
appearance or apparel by your
employer or agency (e.g., being
asked to cut your hair)?
• Being asked by a stranger if he or
she could touch you because you
are Native?
• Hearing from non-Natives how
surprisingly articulate, well-read, or
good your language skills are?
• Being asked by a non-Native
stranger if you could perform a
ceremony or contact a medicine
person for him or her?
• Non-Natives stating to you that you
“don’t look or act Indian”?
• Feeling “invisible” to nonNatives?
• Hearing discussions by persons in
authority about Indians as if they no
longer exist?
Assault and Violence
• Limited evidence suggests that two spirits
are at higher risk for trauma than
heterosexual counterparts
• Assaults assume many forms from
avoidance to verbal to outright murder
• LGBTs of color more likely to be victimized in
gay-identified settings than their White
counterparts (Comstock, 1989)
Assault Data
• Study on Two-Spirit bias experiences
(Walters, Simoni, & Horwath, 2001) among
14 LGBT-TS found:
– Disproportionately high rates of type III
violence compared to non-Native LGBTs:
•36% vs. 9-24% physical assault
•36% vs. 4-10% assault with a deadly
weapon
•29% vs. 5-14% sexual assault
% of non-AI LGBTs based on studies by Berrill, 1990 and Pilkington &
D’Augelli, 1995
% of AI/AN based on study by Walters & Simoni, 2001
Lifetime Assault
•
•
•
•
Sexual assault by non- spouse/sexual partner
Physical assault by non- spouse/partner
Sexual abuse by spouse/partner
Physical abuse by spouse/partner
MSM
OM
45%
45%
10%
10%
2% **
6% ***
0%*
2%
Simoni, Walters, Balsam, & Myers AJPH, (in press)
Assault Experiences
Trauma Indicator
Child physical abuse
Child sexual abuse
Lifetime sexual assault
Lifetime phys abuse by partner
Lifetime phys assault by other
Lifetime robbed, mugged, attack
2 Spirits
40%
40%
48%
29%
28%
60%
Hets
20%*
26%
35%
29%
24%
48%
No. of historical trauma events experienced by:
Self
1.71
Parent
2.00
Grandparent
2.88
Great Grandparent
2.92
Great-Great Grandparent
2.79
1.45
1.17*
0.49*
1.44*
1.29†
†p<.10; *p<.05
As cited in Cultural Diversity and Ethnic Minority Psychology, Vol. 10 (3), 287-301
What might be the impact of all this trauma
on American Indian Mental Health?
Health Survey of
Two-Spirited Native
Americans
The HONOR Project:
Honoring our Nations, Our Relations
The Honor Project:Two-Spirit Health Study
5-year multi-site national study 2002-2007
Funded by the NIMH
6 + 1 urban sites:
Seattle/Tacoma
San Fran/Oakland
Los Angeles
Minneapolis/St.
Paul
Tulsa/Oklahoma
City
New York City
Denver
Qualitative interviews
with 60 two-spirit
community leaders
12 focus groups
Conduct 400 survey
interviews
Historical Trauma Event Items:
Self
25% Native healing or spiritual practices outlawed or stopped
23% Forced to not speak your language or cultural expression?
17% Adopted or placed into foster care with non-Natives
15% Removed and placed into boarding school
16% Experienced flooding, strip mining, polluting on lands
13% Forcibly removed by U.S. from homelands/relocated
13% Allotted land stolen or taken away
11% Hostage/political prisoner in combat with U.S. or tribal war
7% BIA relocation to meet economic needs
6% Experienced community massacre
5% Medical testing, sterilization, or other procedure without consent
TINWP
Traumatic events by gender
Traumatic events
Female
(N=40)
Male
(N=62)
Serious accident, fire, or explosion (for example, an industrial, farm, car,
plane, or boating accident)
50%
60%
Natural disaster (for example, tornado, hurricane, flood, or major
earthquake)
40%
50%
Non-sexua l assault by a family member or someone you know (for
example, being mugged, physically attacked, shot, stabbed, or held at
gunpoint)
65%
53%
Non-sexual assault by a stranger (for example, being mugged, physically
attacked, shot, stabbed, or held at gunpoint)
63%
61%
Sexual assault by a family member or someone you know (for example,
rape or attempted rape)
83%
34%
Sexual assault by a stranger (for example, rape or attempted rape)
65%
34%
Been in military combat or a war zone.
5%
10%
Sexual contact when you were younger than 18 with someone who was 5
or more years older than you (for example, contact with genitals, breasts)
78%
66%
Imprisonment (for example, prison, inmate, prisoner of war, hostage)
33%
29%
Torture
28%
10%
Life-threatening illness
43%
39%
Other traumatic event
73%
47%
Microaggressions Results
TINWP: In your lifetime/last year, how much were you distressed
by…
Life Year
• Being told by a non-Native person that he or she was an 81% 71%
Indian in a past life or that their grandmother was a
Cherokee princess?
• Being told by non-Natives how they wished they were
Indian too?
76% 67%
• Being told by non-Natives that they felt a spiritual
connection to Indian people?
80% 76%
• Being told you are “paranoid” by non-Natives?
• Being told by non-Natives how “lucky” you are to be
Indian?
44% 33%
73% 36%
Mental Health Outcomes
and Substance Use
among Two-Spirits
Physical and Mental Health Indicators
Variable
Perceived health
Excellent
Very Good
Good
Fair
Poor
2 Spirits
8.3%
37.5%
25.0%
29.2%
0%
Number of ER visits
.72
Mental health TX ever
87.5%
Outpatient sub abuse ever
37.5%
Inpatient MH or SA TX ever
29.2%
BSI general symptom inventory .86
BSI Depression
.91
BSI Anxiety
.91
Posttraumatic stress symptoms (IES) 1.20
TINWP, †p<.10; *p<.05; ***P<.000
Hets
20.9%
24.8%
32.7%
15.0%
6.5%
2.80
52.6%***
22.9%
22.2%
.63 †
.62
.60*
.81*
Substance Use
Variable
Age of first drink in years
Current drinking status
Nondrinker or abstainer
2 Spirits
12.6
Hets
14.7*
57.1%
43.7%
Light drinker
23.8%
37.0%
Moderate or heavy drinker
19.0%
19.3%
Alcohol Use Inventory Subscales
Drinking to improve social skills
Drinking to manage mood/tension
Drinking in social settings/bars
Drinking obsessively
Sustained daily drinking
Negative consequences of drink
Ever used marijuana
Ever used any illicit drug (no pot)
TINWP, †p<.10; *p<.05; **P<.01
3.39
3.61
4.74
1.13
3.35
4.00
95.8%
78.3%
2.07*
1.98**
5.12
0.62
3.41
2.84
84.2%
56.0%*
Drug use by gender
Methamphetamine
Any stimulants
other than
methamphetamine
“Club"
or "designer" drugs
cocaine
narcotics
Hallucinogens
(LSD, acid,
mushrooms)
Inhalants (gas,
glue, pain,
aerosol s)
Marijuana
Tranquilizer
Testosterone (not
prescribed by
physician)
Silicone (not
prescribed by
physician)
Viagra, levitra, other
one? (with or without
a prescription)
Female ever
53%
40%
Male ever
50%
40%
23%
31%
58%
68%
60%
61%
39%
50%
35%
39%
78%
40%
3%
79%
21%
8%
3%
3%
3%
10%
Colonial Trauma
Response
Colonial Trauma Response
• In CTR the traumatized individual unites
with a collective or historical sense of
injustice and trauma
– E.g., Natives being moved in the wake of
Hurricane Katrina may connect with the
collective ancestral pain of being
relocated to reservations in an
immediate and visceral way
CTR Theorized Domains:
• Avoidance & Psychic Numbing
–
–
–
–
–
If I talk about historical trauma, I worry that I might harm relatives
It is taboo for me to talk with other tribal members about historical trauma
I try to numb myself to my ancestors’ pain
It is better to block out thoughts related to historical traumas
I avoid hearing other Native people talk about historical traumas
• Vicarious/Secondary Trauma
–
–
–
–
I have dreams about the historical trauma inflicted upon my ancestors
I am overwhelmed with grief when I think about historical trauma
I experience intrusive thoughts about traumatic events in Native history
When I hear other painful tribal histories, I feel a strong connection
• Survivor Guilt
– I feel that I betray my ancestors since I am excluded from their suffering
– Hearing Native people talk about cultural traumas makes me uncomfortable
– I feel guilty for having a good life compared to my ancestors
• PCS/Unresolved collective grief & loss
–
–
–
–
–
–
I still grieve for the pain of my ancestors
Even if I did not experience a trauma, I feel the pain of other Natives
I feel obligated to share in ancestral pain
If we could just find the right medicine, we would be healed
If we could only go back to traditional ways, then we could heal
I have a deep sense of collective grief across all tribal nations
Faces of the
Community
Thank you
HIV/AIDS in
Indian Country
U.S. AIDS cases Through December
2003
AI/Alaskan
Native
558
2,324
Asian/PI
901
5,890
31,554
Hispanic
Females
Males
133,497
33,684
White, not
Hispanic
333,437
93,361
Black, not
Hispanic
0
100,000
253,014
200,000
300,000
400,000
Cumulative Growth in AI AIDS Cases Through 2003
3,026
1,783
2000
1800
1,569
1600
1,333
1400
1200
1,065
1000
818
800
600
400
200
0
2
<84
6
13
85
31
56
87
89
157
89
233
322
91
448
93
95
97
Disproportionate Increase in
AIDS
The number of Natives diagnosed
with AIDS has grown more rapidly
than in any other ethnic group,
increasing almost 800% from 1990 to
1999
Mitchell et al.,2002
Disproportionate HIV Prevalence
The U.S. Surgeon General noted that
although Natives make up just under 1%
of the total population, they currently
account for 6% of newly diagnosed HIV
cases.
Mitchell et al. (2002)
Reported AIDS Cases in Native Males by
Exposure Category, Through 2003
Exposure Category
•
•
•
•
•
MSM
IDU
MSM/IDU
Heterosexual
Other/Not identified
No.
1,299
370
392
92
171
2,324
Per cent
56%
16%
17%
4%
7%
• 73% of Native male AIDS cases are two-spirit
Challenges to HIV/AIDS Surveillance Data
• Underreporting and racial misclassification
• Lack of a national standard for reporting
AI/AN by state and local health departments
• A review of national studies of
seroprevalence, HIV counseling and testing
data, and national measures of risk behavior
revealed that NONE categorize by AI/AN
• Lack of comprehensive IHS service tracking
• Over-reliance on total numbers of HIV/AIDS
cases rather than on proportion of cases in
relation to AI/ANs and tribes
Lifetime Risk Behaviors Among 71 Native Men
MSM
• Oral sex w/o condom
100%
• Anal sex w/o condom
85%
• Sex w/stranger
85%
• More than 2 partners/mo 80%
• Had an STD
50%
• Vaginal sex w/o condom 35%
• Had sex w/HIV+ person
35%
• Had sex w/IDU
30%
• Traded sex for $, drugs
20%
OM
75%
24%
49%
51%
24%
86%
6%
8%
2%
X2
6/24*
22.47***
7.70***
5.01*
4.71*
17.11***
10.07**
5.83*
7.14**
Simoni, Walters, Balsam, & Myers AJPH, (in press)
Partner Risk Factors
(Includes only men who had vaginal or anal sex
without a condom in the last 12 months)
MSM
•
•
•
•
•
•
•
•
Has had sex w/ a gay or bi man 55%
Was a casual (not steady) partner 40%
Was someone I did not know well 35%
Having sex with other partners
35%
Has traded sex for drugs, $, favs 35%
Has HIV/AIDS
30%
Has injected illegal drugs
10%
Has an STD or genital ulcers
5%
OM
X2
2%
627.16***
14%
5.32**
33%
.06
12%
4.57*
8%
8.23**
0% 15.26***
2%
2.13
4%
.03
Simoni, Walters, Balsam, & Myers AJPH, (in press)
HIV/AIDS Prevalence in Our
Research
• 2%
• 10%
• 6%
• 3%
• 7%
• 17%
Pow Wow sample
DOH two-spirit men
DOH heterosexual men
DOH women
TINWP
HONOR Project