Outreach to and Identification of Women 127

4.2.3 Ethnic and Racial Populations

Successful identification and outreach to women with substance
abuse problems requires racial, ethnic, and cultural knowledge, compe-
tency, and sensitivity. When staff members engage in outreach to women,
they should understand the issues confronted by diverse ethnic and racial
populations and recognize that there is diversity within racial and
ethnic groups. For example, the culture and experience of an African
American woman whose family has lived in an urban area in the Midwest
for generations may be significantly different from an African American
woman who lives in a rural community in the South. Their experiences
will be different from a woman of primarily African descent who recently
immigrated from Jamaica. The culture and experience of a Laotian woman
who recently immigrated to the United States will differ significantly from
a third generation woman of Japanese descent. Cultural values and norms
vary across ethnic groups of Caucasian women as well, particularly among
those who are recent immigrants or first-generation Americans.

African American Women. Having survived a historical experience
that demanded extraordinary courage and inner strength, traditionally
African American women are seen as strong and as not needing anyone or
anything to cope with life and its challenges. This perception is perpetu
ated by continuing socioeconomic conditions that require African Ameri
can women to maintain a predominant role in caring for their families. If
an African American woman believes she should be strong, regardless of
her circumstances, she might feel that admitting she needs help is a sign of
personal failure and that she has failed her family. This can result in low
self-esteem and feelings of shame that could keep her from admitting to herself or others that she has a substance abuse problem.

African American women are most likely to rely on other African
American women or their place of worship for assistance with crises. For
example, African American women often establish sisterhood relationships to help each other with proactive listening, counseling, and emotional support. Informal neighborhood groups (card playing groups), formal clubs (social and charity), church groups and to a lesser degree, sororities have been important sources of networking for African American women. Recently three of the largest sororities (Zeta Phi Beta, Delta Sigma Theta, and Alpha Kappa Alpha) have developed substance abuse prevention programs. These sororities differ from the mainstream sororities in that their dominant focus is on community action and social service.

To facilitate the African American woman's acceptance of treatment, it is important for a program to establish relationships with respected African American individuals and organizations in the community. Religious institutions and community organizations that serve African American women can be vital resources for a successful outreach program.

American Indian Women.

American Indian populations consist of approximately 450 different tribes with varying customs and some 250 languages. For American Indian women, barriers to treatment include the following:

· the disproportionate number of unemployed American

Indian women, which hinders early detection and referral in

the workplace;

· the lack of education in cross-cultural issues among physi

cians, nurses, social workers, and other health care providers

may result in a lack of sensitivity to the values, beliefs, and

practices of American Indian women; the use of stereotypes,

although unconsciously by health care providers, can be a

basis for assessment and diagnosis;

· geographic isolation, which limits access to substance abuse

treatment; the lack of funding in the Indian Health Service

for needed programs; and the disproportionate poverty
among American Indian women, further limiting financial
access to treatment; and

· cultural differences among American Indian women in the
relative value placed on the use of different substances
(some of which they do not consider addictive), may pre- lude the women from accepting or seeking help for their
abuse of other substances.

Because of a long history of a lack of trust in the United States
federal government (because of broken treaties, outlawing of American
Indian languages and religious practices, and inadequate services provided
through the government), American Indians often mistrust health care
programs run by government agencies, including substance abuse pro
grams. Developing a relationship of trust with American Indian women is,
therefore, critical in the outreach phase.
A simple, cost-effective strategy to identify high-risk American
Indian women is for treatment programs to establish relationships with
existing American Indian programs, such as cultural centers, Indian Health
Boards, and Indian healers.

Asian/Pacific

However, it should be noted that a little less than half of all Ameri-
can Indians live in rural and/or reservation communities. The remaining
population lives in urban locations scattered among other racial/cultural
groups rather than in cohesive communities. This poses another barrier in
identifying American Indian women who are at risk.

To design an outreach program for Asian/Pacific Islander women, it is important to understand the com
plexity of the historical, social, economic, political, and cultural factors that
underscore the Asian/Pacific Islander experience in the United States and
the diversity of the population itself. Sue has suggested that for Asian

American populations (as would be true for other recent immigrant populations), it is important to consider the specific ethnic group, place of birth, generational status, and degree of acculturation."

Asian/Pacific Islander women who are immigrants and refugees confront many stressors that exacerbate already severe challenges in their daily ability to cope and function. These challenges may include language barriers (which can make it difficult to obtain basic resources such as health care), racism, social isolation, changes in traditional family roles, economic distress, and family disintegration. Mainstream services are often underutilized by Asian/Pacific Islander women because the services are inaccessible, too expensive, culturally irrelevant, and/or unavailable in their native language.

Sun has suggested the following as useful strategies to intervene with Asian American women:"

· have bilingual and bicultural professionals available who can

engage and be involved in the treatment process for newly

arrived immigrants - the program might gain access to

volunteer professionals through Asian American organiza

tions in their community;

· eliminate terms such as "mental illness" or "psychiatric

dysfunction," which Asian Americans tend to be more

sensitive to than Westerners; and

· include information that reflects cultural sensitivity, includ

ing recognition of the Asian woman's traditional role,

ethnic, and cultural identity(ies) and the importance of

intergenerational relationships in outreach material.

HispaniclLatina Women.

The Hispanic population in the United States is heterogenous, representing different cultures and ethnic groups.

Many communities are inhabited by multiple Hispanic groups where
generational differences exist within each group. Treatment programs
conducting outreach to Hispanic women should become familiar with the
diversity, origins, dynamics, cultures, and problems of the different His
panic groups living in the community. Treatment providers should not
assume that one approach will work for all Hispanic groups or that all
Hispanic women exhibit the same pattern or type of substance abuse
problem.

Many substance abuse treatment programs do not have staff who
can communicate in Spanish. Hispanic women, therefore, tend to view
these programs as less than "user-friendly." If possible, programs serving
Spanish-speaking women should have treatment staff who can speak
Spanish. Also, educational materials on substance abuse and treatment
often assume high levels of reading ability. This presents an obstacle for
those who are not proficient in the English language. Thus, materials
should be available in Spanish.

Outreach to Hispanic women requires a genuine respect for the
women and their family culture. The families of Hispanic women can be
important resources to help these women get treatment for substance abuse
problems. However, if family members feel that a woman's participation
in treatment threatens the status quo or legal standing of the family, they
can work against a woman who is responding to outreach efforts. Disclo
sure may be a particular problem for undocumented Hispanic women who
fear that this may result in their deportation; they may also fear that un
documented family members (and friends) will be discovered and deported
if they enter the "system" in any way.

4.2.4 Other Specific Groups of Women

Women with HIV/AIDS.

During the second decade of the AIDS
epidemic, the number of women with HIV/AIDS has increased dramati-
cally. In recognition of the differences in disease progression and types of
AIDS opportunistic infections of HIV/AIDS in women, the CDC recently revised
the diagnostic categories used to define an individual as having AIDS.
(Chapter 2 presented more detailed epidemiologic data on women and HIV/
AIDS.) The increase in the number of reported AIDS cases may, in part, be
because of this expanded definition.

Outreach and identification of HIV-infected women often occurs at
their point of need, such as through primary or acute health care, public
assistance, or other social service agencies. However, it is important to
note that many women are not aware of their HIV status until they are
symptomatic with AIDS and/or have been diagnosed through the health
care system, often through prenatal testing.
HIV-positive women from lower socioeconomic groups often lack
the resources to meet their most basic needs for food, housing, and trans
portation. As a result, they may delay seeking care for their substance
abuse problems or for their HIV status until they become symptomatic or
until their basic needs, or those of their children, have been met. HIV
positive women who are addicted to illicit drugs may fear interacting with
the health care system, for fear of being placed in the criminal justice
system. They may choose not to seek treatment until they have established
a trusting relationship with a case worker or health care professional or
until there is a medical crisis.
Outreach to and Identification of Women 133

Specific outreach strategies include the following:

· work with local AIDS prevention and advocacy groups,

including street outreach programs, to promote the

program's services for women at high risk for or with HIV/

AIDS; and

· encourage staff members to appear on local radio and

television talk shows to discuss the needs of substance using

women with HIV/AIDS and how the treatment program

tries to address those needs.

Women Residing in Rural Areas.

A shortage of primary care physicians exists in poor urban neighborhoods and in rural areas. Families who must travel from rural areas to urban clinics for health care may have no place to stay in the city. Few have the energy to make multiple visits to different institutions at different times (often waiting for a long time to receive services) to obtain care for themselves and their families. Because it may be difficult to find lodging when traveling long distances for services, many women delay seeking treatment until a crisis develops. Helping women from rural areas to use health and social services is important. This may require providing or helping the women to access transportation. Also important are methods of "getting the word out" about womenspecific services across large, often sparsely-populated geographic areas.

Specific outreach strategies include the following:

· work with staff of rural hospitals and health clinics to

identify women who need services and make home visits,

where appropriate, with health care or social services per

sonnel; and

· advertise program services on local radio stations and in

local county newspapers.

Homeless Women.

Homeless women are vulnerable to a variety of risky behaviors, diseases, and disorders. Many homeless women are
substance-abusing, psychiatrically impaired, and physically ill individuals.
The stigma attached to being "homeless" impedes many women from
seeking assistance. Some homeless women who have children fear that
they will lose their children and/or their places in homeless shelters if they
admit to having substance abuse problems. Homeless women may be
frightened, distrustful, and/or unfamiliar with systems of care and treat
ment. Some women who are homeless and who have few dependents will
move from one shelter to another. It is critical to note here that all home
less women are not in shelters: some may be in living arrangements with
family or friends. Also, some women may be in a battering relationship
and may be abusing alcohol or other drugs as a result of the stressors
caused by this relationship. Such women may live temporarily with
relatives or friends, and their residential status may be difficult to discern.
Because homeless women are outside the mainstream networks of
referrals and intervention, those who require acute medical attention or who
are being detained for alleged civil or criminal violations often come to the
attention of police and emergency room personnel more frequently than
they do to substance abuse treatment professionals. The primary routes of
intervention, therefore, must be through street outreach, medical clinics,
law enforcement, emergency rooms, public housing communities (for those
women still in housing), and jails or detention centers.

Lesbians.

Lesbians, unlike many other minority groups, cannot be
readily identified based on appearance, language, or socioeconomic criteria.
The lesbian category embraces women of all ages (including adolescents
and older women), races, ethnicities, religions, socioeconomic groups, and
physical abilities. Since determining the percentage of lesbians in our
society depends on self-reporting, and knowing that many lesbians will not
identifv themselves because of society's stigmatization of homosexuality.
the number of lesbians in any community is likely to be grossly underesti
mated. Adolescent lesbians (an extremely high-risk group with a very high
suicide rate) and lesbians who are parents (approximately one-third of
lesbians) are underserved by substance abuse treatment providers.
Treatment programs may not have staff who are sensitive to the needs of
lesbians, and in fact, the staff may even be hostile. These factors create barriers
to outreach, treatment, and continuing care because a lesbian would not want to
enter a program with an insensitive or hostile environment.
Women of color who are lesbians face an even greater potential for
discrimination than Caucasian women. Many of these women may be
more difficult to identify and serve effectively than their Caucasian coun
terparts. Very few programs are designed for lesbians of color. Outreach
strategies developed for this population must be detailed, consistent, and
use appropriate language and events. Above all, the outreach strategies
must be safe. As noted by Kanuha, lesbians of color face a variety of
challenges because of the prejudices inherent in both the heterosexual and
lesbian communities. Racism in the lesbian community is reinforced by the to
relative lack of presence of women of color in the mainstream lesbian
culture. For lesbians of color to benefit from therapy, clinicians must
understand the dynamics of being both a woman of color and a lesbian."
The overriding emotion that drives almost all of the individual
barriers to outreach for lesbians is fear. Lesbians fear losing anonymity or
acknowledging homosexuality in a setting outside the lesbian community
or an immediate circle of friends. A lesbian may fear that revealing her
sexual orientation could result in losing a job or being separated from
valuable relationships. ,,

Lesbians are cautious about obtaining help if they feel that their partners or significant others will not be treated with respect. Very often, programs are not willing or prepared to integrate same-sex partners into
groups of couples or family therapy sessions. In addition, many lesbians who are mothers hesitate to seek services because they fear they will lose custody of their children.

Outreach to lesbians must be specific to the population, must be community-based, and safe. Resources for lesbians in rural settings will, as a rule, be more difficult to develop because lesbians may be more difficult to reach (i.e., be less open about their sexual orientation) than those living in urban areas. Programs that seek to serve lesbians must be prepared to advocate on their behalf for health and social services, to anticipate the possibility of receiving criticism from the heterosexual population, and to invest time developing credibility within the lesbian community.

Specific outreach strategies include the following:

· develop relationships with gay/lesbian bookstores, offering

them, for example, space to sell books at program events in

return for their distributing program materials at gay/lesbian

bookstores;

· support lesbian-specific community events, and provide

staff and/or assistance with advertising and distributing

announcements;

advertise programs and activities in publications created

specifically for the lesbian community;

have an information booth at lesbian and gay events;

- use language in program materials to indicate that services

are available for partners of women, rather than for husbands

or spouses only; and

· sponsor alcohol and drug-free social and sports events for

lesbians.