Conceptualizing Native American Health: The Importance of Historical Context

Jane M. Simoni, Ph.D.

Department of Psychology

Dr. Jan Leu’s Undergraduate Course Cultural PsychologyNovember 17, 2008

Outline of Presentation• Context

– Plight of Urban Indians

– Historical Trauma

– Discrimination & Microaggressions

– Physical and Sexual Assault

• Consequences (Results from the HONOR Project)

– Adverse Mental Health Outcomes

– Substance Use

– 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, Kill and scalp all, little and big…nits make lice.” little and big…nits make lice.”

- Colonel John Chivington- 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 JeopardyStonewall 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)

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)

Discrimination: Microaggressions

Microaggressions Concepts

• Being asked if you are a “real Indian” by a non-Native person?

• Being asked to prove your Indianness or authenticity by a non-Native person (other than for BIA purposes)?

• Being asked by a stranger if he or she could touch you because you are Native?

• Being asked by a non-Native stranger if you could perform a ceremony or contact a medicine person for him or her?

• Feeling “invisible” to non-Natives?

• Teaching “Indian 101” to non-Natives to make your point or be heard?

• Being asked to change your Native appearance or apparel by your employer or agency (e.g., being asked to cut your hair)?

• Hearing from non-Natives how surprisingly articulate, well-read, or good your language skills are?

• Non-Natives stating to you that you “don’t look or act Indian”?

• 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

MSM OM

• Sexual assault by non- spouse/sexual partner 45% 2% **

• Physical assault by non- spouse/partner 45% 6% ***

• Sexual abuse by spouse/partner 10% 0%*

• Physical abuse by spouse/partner 10% 2%

Simoni, Walters, Balsam, & Myers AJPH, (in press)

Assault Experiences

Trauma Indicator 2 Spirits Hets

Child physical abuse 40% 20%*Child sexual abuse 40% 26%Lifetime sexual assault 48% 35%Lifetime phys abuse by partner 29% 29%Lifetime phys assault by other 28% 24%Lifetime robbed, mugged, attack 60% 48%

No. of historical trauma events experienced by:Self 1.71 1.45Parent 2.00 1.17*Grandparent 2.88 0.49*Great Grandparent 2.92 1.44*Great-Great Grandparent 2.79 1.29†

†p<.10; *p<.05

As cited in Cultural Diversity and Ethnic Minority Psychology, Vol. 10 (3), 287-301

Health Survey of Two-Spirited Native

Americans

What might be the impact of all this

trauma on American Indian Mental Health?

The HONOR Project:Honoring our Nations, Our

Relations

The Honor Project:Two-Spirit Health Study5-year multi-site national study 2002-2007

Funded by the NIMH6 + 1 urban sites:Seattle/TacomaSan Fran/OaklandLos AngelesMinneapolis/St.

PaulTulsa/Oklahoma

CityNew York CityDenver

Qualitative interviews with 60 two-spirit community leaders12 focus groups Conduct 400 survey interviews

Historical Trauma Event Items: Self

25% Native healing or spiritual practices outlawed or stopped23% Forced to not speak your language or cultural expression? 17% Adopted or placed into foster care with non-Natives15% Removed and placed into boarding school16% Experienced flooding, strip mining, polluting on lands13% Forcibly removed by U.S. from homelands/relocated13% Allotted land stolen or taken away11% 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 ResultsTINWP: In your lifetime/last year, how much were you

distressed by…

• Being told by a non-Native person that he or she was an 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?

• Being told by non-Natives that they felt a spiritual connection to Indian people?

• Being told you are “paranoid” by non-Natives?

• Being told by non-Natives how “lucky” you are to be Indian?

Life Year81% 71%

76% 67%

80% 76%

44% 33%

73% 36%

Mental Health Outcomes and Substance Use among Two-Spirits

Physical and Mental Health Indicators

Variable 2 Spirits HetsPerceived health Excellent 8.3% 20.9% Very Good 37.5% 24.8% Good 25.0% 32.7% Fair 29.2% 15.0% Poor 0% 6.5%

Number of ER visits .72 2.80 Mental health TX ever 87.5% 52.6%***Outpatient sub abuse ever 37.5% 22.9% Inpatient MH or SA TX ever 29.2% 22.2%BSI general symptom inventory .86 .63 †BSI Depression .91 .62BSI Anxiety .91 .60*Posttraumatic stress symptoms (IES) 1.20 .81* TINWP, †p<.10; *p<.05; ***P<.000

Substance Use

Variable 2 Spirits Hets Age of first drink in years 12.6 14.7*Current drinking status Nondrinker or abstainer 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 3.39 2.07* Drinking to manage mood/tension 3.61 1.98** Drinking in social settings/bars 4.74 5.12 Drinking obsessively 1.13 0.62 Sustained daily drinking 3.35 3.41 Negative consequences of drink 4.00 2.84

Ever used marijuana 95.8% 84.2%Ever used any illicit drug (no pot) 78.3%

56.0%*

TINWP, †p<.10; *p<.05; **P<.01

Drug use by gender Female ever Male ever

Methamphetamine 53% 50%

Any stimulants

other than

methamphetamine

40% 40%

“Club"

or "designer" drugs 23% 31%

cocaine 58% 61%

narcotics 68% 39%

Hallucinogens

(LSD, acid, mushrooms)

60% 50%

Inhalants (gas, glue, pain, aerosol s)

35% 39%

Marijuana 78% 79%

Tranquilizer 40% 21%

Testosterone (not prescribed by

physician)

3% 8%

Silicone (not prescribed by

physician)

3% 3%

Viagra, levitra, other one? (with or without a prescription)

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

253,01493,361

333,43733,684

133,49731,554

5,890901

2,324558

0 100,000 200,000 300,000 400,000

Black, notHispanic

White, notHispanic

Hispanic

Asian/PI

AI/AlaskanNative

Females

Males

Cumulative Growth in AI AIDS Cases Through 2003

2 6 13 31 56 89157

233322

448

818

1,065

1,333

1,569

1,7833,026

0

200

400

600

800

1000

1200

1400

1600

1800

2000

<84 85 87 89 91 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 No. Per cent• MSM 1,299 56%• IDU 370 16%• MSM/IDU 392 17%• Heterosexual 92 4%• Other/Not identified 171 7%

2,324

• 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 OM X2

• Oral sex w/o condom 100% 75% 6/24*• Anal sex w/o condom85% 24% 22.47***• Sex w/stranger 85% 49% 7.70***• More than 2 partners/mo 80% 51% 5.01*• Had an STD 50% 24% 4.71*• Vaginal sex w/o condom 35% 86% 17.11***• Had sex w/HIV+ person 35% 6% 10.07**• Had sex w/IDU 30% 8% 5.83*• Traded sex for $, drugs 20% 2% 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 OM X2

• Has had sex w/ a gay or bi man 55% 2% 627.16***• Was a casual (not steady) partner 40% 14% 5.32**• Was someone I did not know well 35% 33% .06• Having sex with other partners 35% 12% 4.57*• Has traded sex for drugs, $, favs 35% 8% 8.23**• Has HIV/AIDS 30% 0% 15.26***• Has injected illegal drugs 10% 2% 2.13• Has an STD or genital ulcers 5% 4% .03

Simoni, Walters, Balsam, & Myers AJPH, (in press)

HIV/AIDS Prevalence in Our Research

• 2% Pow Wow sample• 10% DOH two-spirit men• 6% DOH heterosexual men• 3% DOH women• 7% TINWP• 17% HONOR Project