PART 1- Does an individual’s membership in a diverse population define his or her personality, or does the personality determine the diverse populations to which the person will belong? PART 2-

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Does an individual’s membership in a diverse population define his or her personality, or does the personality determine the diverse populations to which the person will belong?


What is the significance of diversity when everyone is diverse in some way?



this week’s course materials and learning activities, and


on your learning so far this week.


to one or more of the following prompts in one to two paragraphs:

  1. Provide citation and reference to the material(s) you discuss. Describe what you found interesting regarding this topic, and why.
  2. Describe how you will apply that learning in your daily life, including your work life.
  3. Describe what may be unclear to you, and what you would like to learn.


Option 1: Diversity Identity Self-Evaluation Paper


the University of Phoenix Material: Diversity Case Study located on the student website. The case study serves as an example of the diversity within self-identity.


a 700- to 1,050-word self-evaluation paper about your diversity identity.


the following information in your self-evaluation:

· A minimum of five diverse groups you belong to

· Significance of belonging to the diverse groups

· Assumptions others may make about you based on the diverse groups you belong to

· How these assumptions affect your own self-identity.


your paper consistent with APA guidelines.

Option 1: Diversity Identity Self-Evaluat


the University of Phoenix Material: Diversity Case Study located on the student website. The case study serves as an example of the diversity within self-identity.

PART 1- Does an individual’s membership in a diverse population define his or her personality, or does the personality determine the diverse populations to which the person will belong? PART 2-
CHAPTER 11Women Across Cultures Hilary Lips and Katie Lawson Women’s lives differ, sometimes drastically, across cultures. Yet there are themes in their difficulties and challenges, in their strengths and successes, that link women’s experiences across cultural boundaries. In diverse cultures, women face, for example, an emphasis on molding their bodies to fit cultural standards of physical appearance and beauty, an expectation that they will carry the major burdens of childrearing, and ascribed status that is lower than men’s. Yet women in different cultures deal differently with such issues. This chapter examines some of the important commonalities and differences across cultures in women’s lives. Included in our narrative are issues linked to physical bodies, motherhood and family, work and pay, violence, power and leadership, and feminist activism. A theme that links all these issues is the gendering of power. Women and men control different amounts and types of the resources upon which power is based; such differences in access to resources help shape gender differences in behavior in each of these realms. Physical Bodies Worldwide, women face enormous pressure to adhere to strict standards of physical beauty—in part because a beautiful body is one resource a woman can use to gain status, solidify relationships, and attract other resources. Due to the body dissatisfaction that often results from this pressure to be beautiful, women go to great lengths to mold their bodies to conform to cultural standards. In parts of Africa and Thailand, girls as young as age 3 begin to wear rings around their necks in an attempt to make them appear longer, in order to attract an affluent husband as an adult. Over the years, additional rings (weighing up to 12 pounds) are added to the neck. The rings push down the collarbone and ribs to create the illusion of a neck up to 10 to 12 inches longer (Mydans, 2001). In the United States, nearly 91% of the 11.7 million cosmetic surgeries were performed on women in 2007 (American Society for Aesthetic Plastic Surgery, 2008). These surgeries include breast and buttocks implants, collagen lip injections, and liposuction (Gangestad & Scheyd, 2005). Although women worldwide are often dissatisfied with their bodies, the type of dissatisfaction depends on the culture. Women in Western cultures often strive for thinness (which is associated with control, wealth, and happiness), while individuals in non-Western, poorer cultures often associate thinness with poverty, disease, and malnutrition, and thus admire larger women. Although traditionally more affluent cultures prefer thin women while poorer cultures prefer larger women, the gap between these cultural preferences has been shrinking due to the “Westernization” of many cultures (Grogan, 2008). Cultures not only differ on weight preferences, but also on desirable size for particular areas of the body. Women between the ages of 18 and 24 in Canada report more dissatisfaction and concern for the weight of their lower torso (abdomen, hips, thighs, and legs) whereas women in India report more concern for the weight of their upper torso (face, neck, shoulders, and chest) (Gupta, Chaturvedi, Chandarana, & Johnson, 2001). Theories Research focuses on two main theories for women’s dissatisfaction with their bodies. Sociocultural theories suggest that cultures influence body dissatisfaction through the media, family, peers, and other sources (Becker, Burwell, Gilman, Herzog, & Hamburg, 2002). According to this approach, women compare themselves to ideals presented by these sources to make judgments about their own body size. Upward social comparisons (comparisons made with other individuals who have a body closer to the cultural ideal) lead to more body dissatisfaction in women. Therefore, in cultures where women are constantly exposed to images of very thin women (e.g., the United States), women make numerous upward social comparisons daily, thus increasing body dissatisfaction (Leahey, Crowther, & Mickelson, 2007). The sociocultural theory is supported by the observation that “Westernization” appears to be correlated with the increasing preference of non-Western cultures for thin women (Grogan, 2008). Feminist theories, on the other hand, suggest that women’s cultural roles play a large part in body dissatisfaction. According to these theories, male power is a key issue in body dissatisfaction; body standards are used as tools for oppressing women. Unachievable body ideals, along with drastic amounts of pressure from society to attain the perfect body, can lead women to focus on these superficial aspects, rather than more important issues such as their own competencies. Therefore, in cultures where there is rapidly increasing equality in women’s roles, feminist theories predict more body dissatisfaction in women (because there is more pressure for the perfect body as a backlash against women’s advances). This interpretation is supported by research showing that Korean women (who are living in an area with increasingly equal gender roles) reported more body dissatisfaction than women in the United States and China (Jung & Forbes, 2007). Consequences of body dissatisfaction Body dissatisfaction in women is often associated with depression and lower levels of self-esteem (e.g., Paxton, Eisenberg, & Neumark-Sztainer, 2006). It also leads to actions with sometimes dire consequences for women’s physical health. After years of wearing rings to elongate their necks, women in rural areas of Africa and Thailand lose the ability to hold up their heads with their own neck muscles if the rings are taken off (e.g., to punish the women for adultery). Even in countries with very sophisticated medical technology, cosmetic surgery can lead to deformed bodies, infection, or even death. Researchers also worry about the mental consequences of cosmetic surgery due to the fact that some patients have shown adjustment problems, anger toward surgeons, and isolation after surgery (Dittmann, 2005). Body dissatisfaction can also lead to eating disorders (e.g., anorexia, bulimia), which have profound health effects on women. The Renfrew Center Foundation (2002) estimated that 70 million individuals worldwide have eating disorders, with 24 million of those in the U.S. Eating disorders are associated with mental health problems (e.g., depression, anxiety, substance abuse) and a number of physical health problems, including low blood pressure, anemia, osteoporosis, hair and bone loss, kidney failure, heart attacks, and even death (National Institute of Mental Health, 2008). Motherhood and Family One reason women have traditionally been defined so strongly by their physical bodies is that the biological processes of reproduction—menstruation, pregnancy, childbirth, lactation—are so obvious in women. Historically, many cultures have surrounded these processes with myths and elaborate rituals and taboos, underscoring the importance (and dangers) of childbearing. For example, some Native American cultures regarded menstruating women as so powerful that they must stay away from men preparing for battle, lest their power interfere with the warriors’ power (Allen, 1986). Indeed, the onset of menstruation, with its implication that pregnancy is now a possibility, is the trigger for new behavioral restrictions on young women in many cultures—from veiling in countries such as Saudi Arabia (Sasson, 1992) to increased parental control and admonitions about sexuality in North America (Lee, 1994). Although constructed from a biological link between mother and child, motherhood is a profoundly cultural role and process. As Sudarkasa (2004) notes, Even the act of childbirth itself varies according to culturally prescribed rules and expectations … we are all aware that the typical contemporary Western mode of childbirth, where a woman lies on her back, with her legs spread apart is by no means the “natural” or relatively comfortable position for delivery. In parts of Africa and elsewhere in the world, the more traditional women still give birth from a kneeling position. (Introduction section, para. 4) Clearly, this physical process of labor and delivery is shaped to some extent by cultural norms. Aligned with the focus on reproduction is the notion, common to most cultures, that motherhood, and the domestic responsibilities that go with it, is a primary role for women—and that women are better suited to such work than men. Around the world, women devote vast amounts of their time to the bearing and rearing of children. One 10-country study showed that mothers spent from 5.2 to 10.7 hours daily on childcare, whereas fathers spent from 0.1 to 0.9 hours (Owen, 1995), and a more recent overview of time use studies carried out in 20 countries between 1965 and 2003 shows that men spent an average of only 14 minutes per day on childcare, thus leaving most of that work to women (Hook, 2006). Furthermore, women’s family caring activities are not limited to children; women all over the world do most of the caring work for family members who are ill, disabled, or elderly (Forssén, Carlstedt, & Mörtberg, 2005). Motherhood is understood to be a major aspect of women’s identity (Wilson, 2007). In many cultures, a woman without children is considered a failure—perhaps not even a real woman. However, just producing children is not enough to succeed at this role. Depending on the culture, mothers may be held to high standards in terms of the ways they are expected to feel and behave toward their children. In North America and other Western cultures, motherhood is supposed to involve trying to live up to an ideal of love and self-sacrifice (Wilson, 2007) and conforming to an ideology of “intensive mothering”—an approach to mothering that is highly child-centered, labor-intensive, expensive, emotionally absorbing, and reliably puts the child’s needs before the mother’s (Hays, 1996). This ideology of motherhood appears to fit into a broader ideology that women are supposed to care for others— that they must be sensitive and responsive to the needs of others, even when they themselves are exhausted, stressed, and ill (Forssén et al., 2005). Women who fail to live up to this ideology may suffer guilt, anxiety, and a loss of self-esteem. The ideology that a good woman ought to be caring does not portray mothers as particularly powerful—indeed, they even seem to be subservient to their children in some respects. Expectations are somewhat different across cultures, however. For example, the mother role for Japanese women has traditionally involved independence and power, with mothers having almost complete control over family decisions related to their children and having respected status as an influence group when speaking about children’s needs to government officials. Japanese women report gaining status, respect, and self-worth from their roles as mothers (Bankart, 1989). In some Igbo communities in Africa, as in other matrilineal cultures, family lineage is determined through the mother, making mothers a central force in defining their families (Nzegwu, 2004). Indeed, it is the mother role that brings power and prestige in both family and community settings to many African women (Sudarkasa, 2004). Although mothers’ relationships with their children are expected, in most developed cultures, to be defined by caring and attachment, there are numerous examples of mothers abandoning or even killing their babies. In cultures plagued by extreme poverty, where infant mortality is especially high, mothers may deliberately refrain from developing attachment to infants until they have survived their first months of life, sometimes not even naming them. Among the mothers observed in one desperately poor Brazilian shantytown, mothers expressed pity toward, but selectively neglected, infants who they thought would not survive— saying that it was best to let weak children die because they would never be strong enough to defend themselves as adults. Yet, these mothers were generally very affectionate toward their children and, in the few cases when neglected children actually managed to live, they were accepted and loved by their mothers (Scheper-Hughes, 1985). Based on her observations, this researcher argued that the mother– child bond is not necessarily automatic, and should be understood in the context of the culture and level of surrounding resources into which a child is born. Mothers in this impoverished Brazilian community were important to the survival of their children, but did not have the power to provide resources for their survival. In some respects, their only choice was whether to emphasize grief or resignation when faced with the imminent loss of a sickly child. Across cultures, mothering and caregiving are viewed as women’s work, but women are not necessarily given the resources and support they need to do that work. Furthermore, the high importance placed on motherhood does not mean that most women can choose to stay at home and focus on rearing children; the typical woman in most countries combines motherhood with economic activity outside the home. Work and Pay Cultural norms play a large role in whether women work outside the home. For example, in Saudi Arabia, only 18% of women are economically active, compared with 92% in Burundi. However, over half of the women in a majority of the countries polled by the United Nations are economically active, suggesting that the worldwide norm is for women to carry the double burden of work both outside and in the home (United Nations Statistics Division, 2008a). In the United States, half of all paid workers are women, and women are two thirds of primary or cobreadwinners for families (Shriver & Center for American Progress, 2009). Despite the fact that both men and women are economically active, women are paid less than men worldwide. Culture plays a large role in the extent of this gap. In 2008, the Nordic countries Norway and Sweden had the smallest gender wage gap in the world, with women earning 77% and 81% of men’s wages, respectively, according to a survey by the World Economic Forum (Hausman, Tyson, & Zahidi, 2008). The same data source puts U.S. women’s earnings at 67% of men’s. Middle Eastern and North African countries are characterized by less equality in regard to gender, and have much wider gender wage gaps (e.g., women earn 30% of men’s earnings in Yemen) (Hausmann et al., 2008). Depending on the measures used, the gender wage gap may appear smaller or larger (for example, according to the 2009 figures of the U.S. Census Bureau, women earn just under 78% of men’s wages); however, there always seems to be a gap in favor of men. The cost of motherhood One aspect of the gender pay gap is often referred to as the “motherhood penalty”; motherhood appears to be the number one influence on women’s lower wages. In Anglo-American, continental European, and Nordic countries, mothers may earn less money than childless women and men because they work fewer hours due to other family responsibilities (and therefore have less work experience and job tenure), choose jobs based on flexibility, location, etc., that work better with childcare responsibilities (which leads to occupational segregation), and less successful women in occupations may choose, more often than successful women, to have children (Sigle-Rushton & Waldfogel, 2007). Occupational segregation On average, men tend to work in higher paying and more powerful occupations than women. Such jobs are often less flexible, and require more time commitments that can be especially difficult for women with childcare responsibilities. Thus, the childcare responsibilities placed on women in many cultures indirectly contribute to the gendering of power seen across the world. For example, in 2006, according to statistics collected by the United Nations, only five out of 117 countries had at least 50% of legislative and managerial positions filled by women. In other countries, very few women hold these powerful positions (e.g., only 3% of all legislators and managers in Pakistan were women in 2006) (United Nations Statistics Division, 2008b). In other words, without cultural norms involving a more equal distribution of childcare responsibility, women will continue to struggle to obtain powerful and high-paying positions in society. Countries that have attempted to reform cultural norms so that childcare responsibility is shared more equally between women and men have the most equal balance of men and women in high-paying jobs, and thus a narrower gender wage gap. For example, in Norway both men and women are given an opportunity for paid parental leave (approximately 42 to 52 weeks) when a child is born, thus reducing the time off women must take after having a child. Often, parents are paid 80 to 100% of their wages, provided by a social insurance fund. Yemen, on the other hand, gives shorter time periods for paid maternity leave (approximately 60 days), which is paid for by employers. These very different leave benefits for new parents might reasonably be expected to have a profound impact on the gender wage gap; indeed Norway has a significantly narrower gap than Yemen (Hausmann et al., 2008). Pay/hiring discrimination Even if a mother wants to work in a more powerful, higher-paying occupation, she is likely to face discrimination along the way. In many societies, mothers (but not childless women) are perceived as lacking the characteristics necessary for jobs (e.g. competence and availability), and are thus chosen less often for hire, for management positions and promotions, and are offered lower starting salaries (Correll, Benard, & Paik, 2007; Cuddy, Fiske, & Glick, 2004; Cunningham & Macan, 2007; Fuegen, Biernat, Haines, & Deaux, 2004). However, because most cultures do not place childcare responsibilities on men, fathers do not face the same discrimination in the workplace. In fact, often fathers are preferred as employees over men without children (Cuddy et al., 2004). Education/training In much of the world, men and women have the same access to educational routes that will allow for higher-paying, more powerful positions. However, there are still places in Africa, the southern and western areas of Asia, and Arab states where opportunities for education are not equal for women and men. In these areas, approximately 100 million children, a majority of them girls, do not have access to primary education. In rural Africa specifically, 70% of young girls are not given the chance to finish primary school. Worldwide, for every 100 literate adult men, only 88 adult women are literate (Bureau of Public Information, 2006). Without an education, as adults these girls will not be in a position to become economically independent individuals, thus reducing their power. This, in turn, has a dramatic effect on many aspects of life, including the ability to escape from harmful, violent situations. Violence Against Women In most cultures, men, far more often than women, are the targets of male violence, perhaps because many cultures stress a competitive, aggressive ideal of masculinity (Archer, 1994; Gilmore, 1990). However, around the world, women are the most frequent targets of intimate partner violence and sexual violence perpetrated by men. Both intimate partner violence and sexual violence have a private face; they often take place behind closed doors and are not reported by shamed and frightened victims. Indeed, underreporting makes it difficult to obtain accurate estimates. A World Health Organization study of more than 24,000 women at 15 sites in 10 countries found that, depending on the site, between 15% and 71% of women interviewed reported they had been physically or sexually abused by a male partner during their lifetime; between 4% and 54% said they had been physically or sexually abused by a partner during the past year (Garcia-Moreno et al., 2006). As for the prevalence of rape, researchers estimate that in industrialized countries one of every five women is raped sometime during her life (Parrot & Cummings, 2006). Research in non-industrialized countries is harder to come by, but all indications are that sexual violence directed at women is common all over the world, and that the younger a woman is at first intercourse, the more likely it is that she was forced (Watts & Zimmerman, 2002). Common threads in these forms of violence against women are that they are often long-term, repeated patterns of abusive activity rather than isolated incidents; they are frequently perpetrated by men (spouses, relatives, acquaintances) who are known to the victims; and the female victims are often blamed for causing the violence (Watts & Zimmerman, 2002). Cultural norms and practices that grant higher status, power, and resources to men provide underlying support for these patterns. For example, the notion that men should be the heads of their households implies that they should be able to control “their” women, and women’s dependence on men for economic and social resources can mean they have few options for leaving an abusive situation. Cultures in which there is an emphasis on male dominance, separate spheres for the two sexes, and high levels of interpersonal violence have a higher incidence of rape (Sanday, 1981), and women who report intimate partner violence are more likely than other women to be surrounded by men who engage in controlling and limiting behavior toward them (Ellsberg et al., 2008). Violence against women as public performance of the gender system Although the kinds of violence described here are often hidden, both intimate partner violence and sexual violence also have a public face, and the connections between the private and public forms of violence against women are stark. In certain situations, violence against women becomes a public performance of gender hierarchy and male status: an overt statement about men’s ownership of and right to authority over “their” women. The most dramatic example is honor killing: the murder of a woman whose behavior is deemed to have brought dishonor to her husband, father, and/or other family members. The behavior that prompts this reaction usually involves women transgressing cultural boundaries of propriety in ways that may range from dressing in unapproved ways, going unchaperoned to particular places, or being in the company of unrelated men, to having intimate relationships outside of marriage, being raped, or even marrying a man without family approval. Such killings, which are most often carried out by a male relative such as a brother, claim the lives of more than 5,000 women every year worldwide (United Nations Population Fund, 2000). They occur with some frequency in countries as diverse as Turkey, Jordan, Egypt, Pakistan, India, Israel, and Brazil, and are often treated leniently by legal systems (Parrot & Cummings, 2006). Underpinning the practice of honor killings are cultural norms that not only assume higher status for men than women, but also tie a man’s honor and standing in the community to his ability to control his wife and daughters. In certain poor communities where such norms are strong, the only possession of value a man may feel he owns is his honor. An indiscreet woman is seen as bringing shame on her family and destroying that one important possession—a possession that is clearly viewed as much more important than the woman herself. The cultural assignment of higher value to men’s honor and community standing than to women’s lives is a grim indicator that women’s welfare is considered inconsequential relative to men’s. Ironically, rape (for which women are often punished) is also used as a tool of punishment against women for violating rules of sexual propriety, or even just for intruding into spaces, occupations, or situations where they “do not belong.” Rape is also used as a tool of male–male hostility: one man can dishonor another by raping his wife, daughter, sister, or mother. In one case that stirred international protests, Mukhtaran Bibi, a young woman in rural Pakistan, was gang-raped by four men on the orders of the tribal council, and then forced to walk home naked in front of jeering villagers—all because her brother had been seen with a woman from that village (Kristof, 2005). The rape of women during war by enemy soldiers is a common way of dishonoring and demoralizing a community, leaving a lasting legacy of humiliation and bitterness. For example, during the war in Bosnia in the early 1990s, some estimate that more than 20,000 women were raped (Parrot & Cummings, 2006); during the genocide in Rwanda in 1994, between one-quarter and one-half million women were raped (Human Rights Watch, 1996). These women were then viewed by others in their societies as “ruined” and the pregnancies that often resulted from the rapes provided a constant reminder of the trauma and of this “spoiled” status. Under these circumstances, many women have killed themselves and/or their infants (Drakulic, 1994). The business of violence against women In many contexts, the abuse of women is a for-profit enterprise. Sexual exploitation of girls and women, trafficking of women for the purpose of prostitution or forced labor, pornography that exploits images of female humiliation—all are thriving businesses in many parts of the world. For example, it has been estimated that as many as 800,000 persons, 80% of them women, are trafficked across national borders each year to find themselves caught in situations of forced servitude (U.S. Department of State, 2008). Like other forms of violence against women, these practices are grounded in cultural norms and practices that provide men with more access to resources and in attitudes that women can be considered property. Although there are ongoing attempts, often through the United Nations and other non-governmental organizations, to stem these practices, many governments have responded weakly to the problem. Turning a blind eye suggests tacit support for male control over women and the primacy of male needs and wants over women’s welfare. Impact of violence on women’s health Violence has a multitude of consequences for women’s physical and mental health. In almost every site covered by a large international study, women who had experienced partner violence in their lifetimes were more likely than other women to report poor health; frequently reported problems included difficulty walking, trouble carrying out daily activities, pain, memory loss, dizziness, and vaginal discharge (Ellsberg et al., 2008). In the same study, women who reported experiencing intimate partner violence at least once in their lives were significantly more likely than other women to report emotional distress, suicidal thoughts, and suicide attempts. The psychological impact of violence has profound implications for women’s ability to achieve success, status, and power relative to men. Women who are victimized by partners often experience long-lasting anxiety, depression, and low self-esteem, making it difficult for them to function effectively (Matud, 2005). Women who live in situations where violence against women is common learn to be alert, careful, and avoidant (Khalid, 1997). Such caution limits their mobility and interferes with their economic and social opportunities. Thus, an atmosphere of violence against women, whether in the private context of the home or the public context of the street, serves as an effective way of controlling women. Given these diverse consequences, violence against women is now viewed by international policy analysts as both a public health problem and a human rights issue. The shift from viewing violence against women as a private, interpersonal matter to viewing it as a public policy concern may be a direct result of women’s increasing access to resources such as education, employment, and a voice in the media, that promote their movement into positions of public power and leadership. Power and Leadership Across cultures, public positions of leadership are most often held by men. Women are routinely stereotyped as less powerful, dominant, and influential and are ascribed lower status and importance than men. Indeed, the association of men with power is so normative that, in many situations, women who behave in overtly powerful ways are disparaged as unfeminine, unattractive, and unlikeable (Parks-Stamm, Heilman, & Hearns, 2008). If they persist, they may even become targets of violence—as in the case of Dr. Mina Hassan Mohammed, who received death threats when, as newly appointed first female director of an African hospital, she tried to exert her authority (Richburg, 1993) or of Malalai Kakar, the first Afghan woman to graduate from the Kandahar Police Academy, murdered by the Taliban in October 2008 for daring to step into a role reserved for men (BBC News, 2008). It has not always and everywhere been the case, however, that powerful women are disparaged. For example, in certain Native American cultures, women were ascribed high levels of spiritual and political power (Kehoe, 1995). Some cultures make exceptions for older women, whose perceived power may increase with age (Freidman, Tzukerman, Wienberg, & Todd, 1992) and who may even, among groups such as the Maori and the Lahu, achieve high status as elders and as wise, powerful matriarchs (Dashu, 1990). Interpersonal power The exertion of interpersonal influence is based upon control of resources: the capacity to reward, punish, or convince another to take an action or position s/he did not originally intend to take (French & Raven, 1959). Such resources may be relatively concrete (money, objective information, physical strength) or personal (expressed disapproval, affection, or admiration) and may involve mainly individual relationships or cultural expectations and norms. The exertion of interpersonal power is gendered precisely because access to such resources is gendered. In many situations, for example, men have more access than women do to money and education, giving them more scope than women to exert interpersonal power by rewarding or convincing others. In the many cultural situations where men are deemed to have legitimate authority over women, the full force of cultural norms helps men to wield power over women. Thus, for example, if culture dictates that the man is “head of the house,” a woman opposing her husband on some decision must push against not just her husband’s individual arguments, threats, or promises, but the weight of cultural expectations that a wife should give in to her husband’s wishes. When the exertion of influence is viewed as illegitimate, the would-be influencer is pressured to use strategies that are indirect and hidden, rather than direct. Researchers have confirmed that, across at least some cultures, direct influence strategies are preferred over and valued more highly than indirect ones (Steil & Hillman, 1993). Because cultural norms so often dictate that women trying to influence men are acting illegitimately (i.e., in defiance of accepted social norms), women may often find themselves pushed toward using less-preferred influence strategies. In cultures where power and dominance are viewed as unfeminine, research has shown that both men and women penalize women who exhibit these characteristics. This reaction includes the penalization of female workers who are successful in masculine occupations. The counterintuitive finding that women themselves penalize powerful, dominant women may be due to social comparison. Research suggests that women who also see themselves as possessing these masculine qualities are less likely to penalize powerful women (Lawson, 2009). Due to the possibility of penalization, often women who want to exert influence learn to do so by “softening” their approach and/or their image. Indeed, researchers find that women can defuse potentially negative reactions to their power by emphasizing such qualities as cooperativeness and concern for others (Carli, 2001). One recent study showed, for example, that providing information about a female leader’s communal qualities prevented observers from judging her as unfeminine and interpersonally hostile (Parks-Stamm et al., 2008). Public leadership Women are still far less likely than men to hold positions of public leadership. As of this writing, for example, women headed only 13 of 189 national governments (International Women’s Democracy Center, 2008). The Gender Empowerment Measure (GEM), an index conceived by the United Nations Development Program, provides one way to quantify women’s public power and compare it across countries (United Nations Development Program, 2008). Using this index, which includes measures of women’s political participation and decision-making power, their workforce participation as managers and professional and technical workers, and their level of earned income, it is possible to see some of the large differences among countries in women’s access to power and leadership. Recent statistics show Norway and Sweden as the countries with the highest GEM scores, and thus as the countries in which women’s and men’s public power is closest to equal. Both countries have index scores higher than 0.9, where 1.0 would indicate equality on the selected measures. By contrast, Yemen and Saudi Arabia have extremely low GEM scores (less than 0.3), indicating a great deal of inequality in the distribution of public power between women and men. The United States ranks fifteenth on the list, with a GEM score of 0.762 (United Nations Development Program, 2007/2008). What cultural factors promote female leadership? One dimension appears to be the degree to which a culture accepts hierarchies and an unequal distribution of power. One 25-country study revealed that countries with strong acceptance of hierarchies are also characterized by high gender inequality (Glick, 2006). Other contextual issues also appear to be important. One review of leadership research revealed that women are most likely to be evaluated harshly as leaders in situations where people are not used to female leaders, settings where most of the participants are male, and leadership positions that seem to call for a directive “masculine” leadership style (Eagly, Makhijani, & Klonsky, 1992). Women political leaders have sometimes adjusted to these requirements by styling themselves as “ mothers” of their countries— thus adopting a “feminine” aspect to their leadership role (Anuradha, 2008). The presence of women in visible leadership positions may increase the perceived normalcy of female leadership and thus reduce resistance. It may also increase young women’s sense of possibility that they can be leaders—a sense sometimes found to be weaker than men’s (Killeen, López-Zafra, & Eagly, 2006; Lips, 2000, 2001). Thus, cultures in which women leaders are less rare may be supportive of increased female leadership. Apfelbaum (1993) suggested such a conclusion in a cross-cultural study which revealed that the experiences of female leaders in Norway and France differed greatly. Norwegian women in leadership relished and felt entitled to their power; French women felt isolated, lonely, and continually under siege in their positions. Apfelbaum attributed the difference in these women’s experiences to their cultural context: women in Norway were in a culture where female leadership was common, expected, and supported; French women, by contrast, were trying to lead in a culture where female leaders were still an anomaly. The legitimization of female leadership through explicit cultural rules and laws or by strong and obvious cultural norms is also likely to have a positive effect. For example, a laboratory study by Yoder and her colleagues (1998) compared the influence over an all-male group of a woman leader who either had or had not received special training and was said by a male experimenter to be either randomly appointed or especially trained to lead the group. Only the women who were both trained and legitimated by the experimenter were effective in influencing their groups’ performance. It appears that simply placing women in leadership positions, without legitimizing them through some cultural authority, is not sufficient to ensure their power. Empowerment for women The realization that women so frequently hold less power than men has led to calls for women’s empowerment. Empowerment, a term that has been interpreted as a process by which people gain control over their own lives (Rappaport, 1987) or the ability to choose and achieve their own goals (Kasturirangan, 2008), has figured widely in discussions about how women’s lives could improve in many cultural contexts. For many analysts, empowerment is facilitated by increasing women’s access to resources—an approach that fits well with the social psychological analysis of power discussed above. Thus, for example, advocates urge that women who face domestic violence be given access to safe spaces in which they can define their own goals and determine appropriate actions to reach them (Kasturirangan, 2008). Increasing girls’ access to education is also cited as a source of empowerment— something that will enable young women to improve many outcomes from jobs to health (Grown, Gupta, & Pande, 2005; Olateju, 2007). It is clear, however, that empowerment is not something that can be given to or done for any group of women—it must be achieved by women themselves. Women activists in many cultures have been striving to do just that. Feminist Activism Much of the feminist activism that has improved the lives of women around the world started with small groups of concerned women. For example, many women of St. Croix (an island of approximately 50,000 people) came together for a Women Writers’ Symposium in 1981. After listening to riveting feminist readings of poetry and writings, the women began discussing stories of abuse. About 20 local women exchanged contact information and continued this conversation at later informal meetings, which eventually led to the Women’s Coalition of St. Croix. Today, this very successful organization continues to help abused women and children in a variety of ways, including providing intervention services 24 hours per day, 365 days per year, counseling, food, support groups, and training programs for police and teachers to help sensitize these workers to the needs of abused women and children. The group also owns and operates a crisis center and a shelter for battered women (Morrow, 1994). Small group efforts such as this one can both progress to and stem from large-scale events, such as the World Conferences on Women, which are organized for the purpose of promoting the advancement of women worldwide. The Fourth Conference, hosted in Beijing in 1995, included 189 countries (attracting nearly 50,000 women and men) and led to the implementation of the Beijing Declaration and Platform for Action, which has promoted changes around the world through women’s advocacy groups and governments (United Nations, 1997). For example, after its delegates attended the conference, Rwanda adopted a quota system for electing parliamentary and cabinet seats in their government, requiring 30% of the seats to go to women. In 2008, 56.3% of the members of Rwanda’s lower or single House of Parliament were women (nearly a 40% increase since 1997). These women have provided the driving force behind many important legislative changes, including the overturning of sexist laws (such as one denying women the right to inherit land) and the passing of legislation aimed at ending domestic violence. These women plan to continue weeding out the discriminatory laws of Rwanda, including one that requires a husband’s signature for a bank loan (McCrummen, 2008). This is just one example of a dramatic improvement in women’s lives stimulated by the World Conferences on Women. Strategies Feminist activists use a number of strategies to improve the lives of women. They may contribute to research on women’s issues, provide economically for women, or teach women the skills to provide economically for themselves, work to change legislation, network, and/or educate the public about women’s issues. Legislation Feminist activism can be quite effective at promoting equality for women by influencing legislation. Due to the increase of women in powerful, influential, and decision-making positions, women are in a better position to promote, support, and engage in feminist activism than ever before. For example, in 1972, inspired and pushed by the leadership of Senator Patsy Mink, the United States passed Title IX, which prohibits sex discrimination in any educational institution funded by the federal government. This legislation prohibits schools from excluding female students from classes, sports, or other activities held within the institution (U.S. Department of Labor, n.d.). This legislation has led to a number of significant changes within academic institutions, perhaps most notably within athletics at both the high school and college level. For high school students, girls’ athletic participation increased by 847% after the passage of Title IX. For college students, women’s athletic participation increased from 32,000 women prior to Title IX to 150,000 women in 2007 (National Council for Research on Women, n.d.). Feminists have also supported legislation promoting pay equality in the workplace. Prior to 2009, workers in the United States were allowed to sue for pay discrimination only within six months after they received their first discriminatory paycheck. Unfortunately, this law did not take into account that an individual may work for an employer for years without realizing she is the victim of pay discrimination, as was the case for Lily Ledbetter. Ledbetter, a worker at Goodyear Tire & Rubber Company for 19 years, discovered at the end of her career that she had been receiving significantly lower pay than her male colleagues. Ledbetter sued the company for this discriminatory act, but the courts ruled in the favor of Goodyear because Ledbetter had not sued within six months of her first paycheck. Due largely to the efforts of feminist activism, the U.S. Congress reviewed this unfair law and supported its modification. In January of 2009, President Barack Obama signed a law stating that workers have the ability to sue companies for pay discrimination within six months of the last paycheck received (Goldstein, 2009). Without feminists (both in and out of the government) pushing for this change, this step toward equality might never have been taken. Networking Today’s technology has provided feminists with the opportunity to network with others worldwide in order to communicate and organize activities to support women. Feminist groups develop websites to create awareness of various problems women are facing and to give individuals the chance to contribute money or time. For example, Women for Women International helps women who live in either war or post-war environments by providing financial support for basic necessities (food, water, etc.) and by teaching these women leadership and vocational skills for future jobs (Women for Women International, 2009). College students and others use social networking tools on the Internet, such as Facebook, to promote feminist activism. These students design and encourage others to join Facebook groups which provide information on women’s issues, achievements of the group, and future events. Feminist groups have taken advantage of all the possibilities provided by the Internet to help women in a variety of ways, including raising public awareness of human rights. Education/public awareness The Internet is only one of many tools used to educate the public about issues women are facing around the world. In Nigeria, where rape is a serious problem and victims (rather than perpetrators) are often punished either physically or through ostracism for speaking about the incident, many victims of rape remain silent. A number of activist groups work with community leaders to change the community norms that force women into silence. In order to promote awareness of the human rights issues present in Nigeria, these feminist activists set up media interviews and press briefings, distribute information to promote awareness, and also use popular theater (Onyejekwe, 2008). Indian culture also uses a unique approach to promote awareness about women’s issues. Individuals actually perform what is called “street theater” to communicate these problems (Garlough, 2008). Increased public awareness is essential in changing conditions for women throughout the world. Without knowing the existence and scope of a problem such as domestic violence, people cannot be mobilized to try to solve it. Education on feminist issues such as pressure to conform to destructive cultural standards of beauty, the gender pay gap, discrimination against mothers, and domestic violence are essential because these practices are often so ingrained in a culture that they are taken for granted and essentially invisible. Benefits of feminist activism Examples of feminist activism can be found in most cultures today. Is such activism actually promoting change? At least in some cases, positive change has been a clear outcome. For example, legislative changes in the United States have led to more equality among the sexes. In 1972 (when Title IX was passed) 9% of medical degrees were earned by women, whereas in 2007 women earned 49.1% of the degrees (National Council for Research on Women, n.d.). The Beijing Platform for Action not only indirectly influenced legislative changes in Rwanda, but also led to increased public awareness about human rights in countries such as Guyana, which now includes human rights as a subject in school curricula, and Vietnam, which has attempted to remove school textbooks with gender stereotypes and has radio and television shows focusing on gender equality (Women’s Environment and Development Organization, 2005). Feminist activism also has personal psychological and social benefits. For example, after going through the Functional Adult Literacy Program in Turkey, women reported a more positive self-concept, along with more social integration and family cohesion (Kagitcibasi, Goksen, & Gulgoz, 2005). For activists themselves, feminist activism has also been found to be associated with mental and physical health. Feminist activists worry less about their weight, take fewer diet aids, report less disordered eating after perceiving sexist events, and report more satisfaction with their appearance than their non-activist counterparts (Haas, 2005; Sabik & Tylka, 2006). For lesbian women, activism is also associated with self-acceptance (Rand, Graham, & Rawlings, 1982). Overall, feminist activism has been effective in moving societies in the direction of greater gender equality and also has a number of health benefits for both the women receiving and those giving the help. Conclusion All over the world, women’s (and men’s) roles, rights, and responsibilities have been shaped by cultural norms that support the assignment of more power and importance to men. The strength of these norms and the magnitude of the differences they support vary by culture, but there seems to be no country in which women and men enjoy equal access to political power and economic resources (Social Watch, 2008). Cultures with the highest levels of equality are not necessarily those with the most resources, but rather those for which gender equity is explicitly enshrined in policies such as labor-market regulations banning discrimination and gender quotas for political participation. Activism by women has been the driving force behind the development of such policies. Worldwide, the situation is fluid: as women gain more control over their own lives, their sense of entitlement rises and they seek even more advances. The increasing capacity, nurtured by electronic media, for women to connect across cultures seems destined to speed up this process. Continuing progress toward equality is not inevitable, however, as illustrated by the dispiriting histories of countries (e.g., former Soviet bloc nations, Afghanistan, Iran) in which a shift in government sharply eroded women’s rights. However, both positive examples of women’s progress and negative examples of the ease which such progress can be reversed illustrate that women’s position is very much a function of cultural agreement rather than a function of essential feminine qualities or female–male differences. References Allen, P. G. (1986). The sacred hoop: Recovering the feminine in American Indian traditions. Boston, MA: Beacon Press. American Society for Aesthetic Plastic Surgery (2008, February 25). Cosmetic procedures in 2007. Retrieved from Anuradha, C. S. (2008). Women political leadership and perception: A case study of South Asia. International Journal of South Asian Studies, 1, 1–8. Retrieved January 15, 2009 from Apfelbaum, E. (1993). Norwegian and French women in high leadership positions: The importance of cultural context upon gendered relations. Psychology of Women Quarterly, 17, 409–429. CHAPTER 12Experiences of Sexual Minorities in Diverse Cultures Linh Nguyen Littleford and Mary E. Kite Within all countries around the world, there have always been people whose sexual practices, orientation, and identity differed from the dominant group. It was not until the nineteenth century, mostly in Europe and North America, that people began to use labels to differentiate sexual minorities from sexual majorities (Bristow, 1997; Herek & Garnets, 2007); we begin by defining the terms commonly used in Western societies. Heterosexuals are believed to experience emotional, romantic, and sexual attraction to members of the other biological sex; for homosexual people, this attraction is to members of their own biological sex (American Psychological Association, 1998). Bisexuals have emotional, romantic, and sexual attraction to members of both the same and the other sex. Some people believe that their gender identity differs from the traditional notions of maleness and femaleness and/ or that this identity does not correspond with their biological sex (Lev, 2007). These individuals are referred to as transgendered people. Transsexuals are people who are transgendered and who feel so strongly that they are “trapped in the body of the other sex” that they take sex hormones or have surgery to become the other sex (Hill, 2008). As you have seen throughout this book, a society’s culture is generally defined by the dominant group; across cultures, this privileged group comprises heterosexuals and people whose sense of being male or female is consistent with their biological sex. As we will discuss, individuals who differ from the dominant culture often experience prejudice and discrimination (Matsumoto & Juang, 2008) and this is especially true for people who identify as lesbians, gays, bisexuals, or transgendered (LGBTs); sexual minorities in all nations experience sexual stigma because they violate the norms established and are marked as “devalued, spoiled, or flawed in the eyes of others” (Crocker, Major, & Steele, 1998, p. 504). Both lay people and researchers tend to view sexual orientation as a dichotomous variable; that is, they categorize people as either homosexual or heterosexual. However, it is more accurate to view sexual orientation on a continuum, ranging from completely homosexual to completely heterosexual, and with some individuals having a bisexual orientation. In addition, sexual minorities vary in if, how, and when they self-identify their affective or sexual orientation. Some individuals may feel sexual attractions, have same-gender sexual fantasies, and/or engage in same-gender sexual relations but do not consider themselves gay, lesbian, or bisexual (Garnets, 2002; Greene, 1994). Others may use different sexual identity labels to reflect their masculine or feminine roles, their status in the same-gender relationship, and their roles within sexual activities. For example, in Senegal, men who have sex with men self-identify as either yoos or ibbis(Niang et al., 2003). Yoos are more dominant, masculine, and often the insertive partners in sexual acts. They do not see themselves as homosexuals. In contrast, ibbis are more feminine, more passive in sexual acts, and have less status and power in the relationship. Similarly, in Peru (Caceras & Rosasco, 1999) and Turkey (Bereket & Adam, 2008), men who have sex with men select different identities depending on whether their relationships are egalitarian or adhere to traditional gender roles. Some sexual minorities, particularly those in developing countries and/or who are poor, engage in same-gender sexual behaviors for financial gains (Niang et al., 2003). Still others self-identify as LGB without ever having engaged in sexual relations (Rothblum, 1994). Consequently, defining sexual orientation based on same-gender sexual behaviors or on Western-based LGBT categories without considering other sociocultural factors can be both culturally insensitive and inaccurate (Zhou, 2006). Accordingly, in this chapter we will discuss the experiences of sexual minorities, including those who self-identify as LBGT and those who have same-gender sexual fantasies and attractions, engage in same-gender sexual behaviors, and have atypical gender characteristics, whether or not they self-identify as LGBT. We will use LGBT, LB, or GB when reviewing research that included those labels. We will use sexual minorities to refer to LGBT people in cultures and countries where LGBT categories are not commonly used. Because gay men and lesbians in North America and Europe are the focus of most of the research and theory we discuss, our chapter primarily examines their experiences. When possible, we will also discuss how sexual stigma affects the lives of sexual minorities in other regions of the world and explore the heterogeneity of sexual minorities between and within countries. Conceptually, we use Herek and colleagues’ (Herek, Chopp, & Strohl, 2007; Herek, Gillis, & Cogan, 2009) sexual stigma framework and Meyer’s (2003b, 2007) LGB minority stress model to discuss sexual minorities’ experiences with stigma and its influence on their mental health. Both models propose that LGBT people face many forms of stigma and that these experiences have negative consequences. Herek et al. (2007, 2009) focus on how sexual stigma is transmitted and perpetuated in the U.S. and the extent to which both heterosexual and LGB people internalize these beliefs. Meyer’s LGB minority stress model emphasizes how LGB individuals’ expectations of, subjective experiences with, and interpretations of objective events such as exclusion, marginalization, prejudice, and discrimination affect their mental health outcomes. Both models focus on sexual stigma and its consequences primarily on people within the U.S. We will discuss three levels of stigma: institutional, interpersonal, and intrapersonal. These levels are similar to the cultural and individual forms of stigma discussed by Herek et al. (2007, 2009), and the distal and proximal minority stressors presented by Meyer (2003b, 2007). Our institutionalized stigma category corresponds to Herek et al.’s (2009) cultural form of stigma. At this level of analysis, we will report the current laws and civil rights relevant to members of sexual minority groups. We will then divide Herek et al.’s (2009) individual stigma category into two levels (interpersonal and intrapersonal) to emphasize the ways in which sexual stigma similarly and differently affects sexual majorities and sexual minorities. Specifically, within our category of interpersonal stigma, we will focus on how sexual majorities internalize and exhibit sexual stigma toward sexual minorities. These types of sexual stigma parallel Meyer’s (2003b, 2007) distal minority stressors. In contrast, within our category of intrapersonal stigma, we will highlight how sexual minorities internalize and cope with institutional and interpersonal forms of sexual stigma. These topics correspond to Meyer’s (2003b, 2007) proximal minority stressors. We will conclude by reviewing what is currently known about sexual minorities’ mental health outcomes. Prevalence of Sexual Minorities When considering sexual minorities’ experiences cross-culturally, it is important to consider their representation in the world’s population. It is difficult to pinpoint the proportion of people who are LGBT and/or sexual minorities because these estimates are based entirely on self-report and individuals may choose not to self-disclose this information even on anonymous surveys. In addition, the prevalence rates differ depending on whether the surveys define LGB as ever having sexual relations with a same-gender other, as viewing one’s sexual identity as LGB, or as being involved in the LGB community (Fox, 1995; Rothblum, 1994). Regardless of the method used, LGBTs are a numerical minority group. One common estimate is that approximately 10% of the population is gay or lesbian, but a closer look at the research shows that estimates vary from one to 17% (see Hill, 2008, for a review). The percentage of women who self-identify as lesbian is generally smaller than the percentage of men who self-identify as gay, but national surveys of a representative sample of U.S. residents estimate both to be lower than 3% (Laumann, Gagnon, Michael, & Michaels, 1994). Estimating the percentage of women who identify as lesbian is further complicated by findings that women’s sexuality is fluid. For example, a significant proportion of lesbian women report periodic attraction to men (Diamond & Savin-Williams, 2000). More men than women identify as transgendered, but we know of no research on the actual incidence of transgenderism. Based on U.S. samples, estimates of the prevalence of transsexualism range from one in 2,900 to one in 100,000 (de Cuypere et al., 2007). Institutionalized Sexual Stigma Sexual stigma, or a system of beliefs that considers same-gender sexual practices as immoral or unacceptable and that deems sexual minorities inferior compared to sexual majorities, has been integrated into many societies. This belief system is embedded into virtually all aspects of society such that all individuals, regardless of their sexual orientation, identity, or personal views, know that sexual minorities are denigrated and treated more negatively than sexual majorities (Herek et al., 2007). One level in which people are socialized to stigmatize sexual minorities is through institutional structures, such as laws, that make explicit that sexual minorities do not have the same worth as sexual majorities and thus do not deserve equal rights. Currently, many countries have laws that condemn same-gender sexual practices, punish people who are sexual minorities, and limit these individuals’ civil rights. As of May 2009, 59% (115) of countries have laws that legalize same-gender sexual behaviors while 41% (80) consider the behaviors illegal (Ottosson, 2009). Same-gender behaviors for both sexes are illegal in most countries in Africa and Asia but are legal in all recognized countries in Europe and in all but one country in South America (i.e., Guyana). In Oceania, 8 of 17 countries and territories consider same-gender acts legal. In North America, homosexual acts are legal in 15 out of 25 countries and territories; in the U.S., the 2003 Supreme Court decision to overturn sodomy laws (Lawrence v. Texas, 2003) made it the third most recent country to decriminalize same-gender acts (Ottosson, 2009). In countries where engaging in homosexual acts is illegal, the typical punishment is imprisonment; however, in five countries in Africa (Mauritania and Sudan) and Asia (Iran, Saudi Arabia, and Yemen) and some parts of Nigeria and Somalia those persons are sentenced to death (Ottosson, 2009). Interestingly, 13% of countries have different laws for men and women who engage in same-gender behaviors (Ottosson, 2009). When differences exist, the laws permit women to have sex with women but punish men if they have sex with men; this punishment can be as severe as life imprisonment. The reverse pattern does not occur. Thus, no countries have laws that punish women who engage same-gender sexual behaviors while permitting men to engage in similar acts. Of the countries that have decriminalized homosexual acts, only a few have laws that protect their sexual minority citizens from experiencing discrimination based on sexual orientation. Only 5% of the worlds’ countries specifically prohibit discrimination based on sexual orientation in their constitutions. Employment discrimination based on homosexual orientation is banned in 25% of countries; 10% ban such discrimination based on gender identity (Ottosson, 2009). In addition, 2% of countries extend their institutionalized sexual stigma laws to non-citizens, prohibiting LGB people from entering their countries (Lesotho, Swaziland, Belize, and Trinidad and Tobago; Ottosson, 2009). Very few countries, even with decriminalization, monitor and/or punish those who assault members of sexual minority groups (Ottosson, 2009; Stahnke et al., 2008). Just 5% of countries have hate crime laws providing harsher punishments for those inflicting physical violence because of the victims’ sexual orientation (or perceived sexual orientation). Currently, 9% of countries legally recognize transsexuals’ gender after gender reassignment treatment (Australia, Belgium, parts of Canada, Finland, Germany, Italy, Japan, the Netherlands, New Zealand, Panama, Romania, South Africa, Spain, Sweden, Turkey, United Kingdom, and parts of the U.S.; Ottosson, 2009). Only Uruguay and some parts of the U.S. punish more severely people who commit hate crimes based on the victims’ gender identity (Ottosson, 2009). Although a minority, there are countries in which citizens who are LGB have marriage and parenting rights comparable to their heterosexual counterparts. According to Ottosson (2009), 10% have laws that allow people who are LGB to marry (Belgium, Canada, Netherlands, Norway, South Africa, Spain, and Sweden, and six U.S. states) or to have civil partnerships or unions with most or all rights of marriage (Colombia, Denmark, Finland, Germany, Iceland, New Zealand, some parts of Australia, Switzerland, the U.K., and some U.S. states). Same-sex couples can jointly adopt children in 5% of countries (Andorra, Capital Territory and Western Australia in Australia, Belgium, the Brazilian city of São Paulo, most of the Canadian provinces, Iceland, Israel, the Netherlands, Norway, South Africa, Spain, Sweden, the U.K., and some parts of the U.S.). In addition, the non-biological parent in same-gender relationships may adopt her or his partner’s children in 2% of countries (Denmark, Germany, Tasmania, and Alberta, Canada; Ottosson, 2009). In summary, laws in the majority of the countries in the world allow same-gender sexual behaviors but explicitly limit sexual minorities’ civil rights in multiple domains, including in marriage, adoption, employment, and protection from hate crimes. These laws reinforce the notion that members of sexual minority groups are abnormal and inferior relative to sexual majorities. Sexual minority citizens in many countries in Europe have more civil rights than their counterparts in other parts of the world. However, even in these countries, it was necessary to pass laws to ensure that sexual minorities have the same civil rights as sexual majorities—who have always enjoyed these rights without such legal proceedings. It appears, then, that sexual stigma still exists on some levels in these countries. In the next section, as we discuss sexual stigma at the interpersonal level, it will be evident that sexual majorities continue to view and treat sexual minorities negatively in all countries, including those in Europe. Interpersonal Forms of Sexual Stigma Sexual prejudice The negative emotions and feelings sexual majorities have, as a result of internalized sexual stigma, toward individuals who are LGBT, are referred to as sexual prejudice (Herek et al., 2007). As is true for all cross-cultural research, to answer the question of whether sexual prejudice is higher in some countries than in others, researchers should ask equivalent samples (preferably representative of the population) the same questions using the same procedure. The questionnaires used should have linguistic equivalence—that is, the items must have the same meaning across the different languages used in the different countries. As Matsumoto and Juang (2008) note, failing to do so “creates the proverbial situation of comparing apples and oranges” (p. 29). We are aware of only five studies that meet these criteria. Widmer, Treas, and Newcombe (1998) compared responses to the question “Is homosexual sex wrong?” across large and nationally representative samples from 24 countries; data were from the 1994 International Social Survey Program. As is true for each of the first three studies we describe, respondents were primarily from Eastern and Western Europe and North America. Respondents from the Netherlands, Norway, the Czech Republic, Canada, and Spain were most accepting of homosexual sex; those in Hungary, Bulgaria, Italy, Japan, Northern Ireland, the Philippines, Poland, and Slovenia were least accepting. It should be noted, however, that the majority of respondents in most countries (excepting the five most tolerant countries) reported that homosexual sex was always or almost always wrong. Kelly (2001) reported responses from 29 nations who participated in the International Social Science Survey (ISSS) in 1999/2000. Results replicated Widmer et al. (1998) in that the same group of countries generally emerged as most and least accepting. However, note that Canada and Poland were not included in the 1999/2000 ISSS and that this survey included Switzerland, Denmark (both found to be accepting), and Chile (found to be unaccepting). Further, Kelly (2001) found Sweden and Germany among the most accepting, whereas Widmer et al. (1998) found somewhat less acceptance in those two countries. Štulhofer and Rimac (2009) reported responses from 31 European countries, based on the European Values Survey (EVS) in 1999/2000. Respondents answered whether homosexuality can be justified and whether they would like to have a homosexual neighbor. Similar to the other studies we have discussed, Scandinavians were most accepting and Eastern Europeans least accepting. The Pew Global Attitudes Project (2007) examined attitudes toward homosexuality across 47 countries and, unlike the other surveys we summarize, included several African, Asian, South American, and Middle Eastern countries. Similar to the previously discussed surveys, in response to the question of whether homosexuality should be accepted or rejected, Western Europeans and Canadians were among the most accepting and Russians and Ukrainians were generally negative. Residents of South American countries and Mexico were also accepting (but not respondents in Venezuela and Bolivia). The majority of U.S. respondents were accepting of homosexuality. Residents of African countries were by far the least accepting; in most of those countries over 90% of the population believed homosexuality should be rejected. In South Africa, 64% rejected homosexuality. Residents of Asian countries, with the exception of Japan, also held anti-LG sentiments, with 69% or higher rejecting homosexuality. Israeli and Turkish citizens rejected homosexuality (50% and 57%, respectively), as did residents of the Palestinian territories (58%), but less so than did residents of other countries in the Middle East where rejection rates were 79% or higher. Table 12.1 Average rank of country based on attitudes toward homosexuality Lithuania Hungary Ukraine Latvia Bulgaria Russia Croatia Portugal Malta Chile 10 Cyprus 11 Poland 12 Northern Ireland 13 Belarus 14 Japan 15 U.S.A. 16 Republic of Ireland 17 Italy 18 Slovenia 19 Slovakia 20 Finland 21 Britain 22 Belgium 23 Austria 24 France 25 Czech Republic 26 Germany 27 Spain 28 Luxembourg 29 Denmark 30 Iceland 31 Sweden 32 The Netherlands 33 Note: For countries included in at least two surveys of nations (Kelly, 2001, Pew Global Attitudes Project, 2007, or Štulhofer & Rimac, 2009), average rank for attitudes toward homosexuality were computed. Higher ranks indicate countries with more positive attitudes. To provide a general index of where acceptance of homosexuality is more or less likely, we computed a country’s rank order of attitudes toward homosexuality, based on data reported in Kelly (2001), the Pew Global Attitudes Project (2007) and Štulhofer & Rimac (2009). Table 12.1 reports the average rank for those countries that were included in at least two surveys; higher ranks indicate countries more accepting of homosexuality. Because these surveys asked somewhat different questions, interpretation should be done with caution. Another limitation of this research is that attitudes were assessed with single-item measures that represent people’s acceptance of homosexual behavior but not necessarily their acceptance of homosexual persons. Because the surveys we summarized were part of a larger study of social attitudes across nations, the use of one or two items is understandable. However, research conducted in the U.S. shows that people are generally more accepting of homosexual people than homosexual behavior (Kite & Whitley, 1996) and that people are more reluctant to deny gay men and lesbians basic civil rights than they are to disparage homosexual people or homosexual behavior (Herek, 2002). Overall acceptance rates might be different if, for example, attitudes toward civil rights were assessed, although it seems unlikely that the pattern of differences across countries would substantially change. It is also important to point out that attitudes toward homosexuality are changing toward greater acceptance. In both Canada and the U.S., there has been a remarkable degree of change over the last 20 years (Andersen & Fetner, 2008). Similar to the results reported by Andersen and Fetner (2008), Adamczyk and Pitt (2009) found that younger people were more accepting than were older cohorts across 33 countries. Similarly, Kelly (2001) reported that Australians’ attitudes toward homosexuality were much more accepting in 1999 than in 1984. Likewise, results on the General Social Survey, based on a U.S. sample, showed greater acceptance of homosexuality across time (Hurley, 2005). However, given the extreme negativity, the criminalization of same-gender behaviors, and the laws limiting sexual minorities’ civil rights currently present in some countries, such as many African and Asian nations, this change is unlikely to be universal. Religion appears to be one factor that differentiates between countries that are more accepting of homosexuality from those that are not. Štulhofer and Rimac (2009) found higher levels of acceptance of homosexuality in European countries whose major religion was Catholic or Protestant rather than Eastern Orthodox. Adamczyk and Pitt (2009) analyzed responses to the question of whether homosexuality can be justified in a study of 45,824 people from 33 nations. They found that people who lived in Catholic majority countries (Canada, Puerto Rico, Mexico, Venezuela, Spain, Argentina, Peru, Chile, Uganda, and the Philippines) and Protestant majority countries (U.S., South Korea, South Africa, and Zimbabwe) were more accepting of homosexuality than those in Muslim majority countries (Nigeria, Egypt, Tanzania, Indonesia, Singapore, Bosnia, Bangladesh, Algeria, Albania, Kyrgyz Republic, Jordan, and Pakistan). However, people in these Muslim majority countries had similar attitudes toward homosexuality as those in Christian Orthodox (Moldova, Serbia, Montenegro, and Macedonia), Buddhist ( Japan and Viet Nam), and Hindu (India) countries. In addition to religion, countries’ levels of urbanization and economic development are associated with their citizens’ acceptance of homosexuality (Adamczyk & Pitt, 2009; Štulhofer & Rimac, 2009). Adamczyk and Pitt (2009) theorized that in countries where there are economic uncertainties and the majority of the people still worry about their physical and basic needs (survival orientation), people cope by holding onto familiar cultural norms and laws. In contrast, within countries where there are economic stability and modernization, people can focus more on their psychological well-being and quality of life (self-expressive orientation). Therefore, they can be more accepting of unfamiliar cultural values and diverse worldviews. Consistent with their hypothesis, Adamczyk and Pitt found that people in self-expressive countries are more supportive of homosexuality than those in survival countries. Interestingly, preliminary evidence indicates that people’s acceptance of homosexuality is not significantly related to their countries’ laws about sexual minorities (Adamczyk & Pitt, 2009). It is important to note that the researchers had to omit data from two countries in which sexual minorities are sentenced to death (Saudi Arabia, Iran) and from two countries where homosexual acts were illegal (Morocco) or unclear (Iraq). Thus, more research is needed to determine whether, and under what circumstances, people’s acceptance of homosexuality reflects and perhaps influences the legal status of gays and lesbians in different countries. Of course, within most countries, there are individual differences in acceptance of homosexuality. In fact, attitudes among people from the same country differ more than those held by people from different countries (71% versus 29% of the variance; Adamczyk & Pitt, 2009). We can identify a set of predictors of individuals’ attitudes toward sexual minorities that appear to hold cross-culturally. First, research conducted in the U.S. has consistently shown that individuals who reported knowing a gay or lesbian person are more accepting of homosexuality (e.g., Herek & Capitanio, 1996). This relationship was also found in a study of Puerto Ricans’ attitudes toward homosexuality (Bauermeister, Morales, Seda, & González-Rivera, 2007) and in samples of U.S. residents of Mexican descent (Herek & González-Rivera, 2006), Germans (Steffens & Wagner, 2004), and Italians (Lingiardi, Falanga, & D’Augelli, 2005). The available data suggest that this relationship holds up cross-culturally but we cannot say whether this factor predicts attitudes toward homosexuality better in any particular culture. And, of course, research based on samples from many more countries must be conducted before we can conclude that this relationship is universal. Second, within countries, individuals with stronger religious beliefs, especially those from fundamentalist religions, are more negative toward gays and lesbians. Whitley (2009) found this relationship in a meta-analysis of 64 studies based on U.S. and Canadian samples. Cross-national studies indicated that church-goers (Kelly, 2001) and those who perceived religion as personally important (Adamczyk & Pitt, 2009) were less tolerant of homosexuality. The relationship between religiosity and sexual prejudice also emerged in samples from Canada (Andersen & Fetner, 2008; Hunsberger, Owusu, & Duck, 1999), Ghana (Hunsberger et al., 1999), Puerto Rico (Bauermeister et al., 2007), and of U.S. residents of Mexican descent (Herek & González-Rivera, 2006). Although Protestants had more negative attitudes toward homosexuality than Catholics, Orthodox Christians, Jews, and people with no religious affiliation, people’s personal religiosity influenced their negative attitudes toward homosexuality significantly more in self-expressive oriented countries such as the U.S. than in survival-oriented countries such as Zimbabwe (Adamczyk & Pitt, 2009). Third, the preponderance of evidence shows that, across cultures, women are more accepting of homosexuality than are men. Adamczyk and Pitt (2009) found that, across 33 nations studied, men held more sexual prejudice than women. This finding is consistent with research reported by Kelly (2001), who analyzed 29 nations. However, Kelly noted that these differences were larger in Scandinavian countries, Australia, Austria, France, Germany, Great Britain, and the U.S., but were non-significant in Russia, Chile, and the Philippines. The Pew Global Attitudes (2007) survey found women to be more accepting of homosexuality than men in Canada, Britain, Germany, France, the U.S., Pakistan, Turkey, Bangladesh, Lebanon, and Nigeria, but found no sex difference in Italy, Jordan, Uzbekistan, or Indonesia. In these countries, men were more intolerant of homosexuality than were women: Canada (Andersen & Fetner, 2008), Germany (Steffens & Wagner, 2004), Italy (Lingiardi et al., 2005), and the U.S. (Kite & Whitley, 1996). Studies comparing heterosexual men’s and women’s attitudes toward lesbians and gay men have been limited to the U.S. and the results are mixed. Kite and Whitley (1996) reported that, in U.S. samples, heterosexual men are especially intolerant of gay men. Similarly, Herek and González-Rivera (2006) found Mexican American men held more negative attitudes toward gay men than did women. However, Kite and Whitley (1996) found that men and women evaluated lesbians similarly whereas Herek and González-Rivera (2006) found that women were relatively negative toward lesbians. Bauermeister et al. (2007) found no sex difference in attitudes toward either gay men or lesbians in their Puerto Rican sample. Finally, people with higher levels of education have shown greater acceptance of homosexuality than have those who are less educated. This finding has been reported for samples in the U.S. (Herek, 2002; Herek & Gonzáles-Rivera, 2006), Germany (Steffens & Wagner, 2004), Canada (Andersen & Fetner, 2008), the 21 nations in Kelly’s (2001) study, and across the 33 countries included in Adamczyk and Pitt’s (2009) study. Discrimination against sexual minorities Sexual prejudice conveys sexual majorities’ evaluations of sexual minorities; sexual discrimination is the negative differential behavior directed at members of the latter group. Sexual discrimination includes verbal and physical assaults, often referred to as anti-gay hate crimes or anti-LGBT violence, inflicted on people who are, or are perceived to be, LGBT. As mentioned earlier, not many countries ban anti-gay hate crimes specifically and even fewer have governmental organizations that monitor and report data on sexual orientation hate crimes. Of all hate crimes reported to police in 2007, the prevalence of incidents perpetrated specifically because of the victims’ sexual orientation were 10% in Canada, 20.4% in Sweden, 8.3% in England, 5.6% in Northern Ireland, and 15.5% in the U.S. (Stahnke et al., 2008). In several countries, non-governmental agencies have conducted surveys to assess the prevalence of anti-LGBT violence. In France, of all the reported hate crimes, 11% were due to sexual orientation and/or gender identity. In Germany, 35% of 24,000 gay and bisexual survey respondents reported that they had been victims of anti-LGBT violence within one year. In the U.K., 13% of LGBT people surveyed reported experiencing an anti-LGBT hate crime within the last year, and 20% within the last three years (Stahnke et al., 2008). Summarizing annual reports on hate crimes from nine countries, Stahnke et al. (2008) concluded that the rate of violence against people who are LGBT is high and may be increasing. And yet, these statistics may be much lower than actual incidence because, for many reasons, victims may not be able or willing to report these types of crimes to officials. Survey results revealed that only a small number of sexual minorities reported anti-LGBT violence to officials: 10% in Germany and 14% in the U.K. (Stahnke et al., 2008). Sexual minorities are particularly vulnerable to physical and verbal assaults during adolescence and, as we will discuss later, these experiences may explain why younger LGBT people are at higher risk of suicide than their older cohorts. In Germany, 63% of respondents younger than 18 reported experiencing anti-gay violence (Stahnke et al., 2008). In the U.K., the percentage of GBT men who reported experiencing physical violence (being kicked or hit) while in school was equally high (68%; Rivers, 2001). Although fewer LBT women (31%) than GBT men experienced anti-gay violence, the rates were still significantly higher than those reported by the general student population (24%; Rivers, 2001). More frequent than the physical assaults, the majority of the LGBT respondents recalled experiencing verbal abuse (name calling: 82%, teasing: 58%, being ridiculed: 71%) as youths. In the U.S., Espelage and Swearer (2008) reported that 33% of students reported that they had been victims of anti-gay verbal harassment or physical assaults. In short, in many countries, including those where laws exist to protect LGBT people’s civil rights, sexual majorities continue to hold strong sexual prejudice and exhibit violent forms of discrimination toward people whom they perceive are LGBT. We will next discuss how members of sexual minority groups experience, and the extent to which they internalize, the dominant group’s sexual stigma. Intrapersonal Forms of Sexual Stigma Perceptions of sexual stigma Sexual minorities are aware of their minority status and the negative attitudes that members of the dominant group have toward them. As outlined by Meyer’s (2003b, 2007) LGBT minority stress model, to understand how sexual stigma influences sexual minorities’ mental health outcomes, we need to examine how they interpret their experiences of marginalization. A survey of 12,347 gay and bisexual men in eight countries in Europe found varying levels of perceived acceptance of their sexual minority status (Bochow, Chiarotti, Davies, & Dubois-Arber, 1994). Specifically, most GB men in Denmark (61%) and the Netherlands (68%) believed that all of their family members, friends, and colleagues accepted their sexual orientation. However, the level of perceived acceptance was low for those in the other six countries (i.e., U.K. 34%, Germany [West: 32%, East 30%], Switzerland 28%, France 24%, Austria 19%, and Italy 9%). Gay and bisexual Latino men in three urban cities in the U.S. reported that their most common experiences with sexual stigma were to be told: that gays are not normal (91%); that gay people will be lonely (71%); and that gay people’s sexual orientation causes family members to be embarrassed (70%; Diaz, Ayala, Bein, Henne, & Marin, 2001). Analyzing a nationally representative sample of 3,032 U.S. Americans aged 25 to 74 years, Mays and Cochran (2001) found that 42% of LGB participants reported that they have experienced sexual orientation-based discrimination (e.g., school, work, receiving financial and other services, and social hostility), compared to 2% of their heterosexual counterparts. Sexual self-stigma Living in a culture where they are exposed to laws, attitudes, and behaviors that discriminate against non-heterosexuals, some sexual minorities accept these negative sexual stigma cultural norms. This acceptance of sexual stigma by members of sexual minority groups is known as internalized homophobia (Herek et al., 2007) or sexual self-stigma (Herek et al., 2009). Unlike some stigmas, such as racial or ethnic group membership, sexual orientation is concealable—that is, sexual minorities can choose whether or when to reveal their group membership and many choose to “pass” as a member of the dominant group. Sexual minorities who pass as heterosexuals may be doing so because of their internalized homophobia. In the U.S., LGB adults who endorsed more negative feelings toward LGB people were less likely to disclose their sexual identity to non-family members (Herek et al., 2009). However, many sexual minorities feel compelled to hide their sexual orientation out of fears of familial and social rejection, loss of employment, loss of parental rights, and physical and verbal violence. As discussed in the sections on institutionalized and interpersonal forms of sexual stigma, these concerns have their basis in reality. How and why people conceal their sexual minority status may also be influenced by the norms within their cultures and their countries. For instance, some Korean (Kim & Hahn, 2006) and Chinese (Zhou, 2006) gay men conceal their sexual orientation by marrying women and producing children for fear of social ostracism, lower social status, and family dishonor and shame if they should fail to live up to their cultural and family expectations to continue their family lineage. Similarly, in the U.K., two-thirds of South Asian LGB people surveyed reported that they actively hid their sexual orientation because of incongruity with their Asian cultural expectations (Bhugra, 1997). Some Turkish gay men hide their sexual minority status to maintain their family’s honor and reputation (Bereket & Adam, 2008). Likewise, 64% of gay Latino American male participants in the U.S. presented themselves as heterosexuals (Diaz, Ayala, & Bein, 2004; Diaz et al., 2001). Interestingly, the Latino/Latina American community shows more disapproval toward people who identify as LGBT than they do toward those engaging in same-gender sexual activities (Greene, 1994). Racial/ethnic minorities in the U.S. (e.g., Hispanic/Latino Americans, Asian Americans, African Americans, and Native Americans) who identify as LGBT may feel additional pressure to conceal their sexual orientation. For some of them, identifying as LGBT may cause family members and those within their ethnic communities to perceive them as rejecting their cultural heritage, resulting in ostracism, coercion to conceal their sexual orientation, and withdrawal of social support (Greene, 1994). The loss of support from their own racial/ethnic communities can be more detrimental to ethnic minorities than to European Americans because ethnic minorities may already feel marginalized and excluded by the racial/ethnic dominant European American community (Greene, 1994). Denying one’s group membership does not alleviate the guilt and shame associated with the stigma and can actually heighten these feelings and cause additional stress (Pachankis, 2007). Withholding that one is a sexual minority means hiding an important part of one’s identity; even casual details about one’s intimate relationships must be kept secret, creating stress and anxiety for minority group members (Day & Schoenrade, 2000). In addition, not revealing their sexual minority status precludes opportunities to be accepted by other sexual minorities, to be exposed to more positive messages about their sexual orientation, and to learn protective strategies to address sexual stigma. McLaren, Jude, and McLachlan (2008) found that for Australian self-identified gay men, belonging to either a gay community or the general community led to fewer depressive symptoms. In addition, those who felt valued in a non-gay community also experienced more support in the gay community. The findings suggest that for self-identified gay men, having opportunities to connect with others and to feel valued will reduce depressive symptoms regardless of whether the support comes from sexual minorities or majorities. However, unlike people with a non-concealable stigma, sexual minorities are not born into a community of similar others and thus must seek out other sexual minorities to disclose their own group membership. Even when they wish to disclose their sexual minority status, LGBT people may not always be able to identify each other and thus may remain isolated (Frable, Platt, & Hoey, 1998). Therefore, because it is a concealable stigma, sexual orientation can have more deleterious effects on the individuals’ self-esteem and mood than a visible stigma (Frable et al., 1998; Herek & Garnets, 2007). To summarize, although their reasons may differ, many LGBT people conceal their sexual minority status from others, including their families and friends. Pretending to be heterosexuals or actively hiding their sexual minority status may exacerbate LGBT people’s internalized sexual stigma. In addition, concealment can prevent access to social support and other benefits associated with being a part of the sexual minority community (e.g., community connection, protection, and more positive self-perception). However, research conducted on the benefits associated with participating in LGB communities has been limited to countries in which these communities are visible and where laws and social norms are more accepting of LGBT people. Sexual minorities may be more reluctant to participate in social support groups if they live in countries where disclosure of sexual orientation can result in death, imprisonment, and other legal sanctions. Also, prior research included participants from individualistic countries where it is normative to consider one’s individual needs and happiness before the wishes of the family or community. Future research should include cultures in which people consider others’ welfare before their own and should explore the extent to which sexual minorities adhere to the cultural norm of not seeking support outside one’s immediate family and community. Thus, more cross-cultural studies are needed to determine whether the costs and benefits associated with disclosure are similar in cultures, communities, or countries where people are more collectivistic and where social norms and laws are more punitive of sexual minorities. Consequence of Sexual Stigma: Mental Health Outcomes Regardless of where they live, sexual minorities experience some level of institutionalized and interpersonal forms of sexual stigma, which can impact their physical and mental health outcomes. The effects of sexual stigma on sexual minorities’ physical health, particularly in relation to prevention and treatment of HIV/AIDS, are beyond the scope of this chapter (see Padilla, Vasquez del Aguila, & Parker, 2007, for an excellent review on this topic). We will focus instead on sexual minorities’ mental health outcomes and discuss how these stem from people’s experience of sexual stigma. Between group differences in mental health outcomes Researchers have attempted to understand sexual minorities’ mental health outcomes in two ways. The first approach is to determine whether sexual minorities’ mental health outcomes differ from those of sexual majorities (Meyer, 2003b). Summarizing the research on mental health outcomes and sexual orientation, Herek and Garnets (2007) concluded that based on epidemiological surveys, generally, the rates of suicide and psychological distress are low. In other words, the majority of people surveyed (sexual minorities and sexual majorities) are psychological healthy. When researchers used global psychological distress measures, history of psychiatric hospitalizations, and self-esteem as indicators of mental health outcomes, they found that sexual minorities and majorities do not differ significantly from each other (Balsam, Beauchaine, Mickey, & Rothblum, 2005). However, when researchers used psychiatric disorder classifications, standardized measures, and suicide attempts/ideations as indicators of mental health outcomes, significant group differences emerged. In the most comprehensive analysis of studies on sexual orientation and mental health outcomes to date, King et al. (2008) found that LGB people are at significantly higher risks for experiencing psychological disorders than their heterosexual counterparts. They analyzed data only from studies that included LGB people and a comparable heterosexual cohort and those that used standardized scales and official psychiatric disorder classification systems. Of the studies published between January 1966 and April 2005, 25 met their criteria. Based on data from 214,344 participants, King et al. concluded that compared to heterosexuals, LBG people are 2.47 times more likely to attempt suicide in their lifetime, 1.5 times more likely to have depressive and anxiety disorders within a 12-month period, and 1.5 times more likely to have alcohol and other substance dependence disorders within 12 months (King et al., 2008). Depending on their gender, LGB people have different levels of risks on various psychological disorders. Women who were LB were at greater risk than heterosexual women for alcohol (4 times), drug (3.5 times), and any substance dependence (3.42 times). Men who were GB were four times more likely to attempt suicide in their lifetime than heterosexual men (King et al., 2008). However, King et al. analyzed data collected mostly in the U.S. (except Mathy, 2002), and did not compare mental health outcomes of sexual minorities in different countries. Nevertheless, more recent studies of people in the Netherlands (Sandfort, Bakker, Schellevis, & Vanwesenbeeck, 2006) and New Zealand (Meyer, 2003a) have reached a similar conclusion: LGB people are at greater risk of psychiatric illnesses than heterosexual people. Mathy (2002) conducted the only known cross-national study on suicide and sexual orientation, surveying 37,432 participants in five continents. Analyzing men and women together, Mathy found that LGB in Asia, North America, and South America were more likely to both think about and attempt suicide than their heterosexual cohorts. In Australia, LGB were more likely to attempt suicide than heterosexuals. Therefore, Europe was the only continent in which people’s sexual orientations did not predict suicidal thoughts or behaviors. But, when gender was considered, a different pattern emerged. For women, sexual orientation predicted both suicidal ideations and suicide attempts in only one continent: North America. The lack of differences between heterosexual and LB women in other continents should be interpreted with caution because of their small sample sizes (2 to 8). In contrast, compared to heterosexual men, GB men in Asia and Australia were more likely to only attempt suicide while those in North and South America were more likely to both think about and attempt suicide. Thus, for men, sexual orientation did not predict suicide attempts or ideations in Europe or Australia nor suicide ideations in Asia. However, more recently, de Graaf, Sandfort, and ten Have (2006) reported that, in the Netherlands, the prevalence of gay men (49%) with suicidal thoughts is comparable to that of LGB people in other countries in Europe and North America. These findings highlight the need for researchers to consider the heterogeneity within continents. More recent studies have consistently shown that LGB people are more likely to have suicidal thoughts and attempts than heterosexuals. These results have been found in a nationally represented sample of 14,322 people between 18 and 26 years of age in the U.S., even after controlling for participants’ race, gender, and age (Silenzio, Pena, Duberstein, Cerel, & Knox, 2007). Similarly, a longitudinal study of a large representative sample of Norwegian LGB youths revealed that, even after controlling for 16 risk factors for suicide attempts (e.g., depressed mood, alcohol and drug use, conduct problems, eating problems, loneliness, and social support), those who had same-gender sexual contact were more likely to have attempted suicide; and lesbian girls were at higher risks for attempting suicide in the future (Wichstrøm & Hegna, 2003). Within group differences in mental health outcomes In contrast to ascertaining whether sexual minorities’ mental health outcomes differ from those of sexual majorities, some researchers have sought to explain why the differences exist. Thus, the second approach is to assess the specific factors that affect sexual minorities’ mental health. Researchers proposed that being LGB does not place people at risk for more psychological distress. Rather, it is that their sexual minority membership causes them to have experiences with sexual stigma and sexual prejudice which contribute to more psychiatric disorders (King et al., 2008; Savin-Williams & Ream, 2003). Several studies showed that LGB people’s perceptions of sexual stigma negatively affect their mental health. For example, Persian and Iranian LGB immigrants who perceived their culture of origin as more negative toward LGBs reported more stress. Similarly, European American LGBs who felt more negative cultural stigma reported more stress, depressive symptoms, and lower global self-esteem (Mireshghi & Matsumoto, 2008). In addition, LB women who internalized sexual stigma had more psychological distress (Szymanski & Owens, 2008). Herek et al. (2009) also found that internalized sexual stigma precipitated lower self-esteem, which led to more negative affect and more psychological distress. Similarly, personal experience with sexual stigma has been found to be associated with worse mental health outcomes. Surveys of a representative sample of LG adults in the Netherlands showed that gay men who experienced more anti-gay discrimination reported more suicidality, even after controlling for their psychiatric history (de Graaf et al., 2006). Likewise, in the U.S., LGB participants who experienced sexual discrimination were 1.6 times more likely to have at least one psychiatric disorder (major depression, generalized anxiety disorder, panic disorder, alcohol dependence, and drug dependence) compared to LGB participants who had no experience with sexual discrimination (Mays & Cochran, 2001). Additionally, Polders, Nel, Kruger, and Wells (2008) reported that self-identified gay men and lesbian women in South Africa who experienced verbal abuse and had lower self-esteem were at the most risk of having depressive symptoms. Finally, de Graaf et al. (2006) reported that because fewer Dutch lesbian women experienced discrimination (18.6% versus 24.4% of men), sexual orientation discrimination did not correlate with suicidality for this group. Experiences with interpersonal stigma can heighten risks of suicide and depression particularly for sexual minority youths because they are more likely to be victims of anti-gay violence than their adult counterparts. In a review of eight studies, Cochran (2001) concluded that sexual minority adolescents are at greater risk of suicide attempts than sexual majority adolescents or sexual minority adults. In the U.K., 53% of LGBT participants who had been bullied when they were in school had thought about self-harm and suicide; 40% had attempted suicide at least once (Rivers, 2001). In addition, LGBT people who had been bullied were more likely to report depressive symptoms compared to LGBs who did not experience bullying and to heterosexuals (both those who did and those who did not experience bullying; Rivers, 2001). Overall, these findings suggest that sexual minorities’ negative mental health outcomes are not due to their sexual orientation or identity, per se, but rather to the negative treatment they receive based on their sexual minority membership. Conclusion and Future Directions Currently, regardless of the countries considered, those with a heterosexual orientation and those with typical gender identity are the dominant group and, as such, enjoy many advantages (Herek, 2003). Although levels of institutionalized and interpersonal sexual stigma vary between and within countries, sexual minorities in most parts of the world do not have the same rights as sexual majorities. In contrast to sexual minorities, heterosexuals enjoy privileges such as the freedom to openly express affection for their partners and the absence of concern that their freedom, physical and mental well-being, livelihood, or familial and others’ acceptance depends on their sexual orientation. The empirical evidence suggests that sexual minorities who have worse mental health outcomes than sexual majorities tend to have experienced sexual stigma such as anti-gay attitudes and discrimination. However, because these studies have included only adults from North America, Europe, or Oceania, it is not known whether these findings generalize to people from countries that have yet to be researched. Although it will be a challenge, future studies need to include representative samples from African and Asian countries and to identify factors (institutional, cultural, individual, and familial) that heighten and buffer the negative impact sexual stigma has on sexual minorities’ mental health outcomes. In addition, because of their high rates of suicide and experiences with anti-gay violence, it is vitally important to include adolescent sexual minorities in countries outside the U.S. and Europe in future research. Future studies should also address the dearth of information about sexual minorities with multiple identities. For example, in the U.S., LGBT people who are also racial/ethnic minorities may experience racial discrimination from the European American gay community in addition to sexual prejudice from heterosexuals (Diaz et al., 2004). Thus, some researchers have proposed that membership in multiple minority groups may result in cumulative, additive minority stressors, precipitating in higher psychological distress (Diaz et al., 2001). In contrast, others have argued that being a minority member in one stigmatized cultural group (e.g., race/ethnicity, disabilities) may help an individual learn skills to cope with victimization associated with membership in another stigmatized cultural minority group (e.g., sexual minority, age; David & Knight, 2008). Therefore, future research should explore whether sexual minorities who have other minority identities (e.g., race/ethnicity, age, socioeconomic status, religion) have different experiences, coping styles, and mental health outcomes than sexual minorities who are members of other dominant groups. Researchers have only begun to explore these issues: Jewish gay men in the U.K. (Coyle & Rafalin, 2000); LGBT college students with disabilities in the U.S. (Harley, Nowak, Gassaway, & Savage, 2002); Greek and Turkish Cypriot gay men in London (Phellas, 2005); acculturated Chinese, Korean, and Filipino American men in the U.S. (Matteson, 1997); and LGB Korean, Japanese, and Chinese in their respective countries in Asia and in the U.S. (Kimmel & Yi, 2004). However, more researchers need to expand on the knowledge derived from these qualitative analyses and theoretical discussions. In summary, in addition to the cultural diversity between countries, researchers should examine the heterogeneity among members of sexual minority groups within the same countries when trying to understand sexual stigma and its consequences on people in diverse cultures. References Adamczyk, A., & Pitt, C. (2009). 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(1997). Coming out by South Asian gay men in the United Kingdom. Archives of Sexual Behavior, 26, 547–557. Bochow, M., Chiarotti, F., Davies, P., & Dubois-Arber, F. (1994). Sexual behavior of gay and bisexual men in eight European countries. AIDS Care, 6, 533–549. Bristow, J. (1997). Sexuality. New York: Routledge. Caceras, C. F., & Rosasco, A. M. (1999). The margin has many sides: Diversity among gay and homosexually active men in Lima. Culture, Health and Sexuality, 3, 261–275. Cochran, S. D. (2001). Emerging issues in research on lesbians’ and gay men’s mental health: Does sexual orientation really matter? American Psychologist, 56, 931–947. Coyle, A., & Rafalin, D. (2000). Jewish gay men’s accounts of negotiating cultural, religious, and sexual identity: A qualitative study. Journal of Psychology and Human Sexuality, 12, 21–48. Crocker, J., Major, B., & Steele, C. (1998). Social stigma. In D. T. Gilbert, S. T. Fiske & G. Lindzey (Eds.), Handbook of social psychology, Vol. 2 (4th ed., pp. 504–553). Boston: McGraw-Hill. David, S., & Knight, B. G. (2008). Stress and coping among gay men: Age and ethnic differences. Psychology and Aging, 23, 62–69. Day, N. E., & Schoenrade, P. (2000). The relationship among reported disclosure of sexual orientation, anti-discrimination policies, top management support and work attitudes of lesbian and gay employees. Personnel Review, 29, 346–363. de Cuypere, G., van Hemelrijck, M., Michel, A., Carael, B., Heylens, G., Rubens. R. … Monstrey, S. (2007). Prevalence and demography of transsexualism in Belgium. European Psychiatry, 22, 137–141. De Graaf, R., Sandfort, T. G. M., & ten Have, M. (2006). Suicidality and sexual orientation: Differences between men and women in a general population-based sample from the Netherlands. Archives of Sexual Behavior, 35, 253–262. Diamond, L. M., & Savin-Williams, R. C. (2000). Explaining diversity in the development of same-sex sexuality among young women. Journal of Social Issues, 52(2), 297–313. Diaz, R. M., Ayala, G., & Bein, E. (2004). Sexual risk as an outcome of social oppression: Data from a probability sample of Latino gay men in three U.S. cities. Cultural Diversity and Ethnic Minority Psychology, 10, 255–267. Diaz, R. M., Ayala, G., Bein, E., Henne, J., & Marin, B. V. (2001). The impact of homophobia, poverty, and racism on the mental health of gay and bisexual Latino men: Findings from three US cities. American Journal of Public Health, 91, 927–932. Espelage, D. L., & Swearer, S. M. (2008). Addressing research gaps in the intersection between homophobia and bullying. School Psychology Review, 37, 155–159. Fox, R. C. (1995). Bisexual identities. In A. R. D’Augelli & C. J. Patterson (Eds.), Lesbian, gay, and bisexual identities over the lifespan (pp. 48–68). New York: Oxford University Press. CHAPTER13Cultural Influences on Health Regan A. R. Gurung For those raised in the Western world, there is an easy way to determine health. If we do not experience pain, are disease free, are at the right weight, and are not partaking in any obviously unhealthy behaviors (e.g., smoking, binge drinking) we feel confident in claiming we are healthy. The World Health Organization (WHO) describes health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, 1946, p. 100). What is not clear from this definition, and completely missing from the idea of health as just “the absence of disease” is the fact that health can vary according to where you live, how old you are, what your parents and friends think constitutes health, what your religious or ethnic background is, and what a variety of other factors indicate about you. The one word that nicely captures all these different elements that influence health is culture. It is important to understand the role of culture in physical and mental health in today’s global climate. Mental and physical health varies dramatically across cultural groups (Eshun & Gurung, 2009; Gurung, 2010). Not only is the world diverse, but every state, city, and county is getting increasingly more diverse. Both the objective indicators of physical health and the subjective nature of defining abnormality vary with culture, making an understanding of how culture impacts perceptions, conceptualizations, and treatment of health crucial. There are critical cultural variations in the conceptualization, perception, health-seeking behaviors, assessment, diagnosis, and treatment of abnormal behaviors and physical sickness. This chapter focuses on how different cultural approaches to health shape healthy behaviors, prevent illness, and enhance our health and well-being. What Is Culture? Culture is varied, multilayered, and complex. A given individual may be a part of many different cultural groups, and some of those groups may have a larger influence on her health than others. Many people use the words culture, diversity, ethnicity, and race, as if they mean the same thing. Beyond these specific examples, people also think culture represents a set of ideals or beliefs or sometimes a set of behaviors, both of which are accurate components of what culture is. Although we rarely acknowledge it, culture has many dimensions. Keith (Chapter 1 in this volume) has already nicely reviewed definitions of culture. It is important to remember that culture can also include similar physical characteristics (e.g., skin color), psychological characteristics (e.g., levels of hostility), and common superficial features (e.g., hair style and clothing). The most commonly described objective cultural groups consist of grouping by ethnicity, race, sex, and age. Two of the most important health-related aspects that define cultural groups are socioeconomic status (SES) and sex. Although sex (and, relatedly, gender) has found a place in curricula for some time now (e.g., gender studies, human sexuality classes, women’s studies), socioeconomic status has only recently begun to be better incorporated into curricula. The poor make up a large percentage of Americans without health insurance, and SES is related to a higher occurrence of most chronic and infectious disorders and to higher rates of nearly all major causes of mortality and morbidity (Macintyre, 1997). Research has shown that SES is associated with a wide array of health, cognitive, and socioemotional outcomes, with effects beginning before birth and continuing into adulthood (Gottfried, Gottfried, Bathurst, Guerin, & Parramore, 2003) and is correspondingly a critical aspect of culture to be aware of. Given the wide array of definitions of culture, it should come as no surprise that culture and its influences on life and health are studied by a number of different disciplines. For example, medical anthropologists are individuals who are committed to improving public health in societies in economically poor nations. Based on the biological and sociocultural roots of anthropology, medical anthropologists have long considered health and medical care within the context of cultural systems, although not necessarily using the tools or theoretical approaches of psychologists. That said, medical anthropology has paid more explicit attention to non-Western approaches to health and healing than mainstream psychology (Winkelman, 2009). In a related fashion, medical sociologists work within the framework of the medical model, focusing on the role of culture and a person’s environment in health and illness. No one discipline is enough. In fact the complex interaction of cultural influences and health necessitates an interdisciplinary approach to studying the relationship and working toward elimination of health disparities (Anderson, 2009). Cultural Variations in Health: Health Disparities Health disparities are “differences in health that are not only unnecessary and avoidable, but in addition, are considered unfair and unjust” (Whitehead, 1992, p. 433). There are many examples of disparities: e.g., the infant death rate among African Americans is still more than double that of European Americans, and heart disease death rates are more than 40% higher for African Americans than for European Americans (U.S. Department of Health and Human Services, 2009). Truly staggering is the disparity in life expectancy—there is a 35-year gap between groups with the shortest and longest life expectancies at birth (Murray et al. 2006). In general, health care, mental health, and disease incidence (e.g., tuberculosis) rates also vary significantly across ethnic groups. Thus, the suicide rate among American Indians is 2.2 times higher than the national average (Center for Disease Control, 2008), and those living below the poverty level are significantly more depressed that those higher in SES (Pratt & Brody, 2008). The fact that there are differences in health behaviors and health in general has not escaped the notice of the American government, funding agencies, or health psychology researchers (the latter can do research to better the support of the first two). In fact the Healthy People 2010 project (U.S. Department of Health and Human Services, 2009), identified elimination of health disparities as one of its two overarching goals (the other is increasing the number and quality of years of life). In parallel, the American Psychological Association (APA) has also worked hard toward the elimination of racial and ethnic disparities in health access and outcomes through an increased commitment to behavioral and biomedical research, improved data systems, culturally competent health care delivery, and efforts to increase public awareness of the existence of health disparities and the resources that are available to improve minority health outcomes. (American Psychological Association, 2009, para. 1). APA’s Office of Ethnic Minority Affairs released a special issue of its journal Communique in March 2009, focusing on psychological and behavioral perspectives on health disparities. APA’s Division 38 (Health Psychology) has developed a Health Disparities webpage which introduces the key issues in health disparities research and provides resources to further aid research into this topic. As described on the web-page, the “overarching goals are to advance the understanding of (1) the nature and scope of health disparities and (2) the scientific study of health disparities, from description to intervention” (, para. 2). Research specifically aimed to reduce health disparities, including interventions to reach out to negatively influenced parties, is under way and holds promise for major improvements. The federal government has also created cultural competency standards (National Standards for Culturally and Linguistically Appropriate Services, CLAS,, with corresponding training resources designed to help healthcare practitioners better serve patients from diverse populations. Where do these disparities spring from? There are many answers and a good start is to look to varying approaches to health. Cultural Variations in Approaches to Health In most of the countries around the globe, health is understood using either the Western evidence-based medical approach or traditional indigenous approaches (Prasadarao, 2009). In traditional systems, a wide range of practitioners provides help. For example, in sub-Saharan Africa, four types of traditional healers provide health care, namely: (a) traditional birth attendants, (b) faith healers, (c) diviners and spiritualists, and (d) herbalists. On a global level, health beliefs and practices are closely tied to religion and the country the religion is predominant in—components of culture (i.e., religion and nationality) not given enough attention in Western medicine. In predominantly Hindu countries such as India for example, modern medical practitioners are complemented by three types of traditional healers—vaids (healers practicing indigenous systems of medicine), mantarwadis (healers using astrology and charms for cure), and patris (healers who act as mediums for spirits and demons)—who offer treatment to physical and mental illness in rural villages of India (Kapur, 1979). The vaids believe that illness is due to “an imbalance between the natural elements” brought forth by environmental factors, certain diets, uninhibited sexual indulgence, and the influence of demons (Prasadarao, 2009, p. 153). These factors cause “excess heat, cold, bile, wind or fluid secretions” leading to the development of physical and mental illness. In Muslim countries such as Pakistan, traditional healers include khalifs, gadinashins, imams, hakims, and others who practice magic and sorcery (Karim, Saeed, Rana, Mubbashar, & Jenkins, 2004). Long before there were medical degrees, hospitals, clinics, and pharmaceuticals, people were getting sick and receiving treatment. Yes, many of those treated by early healers and healing practices did not survive the treatment, let alone recover from the illness itself. This notwithstanding, people around the world have worked from the beginning of recorded history (and before) to prolong life and alleviate suffering from illness. There are three or four major philosophical approaches to health and healing that illustrate cultural differences in health. The one we may be most familiar with (and consequently, one I touch on only briefly) is referred to as conventional medicine, or allopathy. Western biomedicine is probably the most dominant form of healthcare in the world today. Hallmarks of this approach are an increasing reliance on technology and the use of complex scientific procedures for the diagnosis and treatment of illness. Treatments using this approach are designed to produce an opposite effect to that created by the disease. If you have a fever, you are prescribed medication to reduce the temperature. Western biomedicine views the body as a biochemical machine with distinct parts. Often called reductionist, Western biomedicine searches for the single smallest unit responsible for the illness. Traditional Chinese medicine Traditional Chinese medicine (TCM) is probably used to treat more people than any other form of medicine. Even in North America, there are a large number of TCM schools and practitioners. In fact, acupuncture, one form of TCM, is covered by most health insurance policies. Two main systems categorize the forces identified in TCM that influence health and well-being: yin and yang and the five phases. According to one Chinese philosophy, all life and the entire universe originated from a single unified source called Tao. The main ideas about the Tao are encompassed in a 5,000-word poem called the Tao Te Ching written about 2,500 years ago. In TCM, health is the balance of the yin and yang, the two complementary forces in the universe. Yin and yang are mutually interdependent, constantly interactive, and potentially interchangeable forces. In TCM, 10 vital organs are divided into five pairs, each consisting of one “solid” yin organ and one “hollow” yang organ. TCM practitioners believe that the yin organs—the heart, liver, pancreas, spleen, kidneys, and lungs—are more vital than the yang organs, and dysfunctions of yin organs cause the greatest health problems. The yang organs are the gallbladder, stomach, small intestine, large intestine, and bladder (though an organ translated as ‘triple burner’ is also said to exist). A healthy individual has a balanced amount of yin and yang. If a person is sick, his or her forces are out of balance (Kaptchuk, 2000). The yin and yang are often translated into hot and cold (two clear opposites), referring to qualities and not temperatures. To be healthy, what you eat and drink and the way you live your life should have equal amounts of hot qualities and cold ones. Balancing hot and cold is a critical element of many different cultures (e.g., Chinese, Indian, and even Mexican), although the foods that constitute each may vary across cultures. Some ‘hot’ foods include beef, garlic, ginger, and alcohol. Some ‘cold’ foods include honey, most greens, potatoes, and some fruits (e.g.,  melons, pears). The five phases or elemental activities refer to specific active forces and illustrate the intricate associations that the ancient Chinese saw between human beings and nature. Energy or qi, another critical aspect of TCM, moves within the body in the same pattern as it does in nature with each season and with different foods helping to optimize energy flow within the body. The five elements of wood, fire, earth, metal, and water each link to a season of the year, a specific organ, and a specific food. Each element has specific characteristics, is generated by one of the other forces, and is suppressed by another. For example, wood generates fire that turns things to earth that forms metals. The heart is ruled by fire, the liver by wood, and the kidneys by water. Fire provides qi to the heart and then passes qi onto the earth element and correspondingly the stomach, the spleen, and pancreas. What you eat correspondingly can influence your different organs and your well-being in general (Kaptchuk, 2000). Ayurveda: Indian health beliefs Ayurveda, a traditional Indian holistic system of medicine was developed by Charaka about 2,600 years ago (Lyssenko, 2004; Singh, 2007). Charaka described four causative factors in mental illness: (a) diet (incompatible, vitiated, and unclean food); (b) disrespect to gods, elders, and teachers; (c) mental shock due to emotions such as excessive fear and joy; and (d) faulty bodily activity. Thus, Ayurveda considers a biopsychosocial approach in formulating causative factors in mental disorders. Charaka, while emphasizing the need for harmony between body, mind, and soul, focused on preventive, curative, and promotive aspects of mental health. Ancient Indian court physicians further developed Ayurvedic practices and were given vast resources because the health of the king was considered equivalent to the health of the state (Svoboda, 2004). The use of Ayurveda flourished until 900 ce when Muslim invaders came into India and created a new form of medicine called Unani, a combination of Greek and Ayurvedic medicine with Arabic medicine (Udwadia, 2000). The use of plants and herbal remedies plays a major part in Ayurvedic medicine. About 600 different medicinal plants are mentioned in the core Ayurvedic texts. Western drug companies have used a number of plants originally used in India to cure diseases. For example, psyllium seed is used for bowel problems, and other plants are used to reduce blood pressure, control diarrhea, and lessen the risk of liver or heart problems. A substance called forskolin, isolated from the Coleus forskohliiplant, has been used in Ayurveda for treating heart  disease, and its use has now been empirically validated by Western biomedicine (Ding & Staudinger, 2005). TCM and Ayurveda share many basic similarities. Ayurvedic science also uses the notion of basic elements: Five great elements form the basis of the universe. Earth represents the solid state, water the liquid state, air the gaseous state, fire the power to change the state of any substance, and ether, simultaneously the source of all matter and the space in which it exists. Each of these elements can nourish the body, balance the body (serving to heal), or imbalance the body (serving as a poison). Achieving the right balance of these elements in the body is critical to maintaining a healthy state. These elements also combine to form three major forces (doshas) that influence physiological functions critical to healthy living (Svoboda, 2004). Ether and air combine to form the vata dosha, fire and water combine to form the pitta dosha, and water and earth elements combine to form the kapha dosha. Vata directs nerve impulses, circulation, respiration, and elimination. Pitta is responsible for metabolism in the organ and tissue systems as well as cellular metabolism. Kapha is responsible for growth and protection. We are all made up of unique proportions of vata, pitta, and kapha that cause disease when they go out of balance. These three doshasare also referred to as humors or bodily fluids and correspond to the Greek humors of phlegm (kapha) and choler (pitta). There is no equivalent to the Greek humor blood, nor is vata or wind represented in the Greek system. Similar to the meridians in TCM, the existence of these forces is demonstrated more by inference and results of their hypothesized effects than by physical observation. Vata, pitta, and kapha are also associated with specific body-type characteristics (Svoboda, 2004). Mexican American/Latino health beliefs Curanderismo is the Mexican American folk-healing system that often coexists side by side with Western biomedicine. Coming from the Spanish verb curarmeaning “to heal,” curanderos are full-time healers. The curandero’s office is in the community, often in the healer’s own home. There are no appointments, forms, or fees, and you pay whatever you believe the healer deserves. This form of healing relies heavily on the patient’s faith and belief systems and uses everyday herbs, fruits, eggs, and oils. In studies beginning as early as 1959, researchers first focused on “Mexican American cultural illnesses,” such as mal de ojo (sickness from admiring a baby too much). More recent work (e.g., Trotter & Chavira, 1997) focuses on the healers themselves, their beliefs, training processes, and processes for treatment. Surveys of Mexican Americans show that even among highly assimilated Mexican Americans, traditional and indigenous practices still persist. The Mexican American cultural framework acknowledges the existence of two sources of illness, one natural and one supernatural. When the natural and supernatural worlds exist in harmony, optimal health is achieved. Disharmony between these realms breeds illness. Beyond this supernatural balance component, the curandero’s concept of the cause of illness parallels that of Western biomedicine. Like biomedical practitioners, curanderos believe that germs and other natural factors can cause illness. However, curanderos believe that there are supernatural causes to illness in addition to natural factors. If an evil spirit, a witch, or a sorcerer causes an illness, then only a supernatural solution will be sufficient for a cure. Illness can also be caused if a person’s energy field is weakened or disrupted. Whether diabetes, alcoholism, or cancer, if a spirit caused it, supernatural intervention is the only thing that can cure it. Unlike Western biomedicine and TCM, the practices of curanderismo are based on Judeo-Christian beliefs and customs. The Bible has influenced curanderismo through references made to the specific healing properties of natural substances such as plants (see Luke 10:34). Curanderos’ healing and cures are influenced by the Bible’s proclamation that belief in God can and does heal directly and that people with a gift from God can heal in his name. The concept of the soul, central to Christianity, also provides support for the existence of saints (good souls) and devils (bad souls). The bad souls can cause illness and the good souls, harnessed by the shamanism and sorcery of the curanderismo, can cure. Curanderos use three levels of treatment depending on the source of the illness: material, spiritual, and mental (Trotter & Chavira, 1997). Working on the material level, curanderos use things found in any house (eggs, lemons, garlic, and ribbons) and religious symbols (a crucifix, water, oils, and incense). These material things often are designed to either emit or absorb vibrating energy that repairs the energy field around a person. Ceremonies include prayers, ritual sweepings, or cleansings (Torres & Sawyer, 2005). The spiritual level of treatment often includes the curandero entering a trance, leaving his or her body, and playing the role of a medium. This spiritual treatment allows a spirit to commandeer the curandero’s body, facilitating a cure in the patient. On some occasions, the spirit will prescribe simple herbal remedies (via the curandero). On other occasions, the spirit will perform further rituals. The mental level of treatment relies on the power held by the individual curandero, rather than on spirits or materials. Some illnesses (e.g., physical) often are treated by herbs alone (DeStefano, 2001), and psychological problems may be treated by a combination of all these types of treatments. In a manner akin to that of health psychologists, curanderos explicitly focus on social, psychological, and biological problems (Trotter & Chavira, 1997). The difference is that they add a focus on spiritual problems as well. From a social perspective, the community where the curanderos work recognizes and accepts what the curandero is trying to achieve. The social world is important to the curanderos, who evaluate the patient’s direct and extended support system. The patient’s moods and feelings are weighed together with any physical symptoms. Finally, there is always a ritual petition to God and other spiritual beings to help with the healing process. Curanderos each have their own set of specializations. For example, midwives (parteras) help with births, sobaderos treat muscle sprains, and herbalists (yerberos) prescribe different plants (Avila & Parker, 2000). For most Mexican Americans, the choice between curanderismo and Western biomedicine is an either/or proposition. Some individuals use both systems, and some stay completely away from Western hospitals as much as they can or because they do not have enough money to use them. Acculturated and higher social class Mexican Americans tend to rely exclusively on Western biomedicine. The existence of this strong cultural and historical folk medicine and the large numbers of its adherents make this approach to illness an important alternative style for us to consider in our study of the psychology of health. American Indian health beliefs Many elements of the American Indian belief system and the approach to health are somewhat consistent with elements of curanderismo and TCM and provide a strong contrast to Western biomedicine. Although different tribes have different variations on the basic beliefs, four practices are common to most (Cohen, 2003): the use of herbal remedies, the employment of ritual purification or purging, the use of symbolic rituals and ceremonies, and the involvement of healers, also referred to as medicine men, medicine women, or shamans (though the latter is primarily used for the healers of northern Europe; Eliade, 1964). Native Americans have utilized and benefited from these practices for at least 10,000 years and possibly much longer. Similar to the ancient Chinese, American Indians believed that human beings and the natural world are closely intertwined. The fate of humankind and the fate of the trees, the mountains, the sky, and the oceans are all linked. The Navajos call this “walking in beauty,” a worldview in which everything in life is connected and influences everything else. In this system, sickness is a result of things falling out of balance and of losing one’s way in the path of beauty (Alvord & Van Pelt, 2000). Animals are sacred, the winds are sacred, and trees and plants, bugs, and rocks are sacred. Every human and every object corresponds to a presence in the spirit world, and these spirits promote health or cause illness. Spiritual rejuvenation and the achievement of a general sense of physical, emotional, and communal harmony are at the heart of Native American medicine. Shamans coordinate American Indian medicine and inherit the ability to communicate with spirits in much the same way that Mexican American curanderos do. Shamans spend much of their day listening to their patients, asking about their family and their behaviors and beliefs and making connections between the patient’s life and their illness. Shamans do not treat spirits as metaphors or prayers as a way to trick a body into healing. Shamans treat spirits as real entities, respecting them as they would any other intelligent being or living person. Ritual and ceremony play a major role in American Indian medicine. One of the most potent and frequent ceremonies is the sweat lodge (Mehl-Medrona, 1998). Medicine men hold lodges or “sweats” for different reasons. Sometimes a sweat purifies the people present; at other times a sweat is dedicated to someone with cancer or another terminal illness. The ceremony takes place in a sweat lodge, which looks like a half dome of rocks and sticks covered with blankets and furs to keep the air locked in and the light out. The lodge symbolizes the world and the womb of Mother Earth. Heated rocks are placed in a pit in the middle of the half dome. Participants in the sweat sing sacred songs in separate rounds during the ceremony. After each round, a firekeeper brings in another set of hot rocks, and more songs are sung or prayers said. The sequence of prayers, chants, and singing following the addition of hot rocks continues until all the rocks are brought in. The hot stones raise the temperature inside the lodge, leading to profuse perspiration, which is thought to detoxify the body. Because of the darkness and the heat, participants often experience hallucinations that connect to spirit guides or provide insight into personal conditions. Other ceremonies are also used. For example, the Lakota and Navajo use the medicine wheel, the sacred hoop, and the sing, which is a community healing ceremony lasting from two to nine days and guided by a highly skilled specialist called a singer. Many healers also employ dancing, sand painting, chanting, drumming (which places a person’s spirit into alignment with the heartbeat of Mother Earth), and feathers and rattles to remove blockages and stagnations of energy that may be contributing to ill health. Sometimes sacred stones are rubbed over the part of the person’s body suspected to be diseased. Although many American Indians prefer to consult a conventional medical doctor for conditions that require antibiotics or surgery, herbal remedies continue to play a substantial role in treatment of various physical, emotional, and spiritual ailments. The herbs prescribed vary from tribe to tribe, depending upon the ailment and what herbs are available in a particular area. Some shamans suggest that the herbs be eaten directly. Others suggest taking them mixed with water (like an herbal tea) or even with food. Healers burn herbs such as sage, sweet grass, or cedar (called a smudge) in almost every ceremony, and let the restorative smoke drift over the patient. African American folk medicine In addition to these four basic approaches to health, there is also a wealth of other belief systems. One group not discussed as often as those above is African Americans. For many members of this cultural group, health beliefs reflect  cultural roots that include elements of African healing, medicine of the Civil War South, European medical and anatomical folklore, West Indies voodoo religion, fundamentalist Christianity, and other belief systems. African American communities have become very diverse, especially with the recent arrival of people from Haiti and other Caribbean countries and Africa. Similar to the American Indians, many people of African descent also hold a strong connection to nature and rely on inyangas (traditional herbalists). Even today in Africa, hospitals and modern medicines are invariably the last resort in illness. Members of some traditional African tribes seek relief in the herbal lore of the ancestors and consult the inyanga,who is in charge of the physical health of the people (Branford, 2005). When bewitchment is suspected, which happens frequently among the traditional people of Africa, or there is a personal family crisis or love or financial problem, the patient is taken to a sangoma(spiritual diviner or spiritual/traditional healer) who is believed to have spiritual powers and is able to work with the ancestral spirits or spirit guides (Branford, 2005). The sangoma uses various methods such as “throwing the bones” (amathambo, also known by other names depending on the cultural group) or going into a spiritual trance to consult the ancestral spirits or spirit guides to find the diagnosis or cure for the problem, be it bewitchment, love, or other problems. Depending on the response from the higher source, a decision will be made on what herbs and mixes (intelezis) should be used and in what manner (e.g., orally, burning). If more powerful medicine is needed, numerous “magical rites” can or will be performed according to rituals handed down from sangoma to sangoma (Branford, 2005). In South Africa, there are more than 70,000 sangomas or spiritual healers who dispense herbal medicines and even issue medical certificates to employees for purposes of sick leave. Many African Americans believe in a form of folk medicine that incorporates and mirrors aspects of voodoo (really spelled “vodou”), which is a type of religion derived from some of the world’s oldest known religions that have been present in Africa since the beginning of human civilization (Heaven & Booth, 2003). When Africans were brought to the Americas (historians estimate that approximately 650,000 slaves were imported by the 1680s), religious persecution forced them to practice voodoo in secret. To allow voodoo to survive, its followers adopted many elements of Christianity. Today, voodoo is a legitimate religion in a number of areas of the world, including Brazil, where it is called Candomblé, and the English-speaking Caribbean, where it is called Obeah. In most of the United States, however, White slavers were successful in stripping slaves of their voodoo traditions and beliefs (Heaven & Booth, 2003). In some parts of the United States the remnants are stronger than in others. Some African American communities in isolated areas such as the coast and islands of North and South Carolina, survived intact well into the twentieth century. Here, Gullah culture involving the belief in herbalism, spiritualism, and black magic, thrived (Pinckney, 2003). What was called voodoo in other parts of the country was called “the root” (meaning charm). A number of other cultures, such as the American Indians described earlier and Hmong Americans, still believe that shamans and medicine men can influence health. Although shamanistic rituals and voodoo rites may seem to be ineffectual ways to cure according to Western science, the rituals have meaning to those who believe in them and should not be ignored or ridiculed. But does it work? Many of the approaches described above may sound like folk medicine without any scientific basis. If you have never heard of them, you may wonder if they actually work. To take a truly culturally relativistic perspective (versus a biased ethnocentric perspective where one’s own culture is always better) the simple answer is “in many cases.” Indeed there are many anecdotal reports of the efficacy of the different cultural approaches to health described above. There is even a growing body of scientific evidence for many of the different treatments and approaches described (for a full review see Gurung, 2010). For example, much of the research conducted on TCM in America analyzes the constituents of herbs used in treatment, and many such studies show that the active ingredients of the herbs facilitate cures (Hon et al., 2007). Similarly, the Ayurvedic use of forskolin for treating heart disease has now been empirically validated by Western biomedicine (Ding & Staudinger, 2005). Culture and Mental Health Culture influences how individuals manifest symptoms, communicate their symptoms, and cope with psychological challenges, and their willingness to seek treatment (Eshun & Gurung, 2009). Understanding the role of culture in mental health is crucial to comprehensive and accurate diagnoses and treatment of illnesses. Even the U.S. Surgeon General has recognized the importance of both a patient’s culture, and that of the healthcare provider in mental health treatment, service use, and diagnosis (U.S. Department of Health and Human Services, 1999). A number of frameworks have been used to understand cultural influences on mental health including the sociobiological, ecocultural, and biopsychosocial perspectives (Eshun & Gurung, 2009). Another perspective that has become increasingly important in our postmodern world, with much migration and resettlement, is multiculturalism. It literally means many cultural views. It is a view that emphasizes importance, equality, and acceptance for all cultural groups within a society, and supports a strong desire to increase awareness about all groups to the benefit of the society as a whole (see Mio, Barker-Hackett, & Tumambing, 2006, for a review). Overall epidemiological, clinical, and other studies suggest a “moderate but not unlimited impact of cultural factors” on mental health (Draguns, 1997). This implies that accurate evaluation and diagnoses of psychological disorders within the bounds of culture are crucial for appropriate and effective treatment and intervention (Arrindell, 2003). However, in spite of efforts in the field of counseling/ clinical psychology to include or emphasize cultural influences on psychopathology in our traditional training programs, we are still limited in the depth and breadth of material available. It is beyond the scope of this chapter to offer an in-depth review of the literature on culture and mental health, but I will briefly review some of the key issues involved. For example, it is important to remember that culture influences the client as well as the therapist. One needs also to focus on a wide range of processes: conceptualization, perception, health-seeking behaviors, assessment, diagnosis, and treatment, in the context of cultural variations. We need to consider issues related to reliability, validity, and standardization of commonly used psychological assessment instruments among different cultural groups, and the role of factors such as religion and stress as they relate to culture. It is also important to look at a bigger picture, focusing on psychotherapy in a culturally diverse world (see chapter 14, this volume), and to international perspectives on mental health (Prasadarao, 2009). Even specific disorders, such as eating disorders, mood disorders, anxiety disorders, post-traumatic stress disorder, and psychotic disorders, vary by culture (Eshun & Gurung, 2009). There are cultural differences and/ or similarities in the symptoms reported, as well as the possibility of misdiagnosing mental illness among people who focus on specific symptoms (e.g., somatic) and less on others for varying reasons. Conclusion One of the most pressing needs for cross-cultural psychology is to spend more time and energy on examining how cultural differences influence health and behavior. There is a strong emphasis for academic curricula to be culturally diverse (Gurung & Prieto, 2009), so why has there not been enough cultural research? The limited focus on cultural differences arises from a number of different factors. Mainstream psychology has tended to be blind to culture, not so much because of some explicit prejudice (although it has been argued that the primarily European American male researchers were biased; Guthrie, 2003), but because of the belief that there are commonalities to human behavior that transcend culture. Conceivably a function of its own individualistic bias, mainstream psychology has only recently begun to consider the theoretical and practical implications of a focus on the collective context—the family, peers, community, and culture, of the individual. References Alvord, L., & Van Pelt, E. C. (2000). The scalpel and the silver bear. New York: Bantam. Anderson, N. B. (2009). Health disparities: A multidimentional approach. Communique, March, 7–9. American Psychological Association. (2009). Racial and ethnic health disparities. Washington, DC: Public Policy Office, American Psychological Association. Retrieved from Arrindell, W. A. (2003). Cultural abnormal psychology. Behavior Research and Therapy, 41, 749–753. Avila, E., & Parker, J. (2000). Woman who glows in the dark: A curandera reveals traditional Aztec secrets of physical and spiritual health. New York: Tarcher Penguin. Branford, D. (2005). African herbalism and spiritual divination. London: New Press. Center for Disease Control. (2008, Summer). Suicide facts at a glance. Retrieved from Cohen, K. (2003). Honoring the medicine: The essential guide to Native American healing. New York: Random House Ballantine Publishing Group. DeStefano, A. M. (2001). Latino folk medicine: Healing herbal remedies from ancient traditions. New York: Ballantine Books. Draguns, J. G. (1997). Abnormal patterns across culture: Implications for counseling and psychotherapy. International Journal of Intercultural Relations, 21(2), 213–248. Ding, X., & Staudinger, J. L. (2005). Induction of drug metabolism by Forskilin: The role of the pregnana X receptor and the protein kinase A signal transduction pathway. Pharmacology, 312, 849–856. Eliade, M. (1964). Shamanism: Archaic techniques of ecstasy. Princeton, NJ: Princeton University Press. Eshun, S., & Gurung, R. A. R. (Eds.) (2009). Culture and mental health: Sociocultural influences, theory, and practice. Malden, MA: Wiley-Blackwell. Gottfried, A. W., Gottfried, A. E., Bathurst, K., Guerin, D. W., & Parramore, M. M. (2003). CHAPTER 14Culture and Psychotherapy:Searching for an Empirically Supported Relationship Junko Tanaka-Matsumi Life is animated by fission and fusion—separation and connection, isolation and relation, independence and dependence are not opposites but merely manifestations of one nature. We must encourage and promote diversity even as we pursue unity. (Marsella, 2009, p. 134) Developing cross-cultural competence is a lifelong journey, replete with many joys and challenges (Heppner, 2006, p. 147). Participant Observation of Culture and Psychotherapy The purpose of this chapter is to examine ways to incorporate culture into empirically supported psychotherapies (Griner & Smith, 2006; Sue & Sue, 2008a; Tanaka-Matsumi, 2008). Keith (Chapter 1, this volume) reviewed various definitions of culture (e.g., Matsumoto & Juang, 2008) and stated that “increased understanding of culture—our own as well as others’—is perhaps the most pressing need for psychological science.” (p. 16) Further, Keith articulated that understanding will come only on the strength of sound methodology and accurate data” (p. 16). The same applies to understanding of psychotherapies across cultures. Psychotherapy outcome research has made great strides since the publication of Eysenck’s (1952) critical report on the lack of clear evidence that any form of psychotherapy was particularly effective. Today, Paul’s (1967) widely cited universal question on the need for identifying specific effects of psychological treatments has been answered to some degree: “What treatment, by whom, is most effective for this individual with that specific problem, and which set of circumstances?” (p. 111) We have increasing knowledge of what works for whom (Roth & Fonagy, 2004) for certain problems such as anxiety, depression, and childhood problems. What we do not know is in what specific ways culture matters in empirically supported psychological interventions (Chambless & Ollendick, 2001) and what we can do to accommodate cultural factors within them. Reflecting the pressing need of the diverse world, studies on the cultural adaptation of empirically supported psychological interventions are clearly increasing in number (Bernal, Jiménez-Chafey, & Rodriguez, 2009; Griner & Smith, 2006; Hays & Iwamasa, 2006). Diversity issues in assessment and therapy occupy an important and legitimate place in the training and practice of professional psychology (Sue & Sue, 2008b). My personal story of becoming a professional psychologist in two culturally different countries (the United States and Japan) underscores the importance of looking at culture as a dynamic context for all our professional activities. I was trained in the scientist-practitioner model of clinical psychologist in the United States. I then taught in an American Psychological Association (APA) approved, combined clinical-school psychology PhD program for 20 years. I subsequently moved back to Japan and currently teach and practice clinical psychology and cross-cultural psychology at a university. In the U.S., I supervised a large number of assessment cases of culturally diverse clients at the university psychological research and therapy center. I also helped Japanese children and their families cope with acculturation stress and developmental issues as they made contacts with American culture. My colleagues and I have been interested in two major questions (Tanaka-Matsumi, Higginbotham, & Chang, 2002). First, how does a cognitive behavior therapist conduct an assessment interview with a client from a culture or subculture different from his or her own? Second, and much more specifically, how can a cognitive behavior therapist use functional assessment (Haynes & O’Brien, 1990) to develop culturally sensitive case formulation and interventions that are culturally acceptable? We developed the Culturally Informed Functional Assessment Interview (Tanaka-Matsumi, Seiden, & Lam, 1996) to generate culture-relevant data from the client. We studied the relationship between culture and psychopathology and ways to advance culturally informed psychological assessment (e.g., Draguns & Tanaka-Matsumi, 2003; Tanaka-Matsumi, 2001; Tanaka-Matsumi & Draguns, 1997). Historical Antecedents of Empirically Supported Psychotherapies: Discovery of Placebo Effects and Common Factors in Psychotherapy Modern Western history of psychotherapy began with Mesmer’s magnetic therapy in Vienna and Paris in 1775 (Ellenberger, 1970). Mesmer’s patients responded to the non-specific placebo effect of the unusual intervention in those days. Mesmer induced the placebo effect by the combination of a dramatic setting for demonstration, colorful therapist attire, and the presence of an intensively curious audience. Historically, the term “placebo” has referred to inactive medications prescribed primarily for purposes of placating or soothing the patient rather than directly treating any real disorder (Parloff, 1986). Placebo has two elements. First, the intervention lacks the specific ingredients for change, and, second, individuals who are offered such inactive interventions must nonetheless be led to believe in their potency (Frank & Frank, 1991; Parloff, 1986). A study by Paul (1966) provided an example of the scientific rigor required to develop appropriate controls in psychotherapy research. Paul conducted the first controlled psychotherapy outcome research to test the effectiveness of Wolpe’s (1958) systematic desensitization therapy with university students who were manifesting “performance anxiety” of speaking in public. Paul (1966) assigned participants to one of four groups: (a) insight oriented psychotherapy, (b) systematic desensitization, (c) attention placebo, and (d) no-treatment control. The participants who were assigned to the attention placebo group were led to believe that a “fast-acting tranquilizer” would help ameliorate their stress reactions. In reality, this was a placebo pill without any chemically active ingredients. The results indicated that the desensitization group improved significantly more than the rest of the groups on behavioral, physiological, and self-report measures of speech anxiety. The attention placebo group also improved more than the no-treatment group. Attention placebo effects include client’s expectation of relief, relationship, the attention, warmth, suggestion, and interest of the therapist (Ullmann & Krasner, 1975). Prince (1980) defined psychotherapy as “the mobilization of endogenous mechanisms” (p. 292) aimed at relieving an individual’s suffering, and called attention to the wide variations in psychotherapeutic procedures. These included sleep, rest, social isolation, dreams, meditation, dissociation states, shamanism, and Western psychotherapies. Prince (1980) warned about the danger of focusing categorically on any one particular therapeutic mode and applying it to other cultures. In other words, therapists may not be aware of their own cultural bias when working with culturally different clients (Ridley, 2005). Over the years, with increased multicultural awareness of practitioners and societal claims for accountability, textbooks on multicultural counseling and therapy have come to clarify the types of cultural biases in psychotherapy, giving guidelines for addressing cultural complexities in the practice of psychotherapy (e.g., Hays, 2008; Sue & Sue, 2008b). Universal Functions of Psychotherapy and Culture-Specific Contents Psychotherapy “alleviates distress, facilitates adaptive coping, and promotes more effective problem solving and decision making” (Draguns, 2008, p. 21) and takes place within the interactive cultural context of the therapist and the client (Draguns, 1975). As Hall (2001) defined them, culturally sensitive treatments involve “the tailoring of psychotherapy to specific cultural contexts” (p. 252). Different cultures practice healing systems in diverse forms that reflect indigenous views of health and illness and ways to help the individual in distress (e.g., Gielen, Fish, & Draguns, 2004; Moodley & West, 2005; Prince, 1980). Frank and Frank (1991) described universal features of broadly defined psychotherapies. These include: (a) helping seeker’s state of demoralization, (b) availability of a socially recognized healer, (c) sharing of a world view by healer and client, (d) endorsement of cultural belief systems; and (d) sharing of cultural explanations of suffering. Attempts to link these cultural features to psychotherapeutic practices have developed into a major field of study with profound implications for teaching, research, and practice (e.g., Gerstein, Heppner, Stockton, Leong, & Aegisdottir, 2009; Gielen, Draguns, & Fish, 2008; Hays & Iwamasa, 2006; La Roche, 2005; Pedersen, Draguns, Lonner, & Trimble, 2008; Sue & Sue, 2008b), and for understanding the importance of quality of life across diverse cultures (Keith, 2000). Techniques are important for behavior change; however, context is also important. Some techniques are frequently used in different cultural contexts to achieve therapeutic aims. For example, clients of Japanese Naikan therapy (Tanaka-Matsumi, 2004a) and clients of Western-derived cognitive behavior therapy (CBT) may both learn to use the same technique of self-observation and self-monitoring as a first step in directing attention to one’s relationships with specific others. However, therapy rationale and cultural context of each therapy are very different. Japanese Naikan therapy clients would engage in self-observation to recall benevolences received from their mothers in terms of specific things mothers did for them to mobilize a forgotten sense of gratitude. European American clients of CBT may engage in self-observation of their interpersonal behavior to increase a sense of independence and autonomy. With regard to interpersonal relationships, assertiveness training was originally developed in the United States with its emphasis on advocating one’s own rights. In Japan, assertiveness training is more functional when it accommodates a positive cultural contingency of using indirect verbal expressions of one’s needs rather than using direct verbal expressions (Mitamura & Tanaka-Matsumi, 2009). To give another example, Latino adults in the United States chose to engage in allocentric (other-oriented) relaxation imagery exercise more frequently than idiocentric (self-oriented) imagery exercise in culturally competent relaxation training (La Roche, D’Angelo, Gualdron, & Leavell, 2006). Anybody can learn to relax with training. In this case, however, the selected content of the imagery exercise matched with the allocentric cultural self-orientation of the Latinos. These examples suggest that psychotherapy’s effectiveness depends on the cultural context of its application. That is, we need to stipulate salient cultural factors and seek empirical support for the claim through appropriate research design. Psychotherapy researchers have been actively investigating the empirically verifiable bases of psychotherapies delivered to clients with a variety of presenting problems (Castonguay & Beutler, 2006). In both the United States and the United Kingdom, healthcare providers mandate the practice of empirically supported psychotherapies for socio-economic reasons. In fact, evidence-based practice in psychology has been officially promoted by an American Psychological Association task force: Evidence-based practice in psychology (EBPP) is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences. (APA Presidential Task Force on Evidence-Based Practice, 2006, p. 273) As of 2001, there were over 130 different manualized treatments listed as empirically supported (Chambless & Ollendick, 2001), with more added each year (Nathan & Gorman, 2006). Most of the validated treatments are cognitive behavioral in orientation. The universal functions of these empirically validated interventions are tested increasingly and, at times, critically, in the age of globalization (La Roche & Christopher, 2008). Globalization, Diversity, and Dissemination of Evidence-Based Practices The development of global transportation and communication systems has increased people’s mobility and altered ethnic and cultural compositions of many countries of the world. The U.S. population, for example, is expected to reach over 380 million in 2050 and the current minority population will constitute the majority group, replacing the non-Hispanic white majority group (U.S. Census Bureau, 2002). Even within the same country, people hold different values and act according to sociocultural value systems which are institutionalized over the years, influencing help-seeking behaviors according to ethnic groups (Akutsu, Castillo, & Snowden, 2007; Comaz-Diaz, 2006; Snowden & Yamada, 2005). In this age of globalization, there is an increased need for training of culturally competent counselors and therapists to provide culturally informed and empirically supported counseling and therapy both within and outside their home countries (Hall, 2006; Marsella, 2009; Sue, 1998). Globalization and diversification facilitate dissemination of information to those who benefit from the knowledge (Marsella, 1998). Psychologists in Europe perform professional activities across borders (Hall & Lunt, 2005). As an example of the cross-cultural spread of empirically supported psychotherapy, we may trace the development of the World Congress of Behavioural and Cognitive Therapy (WCBCT). Seven major associations around the globe participate in this international congress. The groups include the Association for Behavioral and Cognitive Therapies (ABCT) of North America and the European Association for Cognitive and Behavioural Therapies (EABCT) and other such umbrella associations located in all continents of the world. Almost 4,000 people from more than 70 countries attended the 2007 WCBCT in Barcelona. As an indication of strong Asian involvement, three associations jointly sponsored the 2004 WCBCT, held for the first time in Asia, in Kobe, Japan. The three sponsor associations were the Japanese Association for Behavior Therapy, the Japanese Association for Cognitive Therapy, and the Japanese Association for Behavior Analysis. The congress theme was “Toward a Global Standard.” Further, in 2006, the first Asian Cognitive Behavior Therapy Conference was inaugurated in Hong Kong. The second meeting was held in Thailand (Bangkok) in 2008, and the third meeting is anticipated in Korea (Seoul) in 2011. These Asia-based conferences are particularly noteworthy from the viewpoint of cultural accommodation of CBT practices. The programs have emphasized culturally sensitive examination of evidence-based assessment and treatment. The practice of CBTs has been extended to Asia well beyond the  cultural boundaries of their developmental origins in North America and Europe (Oei, 1998; Qian & Wang, 2005). With its emphasis on empiricism, CBT is used on a national scale in the U.K. The Improving Access to Psychological Therapies (IAPT) program in the U.K. began in 2006 to support primary care trusts in implementing National Institute for Health and Clinical Excellence (NICE) guidelines for particularly underserved adults of working age suffering from depression and anxiety disorders (see IAPT utilizes CBT on a community basis to train and increase the number of CBT therapists, eventually by 10,000, to meet the society’s needs for help. In the United States, in a survey conducted every 10 years using Delphi methodology, a panel of 67 psychotherapy experts predicted that CBT, culture-sensitive/ multicultural therapy, cognitive therapy, interpersonal therapy (IPT), and technical eclecticism would be the top five most influential theoretical orientations in psychotherapy by 2010 (Norcross, Hedges, & Prochaska, 2002). The survey results also predicted a required use of evidence-based psychotherapies by healthcare systems and the use of practice guidelines as part of standard clinical practice. Looking at the situation now, we can say these predictions have proven to be largely valid. However, the need for empirically supported and culturally sensitive psychotherapy at the level of community practice is yet to be fulfilled (Miranda et al., 2005; Snowden & Yamada, 2005; Sue & Sue, 2008a). Practitioners’ Knowledge of Empirically Supported Therapies It is frequently reported that there is a wide gap between clinical research and practice. Research-identified psychology treatments have produced efficacy data within an experimental paradigm but their effectiveness in day-to-day clinical practice is another matter (Kazdin, 2006). Psychotherapy outcome research has established outcomes based on multiple types of research evidence. Currently, there are two criteria for evaluating effectiveness of empirically supported psychotherapy outcomes. Treatment efficacy refers to outcomes obtained in an experimental research study and treatment effectiveness refers to outcomes in the naturalistic settings of clinical practice (Nathan, Stuart, & Dolan, 2000). The question is the utility of research-based treatments in day-to-day clinical work with individual clients from diverse cultural backgrounds. One important move emerging out of the dissemination research concerns an empirical assessment of the practitioner’s knowledge of “practice elements” of evidence-based treatments (Stumpf, Higa-McMillan, & Chorpita, 2009). Practice elements are “discrete clinical techniques or strategies, such as relaxation or self-monitoring, that are typically used as part of a larger intervention plan (e.g., a manualized treatment program for depression)” (Stumpf et al., 2009, p. 51). The practice elements are common elements empirically derived by using the “distillation and matching model” applied to a large number of evidence-based treatments for children and adolescents as reported in the literature (Chorpita & Daleiden, 2009). The practice elements (e.g., modeling, praise, and social skills training) are much more specific than the package intervention programs composed of different techniques in evidence-based treatments. Stumpf et al. (2009) developed a 40-item test called the Knowledge of Evidence-Based Services Questionnaire (KEBSQ) in the treatment of child and adolescent mental health problem areas: anxious/avoidant, depressed/withdrawn, disruptive behavior, and/or attention/hyperactivity. A total of 184 community behavioral health practitioners from the American state of Hawaii participated in the study. The group consisted of almost equal proportions of White (34.4%) and Asian (32.5%) practitioners, reflecting the two largest subgroups in Hawaii. The KEBSQ includes 30 practice elements that are actually used in empirically supported treatment protocols for child/adolescent problems (e.g., exposure, relaxation, time out, feedback) and 10 items that are not directly relevant (e.g., play therapy). The KEBSQ proved sensitive to changes in knowledge of empirically supported psychological intervention protocols after the training in evidence-based treatments for youth. As expected, graduate students in clinical psychology scored significantly higher on the test than the community practitioners. This study demonstrated the importance of ascertaining a solid knowledge base when disseminating evidence-based treatments to community practitioners in order to evaluate the clinical effectiveness of efficacious treatments for children and adolescents (Weisz, Doss, & Hawley, 2005). Cultural Competencies in Psychotherapy What are the competencies necessary to perform empirically supported and culturally responsive therapies? Cultural competencies should be generic to all forms of counseling and therapy (Hays, 2008; Pedersen, 2002) and encompass awareness, knowledge, and skills contributing to the practice of psychotherapy and counseling (Pedersen, 1997). Organizationally, the APA Presidential Task Force (2006) identified eight “components of clinical practice that promote positive therapeutic outcomes” (p. 276), each of which is highly relevant to the practice of culturally responsive assessment and therapy. The eight clinical components cover the whole range of clinical activities: (a) assessment, diagnostic judgment, systematic case formulation, and treatment planning; (b) clinical decision making, treatment and monitoring of progress; (c) interpersonal expertise, (d) self-reflection and skills acquisition: (e) empirical evaluation and research; (f) understanding the influence of individual and cultural differences on treatment; (g) seeking available resources; and (h) having a cogent rationale for clinical strategies. The eight clinical competencies are linked by empiricism, attention to individual differences, and multicultural perspectives. Heppner (2006) addressed the same issue for counseling psychologists. He gave an extremely positive direction for the practice of multicultural counseling. Developing cross-cultural competence increases the sophistication of clinical research, expands the utility and generalizability of the knowledge bases in counseling psychology, promotes a deeper realization that counseling occurs in a cultural context, and increases not only counseling effectiveness but also the profession’s ability to address diverse mental health needs across different populations around the globe. Gerstein et al. (2009) stated that there is a growing recognition that counseling and psychotherapy are embedded in the worldwide system of “interconnectedness” of the helping professions across cultures. If cultural competencies are important, are professional psychologists practicing cultural competence? Empirical assessment is lacking in this area. In a national survey, Hansen et al. (2006) developed a 52-item Multi-cultural Practices and Beliefs Questionnaire and investigated the extent to which professional psychotherapists (N = 149, 93% European American) in the United States believe and actually engage in culturally competent practice. The authors found an overall significant difference between mean ratings for practices and beliefs. Among the universally endorsed cultural competence items are: (a) show respect for client’s worldview; (b) avoid idealizing racial/ethnic groups; (c) take responsibility for transcending one’s own negative racial/ethnic cultural conditioning; and (d) evaluate one’s assumptions, values, and biases. Hansen et al. reported that only 22% of the practitioners used the Cultural Case Formulation in DSM-IV-TR (American Psychiatric Association, 2000) with ethnic clients, and only about 33% have used culturally sensitive data-gathering techniques in their practice. These results indicate that culturally adaptive protocols are not yet an integral part of assessment, case conceptualization, and intervention by professional psychologists. Furthermore, these psychologists reported that direct practices and experiences were most influential in developing multicultural competence, rather than guidelines and codes. The survey results indicate the importance of practicum with culturally diverse clients in training to increase self-assessment opportunities (American Psychological Association, 2003). Cultural Adaptation of Empirically Supported Psychotherapy Cultural adaptation is the systematic modification of an evidence-based treatment or intervention protocol to consider language, culture, and context in such a way that it is compatible with the client’s cultural patterns, meanings, and values. Adaptations that are well documented, systematic, and tested can advance research and inform practice (Bernal et al., 2009, p. 361). Cultural adaptation involves incorporation of culture-relevant and culture-sensitive information into the practice of psychotherapy with diverse clients. The multicultural literature has generated a series of guiding questions in order to accomplish cultural adaptation of a particular therapy. Culturally sensitive therapists ask the following questions when working with clients in a cross-cultural setting (Higginbotham, 1984; Tanaka-Matsumi et al., 2002): 1 What is the culture-relevant definition of maladaptive behavior that is considered abnormal in the client culture? 2 What is the accepted standard of role behavior? 3 Who is sanctioned to provide help for the individual in distress? 4 What expectations does the client culture have for psychotherapy and counseling? These questions are designed to raise the clinician’s awareness of the fundamental elements of culture in the practice of helping professions. Heinchs et al. (2006) investigated the relationship between culture, social anxiety, and fear of blushing. The student participants were from individualistic (U.S.A., Australia, Canada, Germany, and the Netherlands) and collectivistic (Japan, Korea, and Spain) countries. Country-level standings on the individualism and collectivism cultural dimensions were determined according to Hofstede’s (2001) work on cultural values and dimensions. They found that students from collectivistic cultures were more accepting toward socially withdrawn behaviors than students from individualistic countries. The authors also found significantly positive relations between the extent to which attention-avoiding behaviors are accepted in a culture and the level of social anxiety or fear of blushing symptoms. The results indicate cultural variations in the tolerance of socially withdrawn and anxious behaviors and suggest differences in normative standards of self presentation. These differences in cultural norms for expected behaviors can be clarified through negotiation (Kleinman, 1980) to resolve any misperception between the client and the therapist. To identify common factors seen in different cultural adaptation guidelines, Van de Vijver and Tanaka-Matsumi (2008) reviewed models of cross-cultural assessment for case formulation. They reported considerable similarities among the models (see Andréas-Hyman, Ortiz, Añez, Paris, & Davidson, 2006; Evans & Paewai, 1999; Hays, 2008; Hwang, 2006; Hwang & Wood, 2006; Ridley, Li, & Hill, 1998; Sue, 1998; Tanaka-Matsumi et al., 1996; Weiss et al., 1992). The common cultural accommodation includes assessment of the following: (a) client’s cultural identity and acculturation; (b) conflict with values; (c) client’s own idiom (expressions) of distress; (d) client’s causal explanatory model of presenting problems; (e) metaphors of health and well-being in the client’s cultural group; (f) client’s motivation for change; and (g) client’s social support network. Our impending question is whether there is evidence that culturally adapted therapies are actually more effective than those without particular cultural consideration. To what extent are they effective? Griner and Smith (2006) conducted a comprehensive literature search on culturally adapted mental health treatments and then performed a series of meta-analyses to determine effectiveness. They found 76 studies, with a total of 25,225 participants. Typically, studies included the comparison of a culturally adapted psychological intervention to a “traditional” intervention. Across all 76 studies, the average effect size was d = .45, indicating a moderately strong effect. The results were especially promising when the intervention was targeted for a specific cultural group (e.g., Hispanics) rather than a mixed group. The authors reported that as high as 84% of the total studies explicitly included cultural values and content into culturally adapted treatment such as the use of folk heroes for children. Griner and Smith’s criteria of cultural adaptation included: (a) reference to cultural values and stories; (b) racial/ethnic matching of client and therapist, (c) service in client’s native language, (d) multicultural paradigm of agency, (e) consultation with a culturally familiar individual, (f) outreach efforts, (g) extra service to retain clients, (h) verbal administration of materials for illiterate clients, (i) cultural sensitivity training for professional staff, and (j) referral to external agencies for additional services. The meta-analytic results (2006) showed the benefit of cultural adaptation of psychotherapy regardless of the technical content of each therapy. These culture-relevant variables are expected to interact with the client’s presenting problems and the treatment process. Assessment is an on-going process within the interactive cultural context of client and therapist (Okazaki & Tanaka-Matsumi, 2004). Culturally Responsive CBT: Asking the Right Questions to Expand the Application Cognitive behavioral therapists are trained to ask important questions with regard to the functional relationship between the expression of distress and cultural  values, or the impact of client ethnicity and religiosity on coping with distress (Hofmann, 2006). Studies of culturally responsive CBT are available on such topics as somatic symptoms of post-traumatic stress disorder (PTSD; Hinton, Safren, Pollack, & Tran, 2006; Otto & Hinton, 2006; Schulz, Huber, & Resick, 2006), panic attacks (Friedman, Braunstein, & Halpern, 2006; Zoellner, Feeny, Fitzgibbons, & Foa, 1999), and depression (Nicolas, Arntz, Hirsch, & Schmiedigen, 2009), among others. In their textbook, Foundations of counseling and psychotherapy: Evidence-based practices for a diverse society, Sue and Sue (2008a) included a section called “Cultural diversity considerations” in each chapter on different forms of counseling and psychotherapy. The title and the content both suggest that the authors are making active efforts to advance evidence-based practices for diverse societies. While recognizing the importance of empirically supported therapies, the authors pay close attention to the quality of the relationship between the therapist and the client. They summarized the conclusions of the APA Division 29 Task Force (Ackerman et al., 2001) on empirically supported therapeutic relationship. The main conclusions are that the therapeutic relationship makes a contribution to psychotherapy outcome, independent of the specific type of treatment, and adapting the therapy relationship to specific client needs and characteristics enhances the effectiveness of treatment. The therapeutic alliance factors are considered to complement the practice of empirically supported therapies. Demonstrably effective “empirically supported relationship variables” (Ackerman et al., 2001, p. 495) included therapeutic alliance, cohesion in group therapy, empathy, goal consensus and collaboration, customizing therapy to deal with resistance or functional impairment, and management of countertransference. Castonguay and Beutler (2006) embarked on a synthesis of the literature related to empirically supported treatments and relationship factors that are effective for clients with depression, anxiety, personality disorders, and substance abuse problems. They asked: What is known about the nature of the participants, relationships, and procedures within treatment that induce positive effects across theoretical models and methods? And, how do the factors or variables that are related to participants, relationships, and treatments work together to enhance change? Sue and Sue (2008a) included both technique and relationship factors as relevant to enhancing therapeutic effectiveness with diverse clients. Under cognitive behavior therapies for depression, the authors questioned if social and cultural influences are the cause of dysfunctional beliefs, if there are cultural factors and norms that need to be taken into consideration, and if the goals being considered are culturally appropriate for the client and his or her cultural group. Asking these and other diversity questions strengthens the cultural basis of empirically supported treatments, and practitioners would benefit from training in cultural orientation to the currently available guidelines. As part of the case formulation methods, the cognitive behavior therapist gathers appropriate idiographic data from the client and other informants. A major advantage of the case formulation approach is its process orientation and individualized approach. The therapist’s knowledge of the client’s cultural definitions of problem behavior and cultural norms regarding behavior, change strategies, and culturally approved change agents will enhance the degree of cultural accommodation. The functional analysis identifies antecedent events and consequences of problem behaviors within the client’s social network. Cultural factors are embedded in the client’s larger social environment and reinforcement history (Biglan, 1995; Hayes & Toarmino, 1995; Tanaka-Matsumi, 2004b). At multiple clinical decision points during assessment, the therapist develops hypotheses for individual clients and probes for the contribution of contextual variables. As part of the case formulation methods, the therapist gathers appropriate idiographic data from the client and other cultural informants (Bruch & Bond, 1998; Nezu, Nezu, Friedman, & Haynes, 1997). The step-by-step functional approach helps the therapist with clinical judgments in seven domains: (a) the problem list, (b) core beliefs, (c) precipitating and activating situations, (d) the working hypothesis, (e) origins or early history of the problem, (f) the treatment plan, and (g) predicted outcome of treatment (Persons & Tompkins, 1997). A major advantage of the case formulation approach is its process orientation and individualized approach. To gather culture-relevant information from the client, it is important to establish a working alliance with the client, so that the therapist and the client can collaborate with each other. La Roche et al. (2006) evaluated the effectiveness of the culturally sensitive relaxation method with Latino adults in a group setting. They used the Culturally Competent Relaxation Intervention (CCRI) which was designed especially for Latinos who hold allocentric self-orientation. Allocentrism at the individual level is connected with the collectivism cultural dimension. Relaxation for individualistic/ idiocentric individuals directs attention to self rather than interconnectedness with the surroundings. The CCRI used a group socializing format before teaching guided imagery with either an allocentric imagery exercise of being with someone who makes one happy, or with an idiocentric imagery exercise of being by oneself on a beautiful beach. The authors reported prelimary results concerning Latinos’ preference for allocentric imagery. The state of relaxation is a universal state of mind, but the content of relaxation exercise can be culturally variable to benefit the person using it. Future study could employ non-Latinos to examine whether allocentric preference is culture-related or more universal. A series of studies conducted in Boston with the Asian community gives excellent examples of cultural adaptation of empirically supported CBT protocols for the treatment of specific anxiety disorders (Hinton et al., 2005; Hinton, Safren, Pollack, & Tran, 2006; Iwamasa, Hsia, & Hinton, 2006). Cognitive behavioral treatment has been recognized as evidence-based and several detailed manuals are available (e.g., Barlow & Craske, 1994; Craske & Barlow, 1994). One important component of these treatment protocols is the use of repeated exposure to feared situations to reduce the intensity of the fear response. In the case of panic attacks, clients are exposed to feared bodily sensations and taught to modify their maladaptive self-statements during exposure. Hinton and Otto (2006) conducted a cultural analysis of somatic symptoms of a panic attack in traumatized Cambodian refugees who received CBT in Boston. The authors introduced the Cambodian  cultural syndrome of “weak heart” based on the ethnographic account of wind as the causal agent of anxiety symptoms that produced somatization of trauma-related distress. They hypothesized that “weak heart” produces catastrophic cognitions and somatic symptoms. According to the authors’ cultural assessment, Cambodians construe a panic attack as a wind attack and consequently engage in self-statements to remove wind. Functional assessment of these “coining” and “cupping” statements indicated that these statements serve as the safety behaviors that maintain and perpetuate catastrophic cognitions about wind. To accommodate cultural context, Otto and Hinton (2006) conducted therapy sessions in a local Buddhist temple with interpreters to help Cambodian refugee clients. They assessed the clinical relevance of culture-specific beliefs about wind travelling through vessels in the body and creating a dangerous bodily condition. They also encouraged the use of cultural metaphors of somatic symptoms and Cambodian cultural concepts whenever possible. Beyond Specific Therapies: Therapy as Negotiation in Cross-Cultural Context Culturally adapted psychotherapy has components of “therapy as negotiation” (Kleinman, 1980). The interactive procedure is helpful for understanding the cultural meaning of the client’s presenting problem. First, the therapist encourages clients to give their own explanation of the presenting problem. Second, the therapist discloses the explanation, or explanatory model, that he or she uses to interpret the problem. Third, the two frameworks are compared for commonalties and discrepancies. Finally, the client and clinician translate each explanatory model into mutually acceptable language, so that they may jointly set the content of therapy, the target behavior, and outcome criteria. In fact, reflecting Frank and Frank’s (1991) definition of psychotherapy, effective communication between the therapist and the client in psychotherapy is based on the shared cultural meanings of the concepts and idioms of distress. Conclusion The recent literature demonstrates successful applications of empirically  supported treatment to culturally diverse clients. The cumulative empirical research on psychotherapy outcome amounts to hundreds of studies since the publication of Eysenck’s (1952) critical report calling for scientific studies of psychotherapy outcome. Today, it is clear that psychotherapy has proven effective in general. More specifically, it is also clear that both techniques and relationship factors contribute to therapeutic effectiveness. A large number of empirically supported therapies are currently available for the treatment of specific disorders (Nathan & Gorman, 2006; Roth & Fonagy, 2004). Similarly, the literature on empirically supported relationship factors has helped direct our attention to the dynamic nature of interaction between the therapist and the client within the cultural context. As I have reviewed in this chapter, there is an increasing number of studies on the adaptation of empirically supported therapy for specific cultural groups. The need for culture-specific clinical services will continue to increase in the near future. Furthermore, practitioners will be increasingly challenged to demonstrate that their services are evidence based. It can be expected, therefore, that there will be an increased need for systematic studies of culturally informed assessment and intervention methods. Finally, the training of culturally competent psychotherapists is expected to increase in the age of globalization. References Ackerman, S. J., Benjamin, L. S., Beutler, L. E., Gelso, C. J., Goldfried, M. R., Hill, C. … Rainer, J. (2001). 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