Asian Women Suffer from Pelvic Floor Disorders Too
I recently had a patient who had been misdiagnosed by two prior surgeons before seeing me. Being elderly, wheelchair dependent, and knowing limited English, I believe that her complaints of urinary leak and pelvic pain were overlooked. She is a primarily Mandarin-speaking woman of Chinese-heritage. She is what we physicians consider medically complicated; we often sum up a patient like this as having “multiple medical morbidities.”
Additionally, her pelvic floor issues are longstanding. She has had multiple prior pelvic surgeries, including one in the last couple of years for vaginal bulge, as well as a mesh sling for urinary incontinence. With a brief pelvic exam I was able to see a very likely source of her current symptoms: she had a large exposure of her sling mesh into the vagina. It looked like it’d been there a while, because debris had actually calcified onto it. Imagine putting gravel into a vagina — that’s essentially what this woman had been carrying around. She’d had a “million dollar workup” in the past — MRI imaging, special bladder testing, multiple specialists. I don’t mean to disparage my colleagues, because clinicians can miss things. I miss things. Also, all surgeons are bound to have their share of complications. But this lady had the burden of feeling dismissed by multiple clinicians despite multiple, invasive exams.
We need a better understanding of Asian race and health outcomes
I share this story to highlight some of the barriers and biases that I believe may have affected this patient in her clinical encounters. One is her race. Asians are commonly thought to suffer from pelvic floor disorders less than other groups, but this understanding is flawed. In this study, which was a review that identified existing research on race and pelvic organ prolapse, the authors only found five articles. Of the 1200+ articles that they originally found, only five specified the racial demographics of study participants. Furthermore, only two of those articles included information about Asian women. From these two studies, we, the readers, are supposed to believe that there is a 3% rate of pelvic organ prolapse among Asian women, compared to 10% among Non-Hispanic White women. However, both of the articles come from Northern California and are survey-based. Furthermore, the surveys were conducted in English in a Kaiser population, which is the largest health insurer in California. So, what we are left with is an understanding of prolapse among English-speaking, insured Asian women in one region of America. Of the races identified in the larger review article, Asians had the lowest rate of prolapse.
It’s data from studies above that play into this narrative of Asians being the model minority. We know that certain factors increase the risk of pelvic floor disorders, including how many children a woman has had, being overweight, and smoking. All of these factors vary among the different Asian ethnicities. We have to appreciate the plurality of Asian-Americans, because Asian immigrants are the largest growing immigrant demographic in the U.S. By 2055, they are projected to surpass Hispanics as the largest immigrant group. Asians include individuals from Afghanistan to Malaysia, and only sampling one region of the U.S. likely over-represents Asians and Asian-Americans of certain origins. Specific to women’s health, the CDC has found that most Asian mothers were born outside of the U.S. An Asian person’s place of origin relates to their level of poverty, education, and likeliness to speak English. We know from other studies that these sociodemographic factors are related to the above-mentioned risk-factors for prolapse.
Language barriers have real consequences in healthcare
A second barrier to care related to my unfortunate patient is language. Elderly Asians, particularly those non-native to the U.S., are less likely to have English as their primary household language. In fact, according to the Pew Research Center, almost two-thirds of all U.S. Asian households speak a language other than English. Chinese languages account for one-third of those homes. This review found that patients with limited English proficiency (LEP) are less likely to receive the care they need, and when they do receive care, they may suffer from gaps in the quality of that care.
My Not so Modelesque, Asian Minority Life
Although I’m half Filipino, I was surprised to learn that Asians are often labeled model minorities. I found this out in medical school when multiple lecturers highlighted how Asians have better health outcomes than other races. This just didn’t line up with my experience. The implication was that, as a whole, Asians were better at accessing care, suffered less poverty, and were more educated. As a Filipina immigrant, my mom at times relied on public health insurance and food assistance while raising my brother and I. She came to the U.S. with a high school degree but later finished college when I was a kid. The other Asians in our Michigan community — Korean, Armenian, Vietnamese — they were also hardworking people though would likely be considered poor or at least lower-middle class.
What epidemiologists are learning is that Asians are not a monolith. There are wide variations between ethnic groups, across different regions of the country, and with regards to origin of birth. Most Americans likely have little immersion in Asian communities, as one-third of all U.S. Asians live in California, and one-half live in the Western U.S. I imagine it could be easy to stereotype Asians in a certain way, particularly if one has limited exposure to Asian communities.
Now I live in Los Angeles County, which has the highest number of Asian Americans in the country. A recent study found that of adults 65 and older, Koreans and Cambodians experience poverty at a rate greater than any other racial group in L.A. From my mom’s own immigrant experience, I’m not surprised that poverty and barriers to quality healthcare are problematic among some Asian Americans. I hope that as this demographic continues to grow in the U.S., more people will recognize that the model minority stereotype is a myth that can itself be counterproductive in meeting the basic needs of those of Asian heritage.