Content uploaded by Isela Martinez
Author content
All content in this area was uploaded by Isela Martinez on Oct 22, 2020
Content may be subject to copyright.
ORIGINAL PAPER
Cultural Perceptions and Negotiations Surrounding Sexual
and Reproductive Health Among Migrant and Non-migrant
Indigenous Mexican Women from Yucata
´n, Mexico
Rebeca Espinoza •Isela Martı
´nez •Matthew Levin •
Alicia Rodriguez •Teresa Chan •Shira Goldenberg •
Marı
´a Luisa Zu
´n
˜iga
Published online: 4 September 2013
Springer Science+Business Media New York 2013
Abstract Information regarding sexual and reproductive
health of indigenous women from Mexican sending and US
receiving communities is limited. This research aims to
explore the perceptions of indigenous women from US
migrant receiving and Mexican migrant sending commu-
nities regarding their sexual health experiences and repro-
ductive health practices. From January to March 2012, two
key informant interviews and 31 in-depth, semi-structured
interviews were conducted among women ages 18–55 in
Tunka
´s, Yucata
´n and Anaheim and Inglewood, California.
Women reported challenges to obtaining routine repro-
ductive clinical care, including access to care barriers and
lack of perceived power over their own sexual health. This
was further compounded by migration processes and defi-
ciencies in health care delivery systems. Socio-cultural
beliefs and gendered power dynamics influence sexual and
reproductive health decisions and behaviors of migrant and
non-migrant women. Findings underscore existing gender-
based reproductive health norms and serve to inform future
transnational research and public health education to
improve the health of indigenous migrant and non-migrant
women in the US and Mexico.
Keywords Women Sexual health Reproductive
health Migration Mexico
Background
In the United States (US), Mexican-born migrants experi-
ence substantial health disparities, and are less likely to
access and benefit from public health programs compared
with other ethnic/racial groups [1,2]. In Mexico and inter-
nationally, evidence indicates that migrant women and
female spouses of migrants often experience elevated risk of
negative sexual and reproductive health outcomes such as
sexually transmitted infections (STIs) [3–5], as well as poor
access to reproductive health information and care [6–8].
Compared to any other region of Mexico, the southern
states, including Yucata
´n, exhibit some of the most pro-
nounced and ongoing health disparities among vulnerable
groups such as indigenous women and children [9,10].
Inequities surrounding women’s sexual health are particu-
larly pronounced in resource limited and rural regions
within Mexico, where negative reproductive health out-
comes such as cervical cancer remain the second leading
cause of mortality among women in the country [10].
To address poor health outcomes related to poverty and
marginalization, especially in Mexico’s rural regions, the
Mexican government implemented the health program
Programa de Desarrollo Humano Oportunidades (Program
for Human Development Opportunities) in 1998, popularly
known as Oportunidades [11,12]. This program aims to
increase levels of education, health status, and nutrition of
low-income families. Eligible families participating in
Oportunidades receive monthly payments, free or low cost
health services and educational incentives in exchange for
family member participation in government-sponsored
R. Espinoza I. Martı
´nez M. Levin A. Rodriguez
T. Chan S. Goldenberg M. L. Zu
´n
˜iga
Division of Global Public Health, Department of Medicine,
University of California, San Diego, La Jolla, CA, USA
M. L. Zu
´n
˜iga (&)
Division of Academic General Pediatrics, Child Development
and Community Health, Department of Pediatrics,
University of California, San Diego, 9500 Gilman
Drive #0927, La Jolla, CA 92093-0927, USA
e-mail: mzuniga@ucsd.edu
123
J Immigrant Minority Health (2014) 16:356–364
DOI 10.1007/s10903-013-9904-7
development programs, that includes routine sexual health
care and family planning [13]. Early evaluation of the pro-
gram indicates initial efficacy in improved educational
attainment and reducing poverty [14], however, indigenous
women living in rural regions continue to face multiple
barriers to care. There are significant language and cultural
differences between indigenous communities and existing
federally sponsored health institutions. This limited capacity
to provide culturally-appropriate care to indigenous popu-
lations often influences this population’s health care utili-
zation, beliefs and behaviors [15]. Indigenous populations in
Mexico have higher rates of poverty, lower levels of edu-
cation and poorer health status than non-indigenous Mexi-
cans [16]. These inequities persist in the US, as indigenous
migrants of Mexican origin are also marginalized by social
status and employment conditions [17]. Health disparities
among indigenous communities have been shaped by a
complex history of political, social and health marginaliza-
tion [18,19]. These inequalities continue to influence health
behaviors and access to health services in Yucata
´n today,
while adding to the complexity of other health care barriers
such as trust in governmental health care systems [19,20].
The introductory paper in this series provides greater detail
on key socio-cultural characteristics of this population that
distinguish it from non-indigenous populations.
Ethnic, cultural and linguistic differences are often
overlooked when describing health practices and under-
standings among Mexican women in context of interna-
tional migration. Consequently, there is a tendency to
generalize understandings and approaches to address health
care issues among culturally distinct Mexican migrant
groups [21]. Sexual and reproductive health beliefs and
practices held by indigenous women from high migrant
sending and receiving communities are poorly understood
and represents a significant research gap. The current study
aims to address this gap in research through qualitative
inquiry with indigenous women from a migrant sending
community in Mexico and migrants in their receiving
communities in the US surrounding their sexual health care
practices and experiences obtaining sexual and reproduc-
tive health care in Mexico and the US.
Theoretical/Conceptual Framework
Challenges to achieving sexual and reproductive health
among women often stem from gender inequality and a
lack of power and authority over their own health [22,23].
We applied a modified framework of The Theory of
Gender and Power [23,24] to guide and contextualize
findings related to the socio-cultural dimensions that shape
perceptions and decision-making surrounding sexual health
among migrant and non-migrant Mexican indigenous
women.
This theoretical framework has been applied in previous
studies to better understand sexual health through the
sexually divided structures of power, labor and cathexis
(socio-cultural norms) [24]. It has helped explain the
broader issues that shape women’s decisions and power
over their own health at the individual and societal level.
For the purposes of this study, we employed the three
constructs of the Theory of Gender and Power (the struc-
tures of labor, power, and cathexis), as used by Wingood
and DiClemente [24], to help guide and frame study find-
ings with regard to women’s health. These components
were extended to include structural factors related to access
to reproductive health care, gendered power dynamics that
influence women’s health and existing socio-cultural norms
regarding women’s sexual health.
Methods
Study Setting
Tunka
´s is small town located 70 miles east of Me
´rida, the
capital of Yucata
´n. In Tunka
´s, 51.2 % of the 3,464 popu-
lation is male [25]. Yucata
´n is a relatively new migrant
sending state and migration from Tunka
´s usually takes
place to the nearby tourist cities of Cancu
´n and Playa del
Carmen, or internationally to Inglewood and Anaheim in
Southern California. Increasingly, more women are taking
part as economic migrants themselves or to reunite with
family who has moved to the US [26]. In Tunka
´s, there is
one small community clinic staffed by two doctors and
three nurses. The clinic has an operating room for per-
forming simple procedures and delivering babies. All
Tunkasen
˜os are eligible to receive care regardless of ability
to pay. Most patients qualify for a federally-sponsored
medical insurance program such as Seguro Popular [27]. In
the US, migrants and their families can seek care at local
community clinics that provide free or sliding scale fee for
service and as of this writing, regardless of documentation
status.
As part of efforts to validate study findings and promote
continued community engagement in research, in February
2013, members of our study team returned to Tunka
´sto
provide a summary of study findings in the form of small
town hall meetings to the Tunkasen
˜o community and elicit
their feedback on findings. Community feedback obtained
during this visit proved invaluable to contextualize in-
depth interviews presented in this study. Relevant com-
munity-member feedback is presented with our results to
better contextualize study findings.
J Immigrant Minority Health (2014) 16:356–364 357
123
Data Collection
Between January and March 2012, we conducted 31 in-
depth, semi-structured interviews with indigenous women
in the migrant-sending community of Tunka
´s, Yucata
´n,
Me
´xico and two migrant-receiving communities in Orange
County and Los Angeles County (Anaheim and Inglewood),
California. In addition, we conducted key informant inter-
views with two nurses in the Tunka
´s clinic who work pri-
marily on reproductive health. This study was nested within
a larger mixed methods parent study among 650 participants
in Tunka
´s and Southern California (n =583 in Mexico;
n=67 in Orange County and Los Angeles County). In the
US, participants were recruited for the current study using a
modified snowball sampling methodology to reach potential
interviewees based on referrals provided by persons inter-
viewed in Tunka
´s or the US Participants were purposively
selected to represent a diverse range in age, marital status
and migration experiences (e.g., migrants vs. spouses of
migrants; single vs. married). In-depth interviews were
conducted in Spanish by four trained, female bilingual
(Spanish/English) and bicultural student researchers of
Mexican-origin. Researchers ensured that interview sched-
uling and locations were conducive to privacy and confi-
dentiality of the participant. Interviews were re-scheduled
for a future date or at a different location specified by the
participant in occasions when this criterion could not be met.
Each de-identified qualitative interview lasted approxi-
mately 30 min to 2 h and was audio-recorded and
transcribed verbatim. Interview topics for this study were
developed from previous research and literature review that
highlighted disparities and gaps related to women’s repro-
ductive and sexual health in this population and region [6,
28–30]. These topics were then refined as respondent’s
narratives produced common themes in the initial part of
this study, which then helped guide the development of
interview questions. Interviews consisted of open-ended
questions covering topics such as contraceptive use, spousal
relationships and sexual health, access to sexual and
reproductive health care services, and self-care (see
Table 1). This study was reviewed and approved by the
University of California, San Diego Human Research Pro-
tection Program and the State of Yucata
´n, Me
´xico’s Sistema
para el Desarrollo Integral de la Familia (DIF) del Estado
de Yucata´n (System for the Integrated Development of the
Family of the State of Yucata
´n).
Data Analysis
Interviews were transcribed verbatim and analyzed in
Spanish by the bilingual and bicultural study authors. Data
analyses employed an iterative process of ‘open’ coding to
deductively analyze key themes in the women’s narratives
and explore how factors related to gender, power, and
migration shape women’s health and related sexual
behaviors [31,32]. We then inductively analyzed the
emergent data through the lens of the Theory of Gender
and Power to guide and further understand the influence of
Table 1 Selected in-depth interview questions
Selected interview questions
Spanish English
>Co
´mo recibe su informacio
´n sobre la salud? >Co
´mo recibe su
informacio
´n sobre los recursos relacionados con la salud reproductiva
y sexual en su comunidad?
How do you receive health information? How do you receive
information and resources related to reproductive and sexual health
in your community?
>Do
´nde acude para recibir atencio
´n para su salud sexual y reproductiva
cuando lo necesita?
Where do you usually go to receive care for your sexual and
reproductive health?
>Que
´tan fa
´cil es acceder a los servicios de salud en su comunidad?
>Con que
´frecuencia recibe atencio
´nme
´dica?
How easy is it to access health services in your community? How
often do you receive routine care?
>Nos puede platicar sobre su experiencia durante su u
´ltima visita al
centro de salud o proveedor de salud?
Can you describe you experience during your last visit to the health
center or medical provider?
>Cua
´les son algunos de los obsta
´culos que usted ha pasado en cuanto el
acceso a servicios de salud sexual y reproductiva en su comunidad?
What are some of the barriers you have encountered in accessing
sexual and reproductive health in your community?
>Cua
´les son algunos de los facilitadores que pueda haber tenido en el
acceso a la salud sexual y reproductiva en su comunidad?
What are some of the facilitators you have encountered in accessing
sexual and reproductive health in your community?
>Que
´papel tiene la migracio
´n, ya sea por parte de usted o de su pareja,
en su propia salud sexual y reproductiva?
Does migration, either of yourself or your spouse, play a role in your
sexual and reproductive health? How?
>Co
´mo se puede reducir el riesgo [si es que existe alguno] relacionado
con la salud reproductiva (por ejemplo, la transmisio
´nde
enfermedades de transmisio
´n sexual)?
How does one reduce risk (if any) associated with issues related to
reproductive health (i.e., STI and STD transmission)?
>Que
´factores influyen en sus decisiones relacionadas con su cuidado
personal?
What factors influence your personal decisions related to your own
self-care?
358 J Immigrant Minority Health (2014) 16:356–364
123
gender and power on participants’ sexual behaviors and
access to sexual and reproductive health care.
Results
The average age of women interviewed in this study was
34 years and ages ranged from 18 to 55 years. Most
women (85 %) were married and had at least one child by
the age of 24 years. Almost one third of the sample had
husbands who had migrated either domestically or inter-
nationally. We did not observe differences by age group
surrounding sexual and reproductive health among women
in this study, which may be attributed to the small sample
size. We did, however, observe similarities in the narratives
related to stages of life when a woman should access
reproductive or sexual health care. Overall, women per-
ceived that pregnant women and new mothers in particular
should begin to access reproductive and sexual health
services. Furthermore, women who had one or two children
were viewed as more knowledgeable and ‘‘experienced’’
and therefore in less need to seek routine health services
compared to women expecting their first child. These views
tended to be held by women of all age groups in Yucatan
and in US study samples and are described in the sub-
sequent two sections.
Institutionalization of Gendered Norms Regarding
Women’s Sexual Health
The construction and reproduction of gendered and social
cultural norms shape the expectations and the interactions
between women and their health care delivery system both in
the US and in Tunka
´s. These processes become normative
and must therefore be evaluated within this framework. The
perceived lack of power women have over their own health,
under normative and cultural expectations, was reported in
various instances by women in this study. In addition to
spouses, male family members may also hold institutionally
condoned power over women’s own sexual and reproductive
health, regardless of their consent. These gender structures
thus perpetuate unbalanced gendered norms that affect
women’s ability to choose and make decisions within the
context of institutions.
One example of this was described by a woman whose
brother was given the power to authorize an invasive
procedure on her while she was under the hospitals’ care.
As a result, she underwent hysteroscopic sterilization
without her prior knowledge or consent.
I didn’t know that they were going to cut off my
[fallopian] tubes….since I had had a lot of problems
with my ovaries, my brother went to the hospital and
told them it was better for them to do it [the
procedure].
Structural institutions such as health care systems were
reported by women to follow existing cultural norms,
reinforcing the unequal gender power dynamics of
women’s sexual and reproductive health. As a result, some
women described feeling a lack of control and decision
making over their own health both at their home and in
health care settings.
In addition to imbalances of power over sexual and
reproductive health, cultural beliefs and expectations
among women often shaped their perceptions regarding
when women should seek reproductive health services.
Cultural norms and expectations about related activities
such as marriage and sexual activity were frequently
imbedded within the narratives of the women in this study.
For example, the beginning of an active sexual life was not
typically regarded as a catalyst or motivator for Tunkasen
˜a
women to seek sexual or reproductive care services. Many
participants reported never discussing sexual health until
their first pregnancy. Only at this time did some women
learn about pap smears and contraceptive options. Nego-
tiations of these traditional social norms regarding family,
sexuality and womanhood often determined when women
felt it was acceptable to initiate health care seeking
behavior. Most participants reported having their first
woman’s health check-up only after having their first child,
which was when many recognized themselves as
‘‘women’’.
Before you have children they can’t do it [pap smear]
to you. After you have kids they start doing it.
Some women also reported that their care seeking
behavior was closely tied to pregnancy:
When I went [to the doctor] it was because I was
pregnant…I would go every month for whatever I
needed. Everything was fine and since then [baby’s
birth] I haven’t returned.
Understandings and conceptions of womanhood often
determine women’s related practices and health care
seeking behaviors. While these notions may be understood
within the larger socio-cultural framework in which
women live, these beliefs may not always follow the rec-
ommended guidelines for women’s health put forth by
biomedical and health systems.
Barriers and Facilitators to Sexual and Reproductive
Health Care and Information
Participants who lived in Tunka
´s(n=22) frequently
described barriers to accessing care at the local public
J Immigrant Minority Health (2014) 16:356–364 359
123
health clinic, including shortages in prescribed medications
and medical staff, long wait times, limited numbers of
available appointments, and privacy and confidentiality
concerns. While not explicitly tied to migration status and
gender roles, for women whose partners are migrants, these
structural issues may play a role in women’s decisions to
seek preventive and timely sexual health care before a
potential infection becomes problematic. For more com-
plex health issues as well as medical technology not
available in the local clinic, patients were often referred for
health services in nearby cities, such as Izamal or Me
´rida,
located 35 min and 2 h away, respectively. As women
frequently explained:
Sometimes they just have nothing there [local clinic],
and you are prescribed medicines that are not
available…
They did my check-ups here [Tunka
´s], then they sent
me to the maternity center in Me
´rida and there I had
my boy.
Tunkasen
˜a migrants living in the US (n =9) explained
that immigrant women lacking health insurance often rely
on community-based clinics to address their health needs.
Information regarding health insurance and women’s
health clinics is often shared and distributed by word of
mouth within the migrant community. Most US partici-
pants reported membership with large healthcare mainte-
nance organization (HMO) networks through their
husbands’ employment. For these women, healthcare
access becomes gendered and dependent upon their male
spouse’s employment and migration status.
You need to have insurance in order not to pay so
much…here [US] it is a bit harder to go to the doctor
and more expensive…he [husband] gets it [insurance
premium] taken out from his paycheck and that is
how I can go to the doctor.
For Tunkasen
˜a women in Southern California who did not
report having access to health insurance or belonging to an
HMO, the nearby free or low cost community health center
was frequently mentioned as their main source of care. While
socioeconomic and immigration status may have played a
role in health care utilization in Southern California, inter-
viewers did not probe this issue, and women did not mention
these topics when discussing potential barriers or facilitators
to care. Southern California interviewees tended to focus on
socio-cultural aspects and differences between countries
when discussing access to health care.
Respondents in Tunka
´s identified the Oportunidades
program as a valuable source of knowledge regarding
sexual health, health promotion and services overall.
However, information regarding culturally sensitive issues,
such as women’s sexual and reproductive health was less
readily available or publicly promoted outside of the con-
text of Oportunidades:
They don’t have health campaigns for those types of
issues [sexual health] for women …mostly new and
expecting mothers get check-ups at the clinic…
Those women who are in the Oportunidades program
go to a meeting each month and there they tell you
everything [about sexual health].
Although the Oportunidades program has facilitated
access for many under-resourced Mexican women, dis-
parities in access remain prevalent. Some women men-
tioned interest in attending the health sessions, but voiced
their disappointment in their inability due to perceived
ineligibility. The exclusion of some women while
empowering others who participated in the Oportunidades
program may contribute to inequities in access to health
information and services. This may be particularly the case
among women with multiple competing priorities such as
taking care of family members, traditionally part of
women’s duties, and who live in rural settings with limited
health resources such as Tunka
´s.
I don’t go to the talks because they are only for the
people who are eligible to enroll in Oportunidades.
While women in Tunka
´s frequently reported that
Oportunidades is a valuable source of information, the
clinic nurse participant believed that gendered norms still
represent barriers for some women’s access and utilization
of reproductive care provided at the clinic. This is partic-
ularly important among women whose partners are
migrants and who may return with sexually-transmitted
infections. When asked about contraceptive use, pap
smears, facilitators and barriers of care for women in her
community, the clinic nurse mentioned husbands as being a
barrier to care.
Currently what most affects it [reproductive care
access] are women’s husbands, there’s women who
come asking for information behind their [husband’s]
back…many women don’t come because of their
husbands, they think that they’re going to put them-
selves at risk if they start [family] planning.
In Tunka
´s, women who go to the clinic for services can
expect to see neighbors, friends and community members
in the waiting area. In the US, however, women described
their clinic experiences visits as more individualized, sol-
itary and less enjoyable. Tunkasen
˜a women in the US
described vastly different experiences accessing sexual and
reproductive health care, in comparison to women living in
Tunka
´s. As illustrated by a US participant:
360 J Immigrant Minority Health (2014) 16:356–364
123
It’s just…different here compared to there…In Tun-
ka
´s you go [to the health center] and it’s friendly, you
see people you know and you chat with them while
you wait, you dress up because you will see a lot of
people…here [United States] well, it’s cold…you go
alone and wait…you come back alone…it’s just a
different experience, I like it more in Tunka
´s.
Although clinic experiences in Tunka
´s were sometimes
described as ‘‘friendlier’’, lack of patient confidentiality
was frequently reported as a prominent barrier to health
care utilization among women. In many instances, Tun-
kasen
˜as reported being less likely to utilize services or
disclose personal health information to health providers
due to lack of trust in the clinic’s ability to keep infor-
mation private and confidential.
That was the only person. It was [my husband], me
and the doctor, the only three that knew…so I ask her
[mother-in-law] ‘how did you find out?’ Well, I
imagine the doctor mentioned it to someone and that
someone mentioned it to someone else and they
found out. That is why now I am more discreet.
Lack of perceived privacy at the town’s clinic may
compromise willingness of some women to disclose
information about sexual and reproductive health with their
health care providers and could affect whether women seek
future reproductive health care services. Perceived trust
and confidentiality of health care systems may conse-
quently negatively affect related health care and informa-
tion seeking behaviors among women from this
community.
Gender Roles Within the Context of International
Migration
In small migrant-sending communities such as Tunka
´s,
traditional and conservative gender roles are deeply
embedded, and have key implications for women’s sexual
and reproductive health. Typically, men seek work locally;
due to limited work opportunities within or nearby their
communities, many migrate to domestic locations such as
Cancu
´n and Playa del Carmen, or internationally to the US
Women are expected to remain in Tunka
´s and generally
rely on their migrant husbands for economic support;
although, as our study also revealed, there are some female
Tunkasen
˜a migrants living in the US, who may have
migrated for family reunification or independently for
economic reasons.
Extramarital relations are common among both inter-
national and domestic male migrants while away from
home. This practice, while not openly condoned, is to some
degree normalized in Tunkasen
˜o society. Acceptability of
partner infidelity as a normative behavior, combined with
low condom use among migrants, poses increased risks to
the health of women who reside in the sending community.
In the city, well, you know how men are…he was
with other girls and when I got there [city] I got that
[sexually transmitted] infection.
This acceptability does not necessarily imply ignorance
of the sexual risks involved, as many women were quite
aware of the need to protect themselves within the context
of sexual relationships with return migrants. A woman
described the need for self-care when engaging in sexual
relations with a man who has been away:
You have to take care of yourself because how am I
to know if he has an infection [STI]? They are never
going to say it.
If the man as well as the woman does not take care of
himself/herself, and if the man is also not faithful,
there is a risk, and if they are faithful, that is good.
If I take care of myself and he does not, he can give
me an infection. If I am not clean, he also can get
infected. I tell him, when one has an infection one has
to put something on and for 7 days not have sexual
relations.
However, while women were aware of the risk, they
frequently reported a lack of power over their sexual
relationships and described the authority and control that
male partners exhibited in relationships and the home. A
lack of communication and/or perceived lack of control in
relationships, especially sexual practices, may result in
adverse health impacts among Tunkasen
˜a women with
migrant partners:
Men are machistas, sometimes they won’t allow their
wives or daughters [to go to the doctor]…The hus-
band won’t let you go get a pap smear because they
are jealous because it’s male doctors at the health
center.
By the time she could go to the doctor, when her
husband let her go, it was too late…she died because
of it [cervical cancer].
Although women were frequently aware of the risks
posed by unprotected sex with migrant spouses, gaps
remained in knowledge and behaviors regarding prevention
of STIs and contraceptive methods (e.g., condoms). Deci-
sion-making power regarding the use of contraception
methods is shaped by traditional gender roles and attitudes
such as machismo, which are further complicated by
spousal migration and the paucity of economic opportuni-
ties for women. Economic dependence on the male partner
frequently leads to acceptance of his role as a caretaker of
the woman’s physical well-being. Consequently, women in
J Immigrant Minority Health (2014) 16:356–364 361
123
Tunka
´s may have limited agency regarding contraception,
self-care, and ability to seek sexual health care or perceived
lack of control over their health by placing trust in their
husband’s fidelity, as the following woman stated:
I don’t take any precautions because I think my
husband is faithful.
Discussion
In this study of Tunkasen
˜a women’s cultural perceptions
and negotiations regarding sexual health, and the over-
arching influence of gender and power within the context
of migration directly and indirectly shape women’s sexual
and reproductive health and access to care. We looked at
two dimensions of sexual and reproductive health (gender
& power) [33], and our data revealed the importance of a
binational perspective as well as a migration perspective.
Migration remains a critical part of our study population’s
health risk in that migrating partners may expose non-
migrant and presumably migrant women, to sexually
transmitted infections that impact their sexual and repro-
ductive health. Our study revealed multiple factors that
shape women’s beliefs and behaviors toward their own
self-care and access to reproductive health services both in
their communities in Mexico and the US These included
gendered power imbalances, socio-cultural expectations for
when it is appropriate for women to access sexual and
reproductive health care, and perceived trust and confi-
dentiality of health systems. Prior research studies have
utilized the Theory of Gender and Power to describe gen-
dered power imbalances, related to the socio-cultural
environment and behavioral risk factors [33,34]. Few
studies, however, have addressed other health determinants
such as migration, marginalization and perspectives of
sexual health in a binational context using a gendered
analytic lens to frame findings. Moreover, even fewer
studies have previously analyzed these issues among
indigenous migrant women and spouses of migrants, who
may be at disproportionately higher risk of negative sexual
and reproductive health outcomes due to the additional
marginalization indigenous populations often face in
Mexico and globally [34,35].
Earlier studies on migration [36,37] have found that
migration of women’s spouses had a negative impact on
women’s sexual and reproductive health. Migrant men
were often described to have other sexual partners when
living or working away from their spouses and places of
origin. In some cases, migrating men acquired diseases and
infections in host locations, which were later transmitted to
their spouses upon their return home. Women’s expecta-
tions of their migrant partner’s infidelity were understood
within the larger socio-cultural environment and normative
beliefs regarding gender roles. Breeches in fidelity were
often identified as part of masculinity (‘‘men will be
men’’), and, in some instances, a necessary biological
behavior specific to the male gender. This ideology
regarding fidelity may be viewed as a protective factor to
promote continuity and family unity without discord, par-
ticularly for those communities with a large migrant pop-
ulation who depend on remittances sent from abroad.
Reinforcement of these beliefs, however, in the context of
transnational and national migration, did not implicate a
lower perception of health risks among women. Women
understood the sexual health risks, but may have perceived
lack of authority and power to negotiate protection mea-
sures (i.e., condom use) to protect themselves. Decisions
around the use of contraceptives, and in one case, the
ability to access treatment for STI’s, are largely influenced
and determined by male spouses. Therefore, the degree to
which women can protect themselves may be predicted by
the husband’s approval or, at times, their ability to take
measures for their own protection such as pap screenings
without their husbands’ knowledge. Thus, the lack of
power for women to negotiate safer sex may result in a
limited ability to communicate sexual health needs and an
increased likelihood for risky sexual practices.
As noted by Comas-Diaz [37] cultural construction of
sexuality in Mexico often perpetuates the expectation of
women to sacrifice their own need for those of their fam-
ilies. Our study found that caring for children, family and
extended family, often took precedence over women’s
health, particularly routine checkups or for preventative
measures. For women living in rural and resource limited
areas such as Tunka
´s, these culturally constructed identities
and power imbalances contribute to sexual health dispari-
ties and pose barriers to accessing care. For Tunkasen
˜as
living in the US, cultural beliefs and gendered notions of
power over sexual health may also be endorsed by migrant
women and men, who often times bring these values and
behaviors to new settings. Other studies [38,39] among
migrant Mexican women found that discrepancies in
patient expectations of US health service delivery and
differences between the US and Mexico in clinic staff
communication may reduce utilization of health services.
Strengths and Limitations
While there is a growing body of research regarding
migration and Mexican women’s health, few studies have
encompassed migrant and non-migrant perspectives among
women from a binational community. A major strength of
the current study is its contribution to a limited body of
health research conducted among migrant, indigenous
women from southern Mexico. In order to better address
362 J Immigrant Minority Health (2014) 16:356–364
123
the sexual health needs of migrant women in Mexico and
the US, it is important to consider their cultural beliefs and
how these women negotiate health care access. While
barriers to reproductive health reported by women in our
study may not be unique to this population, it was imper-
ative to explore barriers in order to discern potential dif-
ferences in comparison to non-indigenous Mexican
migrants about whom more is known. Furthermore, barri-
ers to reproductive health care that are common to both
indigenous and non-indigenous Mexican migrants may
require culturally relevant interventions for women in both
countries. A significant limitation to this study was the
small sample collected of Tunkasen
˜a women living in the
US While the aim and scope of the study was to explore
experiences among women in binational settings, future
studies that include larger samples of US residents are
needed to gather more representative data regarding bina-
tional experiences among women in these closely linked
US and Mexican communities. Our snowball sample was
insufficient in the amount of time we had to complete the
study to achieve the same number of interviews as in
Tunka
´s. While a diverse sample of Tunkasen
˜a women were
interviewed in both countries, findings from this study may
not be representative for all women from the region and
therefore cannot be generalized for this population.
Recruiter efforts to conduct recruitment in a variety of
settings, days of week and hours, however, afford confi-
dence in reaching a variety of women who may have dif-
ferent perspectives, which enrich study findings. In
addition, there was limited information collected on legal
status among women in the United States. This information
was difficult to determine or confirm, but may have been
useful to consider in the context of access to health services
for sexual health and related information. However, a
major strength of this study is its capacity to carry out in-
depth interviews on sensitive topics among vulnerable and
‘‘hard to reach’’ populations in binational settings.
Conclusion
This study contributes to improved understanding of sexual
and reproductive health within the context of migration,
both for women who remain in their rural community and
those who migrate transnationally. We found that gendered
power imbalances, socio-cultural expectations, and per-
ceived lack of trust of health systems shape these indige-
nous women’s sexual and reproductive health perceptions
and behaviors. We also observe that although the Oport-
unidades program has made inroads to improve access to
health care among women in rural regions of Mexico, there
remain perceived barriers among women to participation in
the program. As our study indicates, migration may further
complicate access to care as female migrants navigate new
health care environments. While women residing in the US
often relied on their partner’s employment to access health
benefits and care, many women reported access and utili-
zation of free or low cost health services in their commu-
nity. Socio-cultural factors, normative gender roles and
power imbalances often influence health-seeking behaviors
among women. In addition, transnational migration of
women or their spouses adds to the complexity of health
risks and negotiations regarding sexual health practices.
Our study findings can inform future research and inter-
ventions to reduce barriers to routine reproductive health
care among indigenous migrant and non-migrant women.
Acknowledgments The authors would like to acknowledge the
Tunkasen
˜o community both in Tunka
´s and in Anaheim and Ingle-
wood for their trust, participation and gracious hospitality. This work
was supported by the Research Program on Migration and Health
(Programa de Investigacio´ n en Migracio´n y Salud, PIMSA Cycle
2011–2012), the Health Initiative of the Americas, the University of
California, the Center for Comparative Immigration Studies at the
University of California, San Diego, and the Instituto Nacional de
Antropologı´a e Historia,Me´xico.
Conflict of interest The authors state no conflict of interest.
References
1. Consejo Nacional de Poblacio
´n [CONAPO]. Migration and
health. Mexican immigrant women in the United States. 1st ed.
ISBN: 970-628-959-3; 2010.
2. Leite, Angoa, Castan
˜eda, Felt, Schenker & Ramirez. Health
outcomes of Mexican immigrant women in the United States.
2013. Retrieved from: http://www.migrationinformation.org/
Feature/display.cfm?id=944.
3. Hirsch JS, Meneses S, Thompson B, Negroni M, Pelcastre B, del
Rio C. The inevitability of infidelity: sexual reputation, social
geographies, and marital HIV risk in rural Mexico. Am J Public
Health. 2007;97:986–96.
4. Hirsch JS, Mun
˜oz-Laboy M, Nyhus CM, Yount KM, Bauermei-
ster JA. They ‘‘miss more than anything their normal life back
home’’: masculinity and extramarital sex among Mexican
migrants in Atlanta. Perspect Sex Reprod Health. 2009;41:23–32.
5. Kendall T, Pelcastre B. HIV vulnerability and condom use among
migrant women factory workers in Puebla, Mexico. Health Care
Women Int. 2010;31:515–32.
6. Kessler K, Goldenberg S, Quezada L. Contraceptive Use, Unmet
Need for Contraception, and Unintended Pregnancy in a Context
of Mexico–US Migration. Field Actions Science Reports. The
journal of field actions; 2010.
7. Lindstrom DP, Hernandez CH. Internal migration and contra-
ceptive knowledge and use in Guatemala. Int Fam Plan Perspect.
2006;32:146–53.
8. Zambrana RE, Cornelius LJ, Boykin SS, Lopez DS. Latinas and
HIV/AIDS risk factors: implications for harm reduction strate-
gies. Am J Public Health. 2004;94:1152–8.
9. Erwin DO, Trevin
˜o M, Saad-Harfouche FG, Rodriguez EM, Gage
E, Jandorf L. Contextualizing diversity and culture within cancer
control interventions for latinas: changing interventions, not
cultures. Soc Sci Med. 2010;71(4):693–701.
J Immigrant Minority Health (2014) 16:356–364 363
123
10. Palacio-Mejı
´a LS, Lazcano-Ponce E, Allen-Leigh B, Herna
´ndez-
A
´vila M. Diferencias regionales en la mortalidad por ca
´ncer de
mama y ce
´rvix en me
´xico entre 1979 y 2006. Salud Pu
´blica De
Me
´xico. 2009;51:s208–19.
11. Sosa-Rubı
´SG, Walker D, Serva
´n E, Bautista-Arredondo S.
Learning effect of a conditional cash transfer programme on poor
rural women’s selection of delivery care in Mexico. Health Policy
Planning. 2011;26(6):496–507.
12. Secretaria de Desarrollo Social. Poder Ejecutivo: Decreto por el
que se reforma el diverso por el que se crea la Coordinacio
´n Nac-
ional del Programa de Educacio
´n, Salud y Alimentacio
´n como
o
´rgano desconcentrado de la Secretarı
´a de Desarrollo Social,
publicado el 8 de agosto del 1997. Diario Oficial. 2002. http://
oportunidades.gob.mx/Portal/work/sites/Web/resources/Archivo
Content/908/DECRETO_CREACION_OPORTUNIDADES.pdf.
13. Secretarı
´a de Desarrollo S (SEDESOL). Me
´xico [homepage on
the internet]. Mexico: SEDESOL; 2007. Available from: http://
evaluacion.oportunidades.gob.mx/.
14. McKee D, Todd PE. The longer-term effects of human capital
enrichment programs on poverty and inequality: Oportunidades
in Mexico. Estud Econ. 2011;38(1):67–100.
15. Montes JF. Perceived discrimination among indigenous and non-
indigenous Mexican-Americans living in the United States. Los
Angeles: Alliant International University; 2010.
16. Pan American Health Organization. Human rights & health:
indigenous peoples. 2008. Retrieved 3 Mar 2013 from www.
paho.org/English/dd/pub/10069_IndigPeople.pdf.
17. Holmes SM. Structural vulnerability and hierarchies of ethnicity
and citizenship on the farm. Med Anthropol. 2011;30(4):425–49.
18. Pan American Health Organization. Health in the Americas.
2007. Retrieved 8 Feb 2013 from www.paho.org/hia/
archivosvol2/paisesing/Mexico%20English.pdf.
19. McGuire SS. Agency, initiative, and obstacles to health among
indigenous immigrant women from Oaxaca, Mexico. Home
Health Care Manage Pract. 2006;18(5):370–7. doi:10.1177/
1084822306288057.
20. McGuire S, Martin K. Fractured migrant families—paradoxes of
hope and devastation. Fam Commun Health. 2007;30(3):178–88.
doi:10.1097/01.FCH.0000277761.31913.f3.
21. Fox J, Rivera-Salgado G (Eds.). Indigenous Mexican migrants in
the United States. La Jolla, CA: Center for Comparative Immi-
gration Studies, University of California-San Diego; 2004.
22. Maternowska C, Estrada F, Campero L, Herrera C, Brindis CD,
Miller Vostrejs M. Gender, culture and reproductive decision-
making among recent Mexican migrants in California. Cult
Health Sex. 2010/01/01 2009;12(1):29–43.
23. Connell RW. Gender and power. Stanford, California: Stanford
University Press; 1987.
24. Wingood GM, DiClemente RJ. Application of the theory of
gender and power to examine HIV-related exposures, risk factors,
and effective interventions for women. Health Educ Behav.
2000;27(5):539–65 The Official Publication of The Society For
Public Health Education.
25. Instituto Nacional de Estadı
´stica y Geografı
´a (INEGI) [National
Institute of Statistics and Geography]. Estadı
´sticas a Propo
´sito del
Dı
´a Mundial de la Poblacio
´n: Datos de Yucata
´n. Me
´rida, Yuca-
ta
´n. Aug 2012.
26. Muse-Orlinoff L, Lewin Fischer P, Introduction. In: Mexican
migration and the U.S. economic crisis. La Jolla: Center for
Comparative Immigration Studies at the University of California,
San Diego; 2010. p. 1–13.
27. Perez P, Reyes ML, Seo P, Muse-Orlinoff L. Sweet dreams and
bitter realities: nutrition and health care in Tunka
´s and the United
States. In: Mexican migration and the U.S. economic crisis. La
Jolla: Center for Comparative Immigration Studies at the Uni-
versity of California, San Diego; 2010. p. 217–235.
28. Barber SL, Bertozzi SM, Gertler PJ. Variations in prenatal care
quality for the rural poor in Mexico. Health Aff. 2007;26:w310–23.
doi:10.1377/hlthaff.26.3.w310.
29. Kendall T. Reproductive rights violations reported by Mexican
women with HIV. Health Human Rights Int J. 2010;11(2).
Retrieved 2 May 2013, from http://www.hhrjournal.org/index.
php/hhr/article/view/175/260.
30. Palacio-Mejı
´a, Rangel-Go
´mez, Herna
´ndez-Avila, Lazcano-
Ponce. Cervical cancer, a disease of poverty: mortality differ-
ences between urban and rural areas in Mexico. Salud pu
´blica
Me
´x vol. 45 suppl. 3 Cuernavaca Jan 2003. http://dx.doi.org/10.
1590/S0036-36342003000900005.
31. Crabtree BF, Miller WL. Doing qualitative research. Thousand
Oaks: Sage; 1999.
32. Glaser BG, Strauss AL. The discovery of grounded theory:
strategies for qualitative research. New York: Aldine de Gruyter;
1967.
33. Pulerwitz J, Michaelis A, Verma R, Weiss E. Addressing gender
dynamics and engaging men in HIV programs: lessons learned
from horizons research. Public Health Rep. 2010;125:282–92.
34. Frank R. International migration and infant health in Mexico.
J Immigr Health. 2005;7:1. doi:10.1007/s10903-005-1386-9.
35. McGuire S. Agency, initiative, and obstacles to health among
indigenous immigrant women from Oaxaca, Mexico. Home
Health Care Manage Pract. 2006;18(5):370–7.
36. Coffee M, Lurie MN, Garnett GP. Modeling the impact of
migration on the HIV epidemic in South Africa. AIDS. 2007;21:
343–50.
37. Comas-Diaz L. Cultural variation in the therapeutic relationship.
In: Goodheart C, Kazdin A, Sternberg RJ, editors. Evidence-based
psychotherapy: where practice and research meet. Washington,
DC: American Psychological Association; 2006. p. 81–105.
38. Chavez LR, Cornelius WA, Williams Jones O. Utilization of
health services by Mexican immigrant women in San Diego.
Women Health. 1986;11(2):3–20.
39. Kreuter MW, Lukwago SN, Buchholtz DC, Clark EM, Sanders-
Thompson V. Achieving cultural appropriateness in health pro-
motion programs: targeted and tailored approaches. Health Educ
Behav. 2002;30(2):133–46.
364 J Immigrant Minority Health (2014) 16:356–364
123
