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Title: Cross Cultural Medicine at Home and Abroad 2007


1
Cross Cultural Medicine at Home and Abroad 2007
  • Gregory Juckett, MD, MPH
  • Associate Professor of Family Medicine
  • West Virginia University
  • gjuckett_at_hsc.wvu.edu

2
America is Changing
  • Global Village We now live in multi-cultural,
    multi-ethnic societies both at home and abroad
  • By 2050, almost half of U.S. population will be
    comprised of minorities
  • Todays Tossed salad vs. Yesterdays Melting
    Pot
  • U.S. minority populations are quite diverse and
    not limited to urban areas

3
What is Culture?
  • Beliefs and behaviors that are learned and shared
    by members of a group
  • World view of a culture may have a profound
    effect on healthcare e.g. fatalism
  • Cultural Competence (knowledge, awareness,
    respect for other cultures) is now an necessary
    clinical goal for which we should strive
  • Cultural Sensitivity/Humility caring awareness
    which tries to avoid giving offense to those of
    another culture (achievable)
  • Importance of R-E-S-P-E-C-T

4
Cross Cultural Terms
  • Stereotyping (bad) the mistaken assumption that
    everyone in a given culture is alikeclosed to
    exceptions (ending point)
  • Generalizing (ok) awareness of cultural
    normsopen to educational, generational
    differences (starting point)
  • Ethnocentrism the usually unconscious conviction
    that ones own culture should be the normthis is
    almost a universal human trait
  • Racism the misguided belief that ones own
    race/ethnicity is superior to that of others
  • Discrimination treating people differently due
    to prejudice may be unconscious you people

5
Remember that every person is unique
6
Cultural Dynamics Influencing the Clinical
Encounter
Scott Cottrell
7
Cultural Dynamics Influencing the Clinical
Encounter
Scott Cottrell
8
Cultural Dynamics Influencing the Clinical
Encounter
Scott Cottrell
9
Cultural Dynamics Influencing the Clinical
Encounter
Scott Cottrell
10
The Cross Cultural Interview Exam
  • Developing Trust (view this as an investment of
    time that pays you back later) and listening to
    patient
  • Eliciting pertinent history always ask
    (non-judgmentally) what alternative therapies
    your patient is using and what providers have
    they already seen (hierarchy of care)
  • Understanding how the illness is viewed ( its
    meaning) and acknowledging differences in
    worldview
  • Culturally Sensitive Physical Examination
  • Explaining diagnosis to patient and family in
    understandable terms
  • Negotiating treatment plan and follow-up have
    patient repeat your instructions and have them
    written down (if patient or family member is
    literate) Teach-Back

Knowledge of language and culture Effectiveness
11
LEARN Model for Cross Cultural Interview
  • Listen to the patient and the family's concepts
    of the illness.
  • Explain your medical diagnosis in understandable
    terms.
  • Acknowledge differences (and similarities) in
    cultural perspectives.
  • Recommend your diagnostic and therapeutic
    approaches.
  • Negotiate all areas of care.
  • Reference A teaching framework for
    cross-cultural health care.
  • Application in family practice.
  • West J Med. 1983 Dec139(6)934-8.

12
ETHNICS Mnemonic a framework for culturally
appropriate care
  • Explanation why do you have this problem?
  • Treatment what have you tried for it?
  • Healers who else have you sought help from?
  • Negotiation how best do you think I can help
    you?
  • Intervention this is what I think needs to be
    done.
  • Collaboration how can we work together on this?
  • Spirituality what role does spirituality play in
    this?

Kobylarz, Heath, Like. The Etnics Mnemonic A
Clinical Tool for Ethnogeriatric Education. J Am
Geriatr Soc 2002 50 1582-89
13
The Spirit Catches You and You Fall Down by
Anne Fadiman
  • Poignant story about a Hmong refugee child from
    Laos with intractable epilepsy
  • Clash of Hmong-U.S. health care cultures with
    difficult consequences for all involved
  • Asks what questions could have led to better
    cross cultural understanding?
  • Should be required reading in medical schools

14
Kleinman Cross Cultural Interview
  • What do you call the problem?
  • What do you think has caused the problem?
  • Why do you think it started when it did?
  • What do you think the illness does? How does it
    work?
  • How severe is the sickness? Will it have a long
    or short course?
  • What kind of treatment do you think is necessary?
    What are the most important results you hope to
    receive from this treatment?
  • What are the chief problems the sickness has
    caused?
  • What do you fear most about the sickness?
  • Adapted from Kleinman A, Eisenberg L., Good B.
  • Culture, Illness and Care Clinical Lessons from
    Anthropologic and Cross-Cultural Research
  • Annals of Internal Medicine 1978 88 251-258.
  • Always ask about alternative therapies, herbs
    and supplements the
  • patient may be usingif you dont ask, the
    patient is unlikely to volunteer
  • this information.

15
Applying Kleinman Questions and LEARN
Center for the Health Professions
Information
Example
16
Applying Kleinman Questions and LEARN
Example
Information
Center for the Health Professions
17
Applying Kleinman Questions and LEARN
Information
Example
Center for the Health Professions
18
Cross Cultural Interview
  • Establishing trust (and understanding each other)
    may take much more timeoften mistrust is
    inherent
  • Eye contact issues may be avoided among less
    Westernized Asians (unless of equal
    status/gender)
  • Personal space/Touch issues (low touch)
  • Gender issues and casual touch
  • Facial expressions/Body Language e.g. smiling as
    embarrassment instead of happiness
  • Time and Punctuality Agrarian rubber time vs.
    Industrial time

19
Interpreter Pitfalls Family or Friends
  • Limits scope of inquiry unlikely to share
    intimate or embarrassing details (family
    violence, sex, mental illness)
  • Lack of training medical terminology may be
    either misunderstood or mistranslated out of
    embarrassment
  • No confidentiality guarantee
  • Sometimes family member has a personal agenda
  • Better to use trained medical interpreters if
    available but if unavailable must recognize the
    limitations
  • Try to speak directly to the patient, not to the
    interpreter

20
Name Conventions
  • Best to use formal title (especially with older
    patients) until given permission to be
    informalnever assume its ok
  • Chinese and SE Asian names are usually written
    and pronounced backward Surname precedes given
    name if not already U.S. acculturated e.g.
    Xumiao is Dr. Xu. Married women usually dont
    take their husbands name.
  • Latino names complex surnames usual (fathers
    name precedes mothers) e.g. Senorita Maria
    Sanchez Rodriguez becomes Senora Maria Sanchez de
    Gutierrez (usually Senora Gutierrez) after she
    marries Senor Gutierrezmothers name is usually
    dropped some Latinas just retain their maiden
    name however or adopt U.S. customs
  • Marias children will go by Gutierrez- Sanchez
  • Don and Dona indicate respect for older Hispanic
    patients
  • If in doubt, just ask How do you wish to be
    addressed?

21
Language and Body Language Signals
  • Embarrassment or respect prevents the asking of
    many necessary questions
  • Patients will say they understand when they
    really have no clueinstead have them repeat what
    you want them to do
  • Nodding vigorously may indicate respectful
    attention but not agreement or understanding!!!
  • Dont confuse Indian head wagging with
    disagreement! It means I hear what youre
    saying.
  • Speak slowly and simply but not loudly (unless
    your patient really is deaf!) Short sentences!
  • Eye Contact in non-western cultures may indicate
    disrespect of authority and/or sexual interest
  • Avoid idioms and dont use negative queries You
    dont or you wouldnt mind if)

22
Culturally Appropriate Gestures
  • Beckoning should not be with index finger
    (S. America, Asia) since this is either
    reserved for dogs or considered very rude.
    Instead the palm of the hand should be held down
    and all fingers used
  • Displaying your feet is insulting in Asia never
    touch anyone with your feet
  • Patting a child on the head is an insult in SE
    Asia since the head, as the seat of the soul, is
    sacred
  • Thumbs up sign is the same as the U.S. middle
    finger in Iran

23
Reciprocity and Gifts
  • In many cultures, it is required to demonstrate
    ones gratitude with a gift and its refusal may
    well cause offense
  • However, gifts are often offered to ensure best
    possible care for the patient (a soft bribe for
    the care-giver!)
  • If gift is inappropriate (e.g. money), suggest
    an alternative (such as food) that could be
    shared with staff

24
Giving Bad News
  • In many other cultures, it is customary to first
    inform the family and let them decide if and when
    the patient should be informedviolates U.S.
    HIPAA regulations
  • Anger against the provider is often expressed if
    this custom isnt followed as it is felt that
    giving someone a bad prognosis not only takes
    away any hope but also becomes a self-fulfilling
    prophecy.
  • At least in the U.S., ask the patient how they
    would like their family involved. Explain to the
    family that informing the patient first is the
    standard U.S. practice

25
African-American and African Immigrant Culture
  • Historically the largest U.S. minority but
    recently replaced by Hispanics (some
    African-Americans are also Hispanic)
  • 12.3 U.S. population22 live in poverty and
    life expectancy 5.9 y less (2x stroke death, 36
    B w/ HTN vs. in young black men 15-34) Health Care Inequity
    and Race
  • Most are long term U.S. residents but immigration
    from Caribbean and African countries is
    increasing (immigrants have better life
    expectancies than native blacks!)
  • Mistrust of white institutions common place (and
    sometimes historically justified e.g. Tuskegee
    syphilis experiments)reluctance to donate organs
  • Conspiracy theories regarding HIV, birth control
    common in some areas

26
African-American Folk Conditions
  • Falling Out stress-related collapse (inability
    to move but normal senses) preceded by
    dizzinessmay be confused w/ stroke
  • Bad blood suggests blood contamination,
    usually by syphilis (or other STI)
  • Slang terms miseries pains, low blood
    anemia, sugar diabetes
  • High blood while this is may be slang for HBP,
    it may also refer to hot, thick blood that
    rises in the body for extended periods and its
    treatment involves cooling and thinning the blood
  • High-pertension episodic but temporary
    shooting up of blood to the head which then
    resolves (over 3.3 x as likely to be non-adherent
    as a patient who believed in biomedical
    hypertension) MMWR Oct 12, 1990 39
    (40) 701-704

27
The Why and How of Non-Adherence
  • A 65 year old African American woman with
    hypertension is noted to have a BP of 180/105 on
    follow up even though she had been well
    controlled on the last visit. When asked if she
    was still taking her medicine, she responded
    Those things are supposed to lower the blood,
    arent they? So I just cut them in half and only
    took them for another week , then threw them
    away.
  • Why did she stop taking her medicine after being
    told that the pills were working well?
  • Adapted from Culture and the Clinical
    EncounterRena Gropper

28
Hypertension Control in Blacks
  • More sodium sensitive than white population
  • Thiazides are good first-line therapy
  • Long-acting calcium channel blockers also helpful
    for hypertension
  • Beta-blockers may be less effective than in white
    population
  • Blacks and Asians have 3- 4x greater risk of
    angioedema from ACE Inhibitors compared to whites
  • Controversy over race-specific marketing of
    pharmaceuticals

29
Hispanic or Latino Culture
  • Now the largest, fastest growing U.S.minority
    (12.5)not just in S.W. USA, NYC, and Florida
  • Many nationalities and subcultures Mexican,
    Puerto Rican, Cuban, Brazilian, Guatemalan,
    Colombian
  • Machismo vs. Marianismo dominant male culture
    women traditionally submissive
  • The Importance of Balance in Health Cold/Hot
    Duality similar to the Yin/Yang of Asian Medicine

30
Issues in Latino Medicine
  • Confianza/Personalismo necessary trust or
    rapport should be established prior to the
    medical part of the interview
  • Some Latinos resent Americans for usurping the
    name of both continentsthey are Central or South
    Americans whereas Gringos are North Americans
  • Personal space is less, sometimes resulting in a
    dance where the gringo retreats (and therefore
    is perceived as being cold)
  • Being a little fat gordito is often perceived
    as healthy While MexicanAmericans have up to 5x
    as much type 2 diabetes mellitus as non-Hispanic
    whitesstill the risk of coronary death is lower
    (The Latino Paradox)
  • More relaxed concept of timepeople are more
    important than schedules

31
Latino Folk Medical Diagnoses
  • Mal de ojo (evil eye)
  • Empacho (GI blockade from overeating)
  • Susto (magically induced fright w/ soul loss)
  • Mal puesto (unnatural illness due to sorcery)
  • Ataque de nervios (anxiety attack)
  • Frio de la matriz (frozen womb)
  • Caida de la mollera (fallen fontanelle)
  • Fatiga (shortness of breathnot just fatigue)

32
Case Study Upside Down Baby
  • A nurse visiting a Mexican family was shocked to
    see a baby being suspended upside down over a
    bowl of steaming water and it appeared as though
    the babys head was about to be dipped in.
  • What should she do?
  • Dx Caida de la mollera (fallen fontanelle)
  • Sx irritability, diarrhea (r/o dehydration)
  • Adapted from Culture and the Clinical
    EncounterRena Gropper

33
Hispanic Folk Medicine
HOT
COLD
  • Hypertension
  • Diabetes mellitus
  • GERD and PUD
  • Pregnancy
  • Sore throat/Infection
  • Susto
  • Mal de Ojo
  • Bilis
  • URI colds
  • Pneumonia
  • Menstrual cramps
  • Colic
  • Headache
  • Cancer
  • Frio de la Matriz
  • Empacho

Key Distinction of natural vs. supernatural
causation Mal natural vs. Mal puesto
34
Vitamins Stopped
  • A Puerto Rican family brought in their 4 month
    old with diaper rash. After a prescription was
    written, the nurse-practitioner asked if any more
    vitamin drops were needed. Ive not used up the
    drops from before. As you can see, my baby has a
    rash so I stopped giving them to him. I try to
    take good care of my baby
  • Why were the drops discontinued?
  • Another example is a Latinas reluctance to take
    iron supplements during her pregnancy
  • Adapted from Culture and the Clinical
    EncounterRena Gropper

35
Hypertension a hot condition
  • Hot etiology thick blood, caused by susto (fear)
    or corajes (anger)
  • May be viewed as a temporary rather than
    long-term conditiontherefore patients may not
    adhere to long-term therapy
  • Cool treatments lemon juice, passion flower tea,
    zapote blanco
  • Hot diseases are always treated with cool
    remedies and vice versa but what constitutes
    hot or cold varies by cultural tradition

36
Peruvian Healing
Curandero--Brujo
Curandero Herbalist
sapo
cuyes
37
Asian Culture
  • Third largest U.S. minority (3.6) but multiple
    nationalities Chinese, Japanese, Korean, Hmong,
    Vietnamese, Thai, Cambodian, Filipino (many
    differences)
  • Hierarchical family structure
  • Poverty is still a problem for many Asians
    although there is usually a strong family
    commitment to work, education and advancement
  • Accommodation rather than assertiveness valued
    yes may really mean no in some instances (you may
    also be told what your patient thinks you want to
    hear)
  • Face (personal honor) issues very important so
    be sensitive to thisalways provide a
    face-saving way out

38
The Stigma of Mental Illness
  • Stigma of mental illness is often
    devastatingviewed as a disgrace to the Asian
    family and seldom discussed
  • Somatization is therefore common and depression
    must be suspected early and dealt with tactfully
    as an imbalance
  • Mental illness often presents with physical
    complaints!
  • Counseling viewed by many Asians as suitable only
    for the hopelessly mentally illunlikely to
    follow through
  • Multiple Asian culture bound psychiatric
    presentations Amok (violence w/ dissociation),
    Hwa-byung (suppressed anger w/ abdominal fullness
    or mass), Tajin kyofusho (intense fear of being
    offensive e.g. imaginary body odor), Latah
    (hypersensitivity to fright with trance-like
    behavior)

39
Chinese and Asian Illnesses
  • Wind Illness fear of being cold or exposed to
    wind which would cause of loss of yang
  • Shen kui anxiety, panic, sexual complaints
    attributed to semen loss (believed to be
    life-threatening by patient)
  • Hwa-Byung (Korea) epigastic pain attributed to
    an abdominal mass that pt believes will result in
    deaththought to be caused by unresolved anger
  • Taijin Kyofusho (Japan) pathological fear about
    embarrassing others by an awkward behavior or a
    physical problem such as body odor (social
    phobia)

40
Health Care Concerns for Asians
  • A loud tone of voice (or a friendly slap on the
    back) may be misinterpreted by some Asians as
    showing hostility
  • Correcting or even joking about a personal
    mistake in a public setting may cause intolerable
    loss of face
  • The left hand is often used for personal hygiene
    and is considered uncleanif medical samples or
    business cards are offered with the left hand,
    they may be discarded.
  • Ice water is often refused (upsets hot/cold
    balance)warm or hot water preferred, esp. during
    Chinese sitting month after delivery
  • Avoiding Foot Contact feet are unclean and
    should not come in contact with another or be
    elevated/in view shoes should be removed before
    entering homes

41
The Bruised Baby
  • A Vietnamese mother brought in an infant girl for
    acute respiratory infection manifested by cough
    and fever. Physical examination also showed
    numerous bruises on her chest and back.
  • When the childs mother was asked about these,
    she became embarrassed and changed the subject.
    When the matter was pressed further, the mother
    attributed these bruises to the grandmother.
  • What should be done?

Adapted from Culture and the Clinical
EncounterRena Gropper
42
Coining
  • Coining is a common Asian healing practice
  • Coining is used for conditions associated with
    "wind illness". It is also used with a wide
    variety of febrile illnesses and for stress
    related symptoms (headache, muscle aches and
    pain, and fatigue).
  • The practice produces linear petechiae on the
    chest and back which resolve over several days.
  • It is believed that the bruises bring out the
    wind illness and that their manifestation
    confirms that the disease was present.

43
Treatment of Wind-Cold
Coining in Cambodia -Debra Coats
44
Herbs
Cupping in China G. Juckett
45
Mongoloid Spots
  • Mongoloid spots are common in children from many
    racial backgrounds. Patches of dermal
    melanocytosis are found in the majority of Asian,
    Latino and Black infants. Although they are
    often seen in the lumbosacral /gluteal areas they
    are not limited to those regions.
  • Mongoloid Spots need to be distinguished from
    bruises of child abuse. Compared to a bruise they
    are more uniform in skin color, their borders are
    better defined, there is no induration or
    tenderness and they are stable over time.

The Influence of Culture and Pigment on Skin
Conditions in Children-Dinulos and Graham
46
Moxibustion Scars
Sometimes may be confused with physical abuse
(cigarette burns)
Photo by Debra Coats--Cambodia
47
10 Rules of Thumb in Cross-Cultural Medicine
SUMMARY
  • Allow more time for cross-cultural visits
  • Use formal address until invited to do otherwise
  • Develop trustnote that intrusive questions by
    some of your patients may be a way of determining
    if they can trust you
  • Try not to rely on family/friends as interpreters
    if at all possible
  • Ask about the use of cultural therapies and
    herbsif you dont ask, they probably wont tell
  • Ask about how the illness began and how the
    patient perceives it
  • Hesitation (or discomfort) is often indicative of
    hitting an invisible cultural wall
  • Ask the patient to repeatin their own wordsyour
    instructions to them rather than ask Do you
    understand?
  • Treat your patients the way they would like to be
    treated not necessarily the way you would like to
    be treated. However you are not obligated to meet
    unreasonable demands
  • Negotiate your treatment plans, acknowledging
    cultural differences

Adapted in part from Culture and the Clinical
Encounter by Rena Gropper
48
Benefits of Improving Cross-Cultural Skills
  • Better Outcomes much better patient adherence
    results if your instructions are culturally
    relevant non-adherence may be due to medication
    side effects, poverty, depression, lack of
    understanding, conflict w/ traditional therapies
  • Improved Access to Care
  • Reduce Health Care Disparities
  • Awareness of the hazards and benefits facing your
    patients from traditional care givers
  • Know what aspects of traditional care can be
    adapted to your healing setting
  • Know what needs to be rejected due to danger to
    either spiritual or physical health

49
Books on Cross-Cultural Medicine
  • Culture and the Clinical Encounter an
    Intercultural Sensitizer for the Health
    Professions by Rena C. Gropper Intercultural
    Press, Inc., Yarmouth, Maine 1996 (case studies)
  • Caring for Patients from Different Cultures
    Case Studies from American Hospitals by Geri-Ann
    Galanti University of Pennsylvania Press,
    Philadelphia 1997
  • Cross-Cultural Medicine edited by JudyAnn Bigby
    American College of Physicians, Philadelphia 2003
  • Cultural Diversity in Health Illness 6th Ed.
    by Rachel E. Spector Pearson/Prentice Hall, Upper
    Saddle River, New Jersey 2004
  • Transcultural Health Care a culturally
    competent approach 2nd Ed., edited by Larry D.
    Purnell, Betty J. Paulanka. F.A. Davis Co.,
    Philadelphia 2003
  • Pocket Guide to Cultural Assessment, 2nd Ed., by
    EM Geisler, St. Louis, Mo. Mosby, 1998
  • The Spirit Catches You and You Fall Down Anne
    Fadiman

50
Website Resources Cross-Cultural Medicine
  • Culture Clues Russian, Latino, Albanian,
    Vietnamese, Korean, African-American information
    sheets http//depts.washington.edu/pfes/cultureclu
    es.html
  • EthnoMed Univ. of Washington website with many
    cultural profiles and resources

    http//ethnomed.org
  • Culture Grams fee for service online information
    by country (limited free information)

    http//www.culturegrams.com/
  • The Providers Guide to Quality and Culture
    http//erc.msh.org/qualityculture
  • Resources for Cross-Cultural Health Care
    http//www.diversityrx.org
  • Physician Toolkit Curriculum Univ. of Mass
    Medical School March 2004 http//www.omhrc.gov/ass
    ets/pdf/checked/toolkit.pdf
  • Cross Cultural Medicine in American Family
    Physician 12/1/05
  • http//www.aafp.org/afp/20051201/2267.html

51
Web-based Interpreter Services (fee involved
for first three)
  • Language Line www.languageline.com
    (1-800-628-8486)
  • Cyra-Com www.cyracom.net
  • American Translators Association www.atanet.org
  • Babel Fish (Altavista) translates blocks of text
    http//babelfish.altavista.com/

52
Lost in Translation-1
  • Coors put its slogan, "Turn it loose," into
    Spanish, where it was read as
  • "Suffer from diarrhea."
  • When Gerber started selling baby food in Africa,
    they used the same
  • packaging as in the US, with the beautiful baby
    on the label. Later they learned that
  • in Africa, companies routinely put pictures on
    the label of what's inside, since many people
    can't read English.
  • The name Coca-Cola in China was first rendered as
    Ke-kou-ke-la.
  • Unfortunately, the Coke company did not discover
    until after thousands of
  • signs had been printed that the phrase means
    "bite the wax tadpole" or "female horse stuffed
    with wax" depending on the dialect. Coke then
    researched 40,000 Chinese characters and found a
    close phonetic equivalent, "ko-kou-ko-le," which
    can be loosely translated as "Happiness in the
    mouth."
  • In Taiwan, the translation of the Pepsi slogan
    "Come alive with the Pepsi
  • Generation" came out as "Pepsi will bring your
    ancestors back from the
  • grave."

53
Lost in Translation-2
  • Scandinavian vacuum manufacturer Electrolux used
    the following in an
  • American ad campaign "Nothing sucks like an
    Electrolux."
  • When General Motors introduced the Chevy Nova in
    South America, it was
  • apparently unaware that "no va" means "it won't
    go." After the company
  • figured out why it wasn't selling any cars, it
    renamed the car in its Spanish markets
  • to the Caribe.
  • Ford had a similar problem in Brazil when the
    Pinto flopped. The company
  • found out that Punto was Brazilian slang for
    "tiny male genitals." Ford
  • pried all the nameplates off and substituted
    Corcel, which means horse.
  • When Parker Pen marketed a ballpoint pen in
    Mexico, its ads were supposed
  • to say "It won't leak in your pocket and
    embarrass you." However, the
  • companies mistakenly thought the Spanish word
    "embarazar" meant embarrass. Instead the ads said
    that "It won't leak in your pocket and make you
    pregnant.
  • In Chinese, the Kentucky Fried Chicken slogan
    "finger-lickin' good"

54
Lost in Translation-3
  • Chicken-man Frank Perdue's slogan, "It takes a
    tough man to make a tender
  • chicken," got terribly mangled in another Spanish
    translation. A photo of
  • Perdue with one of his birds appeared on
    billboards all over Mexico with a caption
  • that explained "It takes a hard man to make a
    chicken aroused. Or, my personal favorite it
    takes a virile man to make a chicken pregnant.
  • Hunt-Wesson introduced its Big John products in
    French Canada as Gros Jos
  • before finding out that the phrase, in slang,
    means "big breasts." In this
  • case, however, the name problem did not have a
    noticeable effect on sales.
  • You are invited to take advantage of the
    chambermaid.from a guest directory in a
    Japanese hotel (1991)
  • Japan's second-largest tourist agency was
    mystified when it entered English-speaking
    markets and began receiving requests for unusual
    sex tours. Upon
  • finding out why, the owners of Kinki Nippon
    Tourist Company changed its
  • name.
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