Welcome everyone to the APAMSA AANHPI Health Issues Interview series, where we’ll be interviewing researchers, policymakers, community-based organizations, and other experts on health-related topics that affect the NHAAPI community. My name is Grant Wen and I’m the health advocacy director at APAMSA National. For this interview, I would like to welcome Dr. Kimara Gustafson. Dr. Gustafson works as a pediatrician at the University of Minnesota focusing on adoption medicine and has done research on children with special health care needs as well as racial and cultural identity development for children of transracially composed families.

I’m a practicing pediatrician up here in Minnesota, in the Twin Cities, specifically in Minneapolis, and I did medical school and residency here as well. I originally grew up in upstate New York, just north of Albany and then came out here for school. I have extended family in the area, so I have a little bit of a connection, but mostly came for school. I kind of always knew I wanted to do pediatrics. I was playing around with family practice or not, but ultimately kept coming back to pediatrics. But then within that, I really lucked out in that the University of Minnesota is unique. We have an adoption medicine clinic, there’s just a handful in the country, and this is definitely the one of the oldest and maybe most comprehensive, so I was able to do a rotation there, and eventually have been able to stay on as faculty. I practiced for a couple years in the community as a general pediatrician, but came back to be on faculty. And part of the reason that it’s something that I’m interested in is I have a personal connection. I was born in Korea, and then adopted as a young infant, when I was about seven months old. My parents are American, my mom is white, of Lutheran background from Minnesota. And then my dad is Jewish, and he grew up in Long Island in New York. So kind of a lot of different cultural aspects that have kind of come together as I was growing up, but it kind of makes up our family.

The clinic is over 30 years old. Originally, it was founded by my mentor, Dr. Dana Johnson, and essentially was founded out of necessity. He is a neonatologist by training, and when he was starting to kind of put together his family, he adopted a son from India. And at the time, his son was quite young and had a lot of issues that we think are common to lower resource areas, such as malnutrition, a lot of infectious diseases, and parasites. And then had kind of sequelae from that in terms of delayed development and growth. Being the wise clinician he was, he looked around to see who he could go to in order to navigate this for his son, but he realized that didn’t really exist. 

So he put it together and essentially formed his own clinic. Historically, the clinic has been more geared towards international adoptees. What’s kind of nice and unique about the clinic is that we’ve been able to follow the trends of adoption, which vary based on state department and geopolitical events. So there are trends in international adoption. The last 15 years the trend has been just overall there’s less international adoptees, so our clinic has started to kind of pivot a little bit. We still see children that are internationally adopted at various stages in their adoption, but now we’ve really expanded on the domestic and foster care side. I would say on any given day, I would do probably 70%, maybe even 80%, domestic and foster care medicine, and then 20 to 30% what people think of stereotypically with adoption (international).

We used to think adoption was more of a static event. If you were adopted, with nature versus nurture, nurture would take over. If you had the right environment, then any potential risk factors that you experienced early in life would be overcome, or potentially overcome. 

Now research has evolved, especially piggybacking on the work of Felitti and his group in California with the adverse childhood experience (ACE) study. We know that ACEs, even if the ACE is theoretically buffered by the fact that they were adopted into a middle class family with resources, put individuals at higher risk for health issues like heart attacks, cardiovascular disease, hypertension, diabetes. Similar to that, we know that ACEs may need to be proactively addressed and more proactively buffered than what we previously thought or had hoped. In foster care, international and domestic adoption, if at any point a child has a caregiver transition, then there are long lasting health effects, even if a child is adopted domestically at birth. We used to think if the adoptive family comes to the hospital and takes a child home, they’re a blank slate, but now we know there’s so much influence from the prenatal environment. And so anytime you have a caregiver transition, that potentially can influence or have implications in that person’s ongoing health. What I’m interested in is the next step. We know that ACEs are a thing, but how do we buffer? It’s not, it’s not really fair or helpful to someone to give them just an ACE score. Ideally, we would give an ACE score and then try to help mitigate that. Does it mean that you need additional screenings? Does it mean that you need additional support in terms of how to buffer stress, because maybe your body doesn’t handle stress as well as your peers?

Specifically for the kids that I work with, by and large, they are transracially placed. Not to get too much into the geopolitical side of it, but both internationally and domestically, the families that children are being placed with usually have better financial resources. It’s very expensive to adopt, and it’s still expensive to adopt through the foster care system or domestic adoption, and so the current predominant adoptive family consists of middle class white parents, and the children that are in the system to be adopted are usually brown, black or NHAAPI children. There are kin adoptions, and then on the domestic side, so you’re being adopted within the family, but even with kin options, it’s not necessarily that they are going to be the same race or culture. Often we’ll see a kin adoption where maybe the adoptive family still identifies as white, but the child is mixed race, but gets adopted to the white side of the family. But they’re the only black or brown kid in the family. 

What I’m interested in is what we’re learning about racial trauma. Do we think of racism as an ACE? My research question is—-for parents who are not same-race matched, do they have the tools and information that would best set everyone up to try to buffer that racism? Historically they haven’t. So how do we help them to improve on that? Historically, you hear anecdotally, within the adoption community, that parents have said, “Well, I don’t think of you as being different. I just think of you as my kids.” The origin of that is very admirable, but it usually results in the kid feeling canceled or minimized to some degree, because they’re thinking, “Why am I having these racial racist experiences that my parents don’t believe are happening?”.  Or they just say that the kid is making too big of a deal about it and that they shouldn’t let it bother them. The other thing is that sometimes, unfortunately, it’s coming from within the family, either the immediate family or extended family. 

I would say that parents don’t have intent to cause harm to their child, but they just might not have the knowledge and the tools to really help to address it. And in general, with everything, if we’re uncomfortable about something, we kind of just try to avoid it. We’ve come a long way in the adoption world, but there are still questions about many things. For domestic adoption, let’s say, I still get questions where parents are like, when do we tell them that they’re adopted? And from my standpoint, I say as early as possible, but some families feel that they don’t know how to have this conversation. So the default is they don’t, and then it gets to be kind of this elephant in the room, like, now they’re 8 or 10 or 12. And they don’t know how to really explain it. Whereas we know by research that if you had those conversations from a younger age, it wouldn’t have potentially become such a big thing.

I think it’s been great because there’s been a lot more resources out there on how kids perceive race and at what age do we start talking about it. We know by research that kids as young as six months old will perceive physical differences. They show a preference for a caregiver who looks like their primary caregiver. So, if you have a translationally composed family, and the infant is black or Latinx, then the infant will develop a preference for other white adults. We also know that if you go up developmentally, children of color often will start to have a social preference for the dominant or the majority color when they get to interact in a mixed group. 

It’s not uncommon that children in that kindergarten or preschool will say, “I wish I had blonde hair, I wish I had light skin.” If you have a family that’s the same race, then when the kid goes home,theoretically, the parents would say, “Oh, no, you’re beautiful the way you are. You look just like dad and mom.” So they have that representation and buffer within the home. So then the question is, what do you have when you have a transracial family, and you don’t have that kind of reflection in your home or in your family? 

So if you’re in school, and you’re five or six, and you say, “Oh, I wish I looked like Elsa,” you go home, and everyone in your house looks like Elsa, except for you. Then it starts to impact your self esteem. In adolescence, you’re developmentally supposed to be kind of figuring out who you are and how you fit in your environment. For kids who are adopted or in foster care, a lot of those questions are often answered either because they reconcile with those around them, or it’s in opposition. Everyone’s different, but that time can be really stressful, in the sense that they start to really think about where they come from, and if they’re, like, “I don’t know where I came from.” Oftentimes this has to deal with the narrative around the first or origin family, what some people will call birth families. The adoptive parents, not with the intent to be harmful, will often say, “Oh, your birth mom couldn’t keep you because she was too young, or because she had health issues, substance use.” It’s not uncommon that I’ll have teens who start to think “Oh, is something going to happen to me?”—-because they get so much information from the community or the media and school about genetics and things that are inherited. I actually had one teen who said she was worried she was going to get pregnant, although she’s not sexually active. She was really worried she was gonna get pregnant because that’s what happened to her mom.

The other thing I see is that racial or cultural identity gets put on the back burner, because they’re just dealing with all this other stuff. And then it’s not uncommon that they get to college, and all of a sudden they get to meet other people of their race, particularly if they’re coming from a homogenous community. Unfortunately, they often end up getting rejected from that community too, because they’re like, “you’re not a real Asian, or you’ve never used chopsticks before.” They get stuck in this kind of catch 22 and feel rejected by both. And keep in mind this is all happening in the midst of the larger issues of identity. We know that mental health issues are more prevalent within adoptees, and if these things are left unaddressed or undersupported, they will impact self concept, self esteem, and contribute to depression and anxiety.

I’m actually in the process of trying to create formalized anticipatory guidance for promoting racial and cultural identity. Historically, we’ve thought of that as something that happens in the home. But again, like, what happens if your home doesn’t match? Most parents want to support their kids, but in the absence of knowing how to, they might not. 

Going back to the research, if we know that kids are starting to identify different races and cultures as early as infancy, then similar to anticipatory guidance, where you talk about vaccines, water safety, wearing seatbelts, you try to have the conversation to tell parents that their kids are recognizing that they look different than their siblings or their peers. This involves helping the parents have a developmentally appropriate conversation and making sure that they have materials that are able to best represent the child’s needs.

The hope would be that if the child feels like this is something that their parents want to support, then they feel empowered to self identify. When they get to adolescence, they’ll be able to maybe make connections, so that this process doesn’t get deferred until the young adult stage. For teenagers, even if you’re not adopted or translationally placed, junior high is kind of that time where you’re like, “Okay, who’s where, who’s my group.” I feel like for these kids, they often just stay with the group of their parents instead of finding their own group, and then what happens is when they get to college, it gets turned on its side. This exploration doesn’t have to replace or supersede their family culture, but can kind of intersect a bit better. Research shows that when kids are younger, they are buffered usually by their parents when they experience stress, but when they get older into adolescence, the buffer for stress is usually their peers. So we hope that we’re able to give them the tools to find that friend group that they really feel can buffer. For instance, if they experience some sort of racism, then maybe they have enough peers who are like, “yeah, that sucks,” or “this is what I do when that happens,” instead of if their peers are all the same group as their family and these problems get dismissed. Or perhaps the racism coming from that peer group itself.

I have personal experience with this, but I think this last year has been really interesting in that there’s been a lot of discussions within the adult NHAAPI adoptee group of where we fit in. I was actually talking to Dr. Jonathan Tolentino, a med-peds doctor in Miami, about this concept that within the black community, parents will have the talk with their kids about ,”here’s how society is going to view you, they’re going to view you as an angry black kid.” I don’t have direct experience, but just from talking to friends, and that it’s not as common that Asian parents will have that talk with their kids. And if anything, they try to kind of do as much as they can to kind of buy into that kind of concept of assimilation. Like, yes, we are going to be the model minority. Yes, we are always going to excel, and through our kind of success, you’ll see that we are worthy of acceptance. 

This last year, the young NHAAPI generation is like, “you know what, if we strive to fit ourselves into the model minority myth, and we’re still going to experience racism and discrimination, why should we try to fit ourselves into that?” Because it’s obviously not working. Within the NHAAPI adult adoptee community, now, is this question about where we fit in. Because, historically, the media has tried to pit everyone against each other. The adult adoptees feel like, “well, we look Asian, but we were raised culturally white, so we have some privilege that even Asian Americans might not have due to the proximity to our parents and the white community. And we can serve as a bridge.”

There’s also been discussions where, and this is a gross generalization, but historically in certain Asian countries, there is a preference for lighter skin, and that prejudice is maybe more present in the parental generation. What’s interesting in the adult adoptee community is that there are some parents who are very comfortable in terms of issues about race and racism. Sp for many adoptees, they can say that they lived in a very diverse community, and at least from the home, they didn’t get some of that kind of teaching that maybe had racist overtones. So I think it’s an interesting place to be, because I’ve seen a lot of mobilization and coming together around these issues and feeling a bit more comfortable to occupy space and try to be advocates in all these different ways. 

In general, I think your generation is kind of firing away much farther ahead because I think you’re just like, “we’re tired of having to deal with some of the microaggressions or things that are considered micro but don’t feel micro,” and “we’re tired of having to suck it up and be told that we should just let it roll off our back,” whereas I think the older generations are, like, “don’t rock the boat.” This is also one of the reasons I love working with trainees, because you guys help keep me honest. And also I learn so much from you guys in learning that sometimes you have to upset people to get the change that you want.

I: I wanted to thank you so much for taking time out of your schedule to share with us. This has been a super enlightening talk. I knew next to nothing, essentially, about adoption medicine. But I think I’ve learned so much through this conversation, and I hope that our listeners will as well.

G: Thank you so much for having me and just let everyone know if anyone has questions for me. I’m always available, you can email me. Thank you so much for this opportunity.