White Book

Specific populations - Chapter 17

Working with migrant and refugee communities

‘Planning a safe pathway for migrant individuals requires additional care, as social and community isolation can be extreme. The caseworker or a GP may be their only safe contact.’

Key messages

  • Nearly half the Australian population were born overseas or have at least one parent born overseas, and 21% of Australians speak a language other than English at home.1
  • Some people of migrant and refugee backgrounds may be hesitant to disclose their experiences of family abuse and violence (FAV).2,3
  • Language, level of health literacy and marginalisation impose barriers to accessing welfare, employment and health services. Many non-permanent residents have limited, or no access, to education, support services, income or Medicare.
  • Planning a safe pathway for migrant individuals requires careful inquiry and culturally sensitive care. As social isolation can be extreme, a caseworker or a GP may be someone’s only safe contact.

Background and prevalence

Australia is a culturally diverse nation – almost half of its population were either born overseas (6.2 million, or 26%) or have at least one parent who was born in countries other than Australia (4.5 million, or 21%).1 More than 300 identified languages are spoken in Australia, and 21% of Australians speak a language other than English at home.1

Intimate partner abuse/violence (IPAV) is prevalent around the world,4 and the prevalence of IPAV among women of immigrant and refugee backgrounds residing in various host countries ranges from 17% to 70.5%.5 IPAV is more common in countries where war or social upheaval has recently taken place.6, 7 The few studies of diasporas in various countries have found similar rates of FAV to those in the home country.8–10

General practices play an important role in screening for vulnerability and early identification, providing first-line support and facilitating referral to specialised services.

However, people of migrant and refugee backgrounds may have limited access to primary care services, due to racial discrimination, cultural and language differences, low income, transportation challenges, social isolation or difficulty in navigating the primary care system.11,12

Furthermore, some people of migrant and refugee backgrounds may be hesitant to disclose their experiences and request support.2,3 Reluctance to disclose could be due to personal factors such as shame, fear or self-blame. There may also be wider, societal-level factors, such as being on a dependent visa, fear of deportation, cultural values and beliefs, normalisation of violence in countries of origin, and religious or community influences.13

Immigration policies that reinforce women’s economic dependence on their families and restrict their access to government benefits such as Centrelink and childcare support could pose additional barriers to service access.14

Therefore, culturally attuned and accessible healthcare, conscious of the challenges faced by individuals of migrant backgrounds, is critical to their wellbeing and safety. This chapter outlines how general practices can create a culturally safe environment for people of migrant and refugee backgrounds who are experiencing family or domestic violence.

Instituting culturally competent family violence care in your practice

Culturally competent care requires a combination of actions and efforts at the whole-of-practice and individual levels, as shown in Figure 17.1.15

Figure 17.1. Culturally competent primary care response to family violence<sup>15</sup>

Figure 17.1. Culturally competent primary care response to family violence15

Reproduced with permission from: Pokharel B, Yelland J, Hooker L, et al. A systematic review of culturally competent family violence responses to women in primary care. Trauma, Violence and Abuse, 2021.
Copyright SAGE Publications.

The outer rim shows whole-of-practice policies and actions that can facilitate culturally competent care. The inner part of the wheel shows individual clinician traits and actions that are enabled by the outer rim and allow a safe space for people from migrant or refugee backgrounds. At the centre, patient-centred care respects each individual’s decisions regarding their own situation.

Actions at the whole-of-practice level

As shown in Figure 17.1, actions that can be taken at the whole-of-practice level to facilitate culturally competent care include:

  • implementing policies that
  • ­enable efficient access to and use of interpreters
  • facilitate pathways for referral of patients of migrant backgrounds to FAV support services
  • encourage recruitment of clinical and non-clinical staff that reflect the local cultural diversity – staff from diverse backgrounds may provide insight into how patients express themselves; their expectations and preferences; and what rituals or traditions they may engage i
  • allocating budget to resources that improve efficiency and access to migrant specific healthcare, such as speaker phones for telephone interpreting, additional space for consultations that include interpreters or bi-cultural workers, and extended consultation times
  • using images or objects in the practice building that represent the cultural diversity of the local community to create a culturally inclusive physical setting
  • making resources, such as FAV brochures, available in multiple languages relevant for patients who attend the practice
  • implementing practice systems to support recording of patients’ language, ethnicity, need for an interpreter, country of origin, year of arrival in Australia and visa status. This can help determine the diversity of the patient population that the clinic usually serves. It also enables staff to pre-arrange interpreters specific to gender or ethno-culture and to allocate extended consultation times
  • training clinical as well as non-clinical staff (such as receptionists) on how to respond to FAV and how to best communicate with culturally and linguistically diverse (CALD) clients, including how to work with interpreters
  • assessing the cultural competence of the practice to determine how equipped it is to accommodate patients of migrant and refugee backgrounds who present in the highly sensitive context of FAV. Practices can use the questions in Box 17.1 to assess their level of cultural competency.15,16

Box 17.1. Questions to assess organisational cultural competency15,16

  • Does the practice promote and foster a culturally friendly environment?
  • Is it located in an area where people of migrant and refugee backgrounds live?
  • What countries and ethno-cultural groups do those people originate from?
  • Do staff display attitudes and behaviours that demonstrate respect for all cultural groups?
  • Does the practice involve or collaborate with migrant and refugee community groups or individuals when planning events, programs, service delivery and organisational development activities?
  • Does the practice have policies and procedures that take cultural matters into consideration (eg systems to collect and record data about cultural and linguistic diversity)?
  • Does the practice provide programs that encourage participation by people of migrant and refugee backgrounds?
  • Do the practice systems enable easy access to interpreter services?
  • Does the practice have knowledge of local migrant and refugee groups, their protocols, and methods for communicating with, or referring to local ethnic groups?
  • Does the practice develop and/or implement a collaborative service delivery model with specific multicultural FAV support groups, such as inTouch, that provide culturally diverse FAV services?’

Actions at the GP level

The inner part of the wheel in Figure 17.1 shows how GPs can enable a culturally competent environment for people from migrant and refugee backgrounds, as explained below.

  • Efficient delivery of service is an important aspect of culturally competent FAV care. The window for disclosure or intervention may be small and every opportunity to engage with patients should be taken. For example, if a person who does not speak English attends the clinic, staff should not feel unprepared. Telephone interpreting can be immediately arranged, and a staff member may take extra time to determine what type of appointment the patient needs. Readiness for these types of interactions needs to occur at the whole-of-practice and individual levels.15
  • All practice staff can and should assess their own cultural competency to become aware of their biases and assumptions (Box 17.2).15,16
  • Staff should endeavour to understand the unique ethno-cultural context of their individual patients. People come from not only different countries and cultural groups, but they also follow different religions, hold a broad set of values, and may differ in their response to FAV – these differences exist even between people from the same country or ethnic group. Therefore, staff should aim to understand an individual’s experiences and personal narrative, while avoiding stereotypes and oversimplified schema.15

‘Case study: Sylvia’ demonstrates why it is so important that GPs frequently assess their own cultural competency.

Box 17.2. Questions to assess own cultural competency15,16

  • Are my actions and attitudes culturally appropriate when I am with patients from migrant and refugee backgrounds? Am I being sufficiently careful not to reflect prejudice, bias or stereotypical attitudes? 
  • What practical experience do I have of FAV?
  • Do I have knowledge of cultural practices, protocols and beliefs related to FAV? Have I undertaken any cultural development program that prepares me to best support FAV experiences of patients of migrant and refugee backgrounds?
  • Do I interact with people of migrant and refugee backgrounds experiencing FAV? Have I worked alongside people of migrant and refugee backgrounds experiencing FAV? Have I consulted with people of culturally and linguistically diverse groups?
  • What is my motivation to become culturally competent?’

This section outlines specific clinical considerations for caring for patients of migrant and refugee backgrounds experiencing FAV. Figure 17.2 shows how these can be put into practice. These points complement the recommendations in Chapter 2: Intimate partner abuse and violence: Identification and initial response, Chapter 3: First-line response to intimate partner abuse and violence: Safety and risk assessment and Chapter 4: Intimate partner abuse and violence: Ongoing support and counselling. Box 17.4 includes a summary of practice tips.

Figure 17.2. Considerations for assessing and managing patients from migrant and refugee backgrounds who might be or are experiencing intimate partner abuse

Figure 17.2. Considerations for assessing and managing patients from migrant and refugee backgrounds who might be or are experiencing intimate partner abuse

Creating a safe environment for disclosure

Confidentiality and consent

Migrant, asylum seeker and refugee patients are often hesitant to disclose experiences of abuse because of fear of confidentiality breaches, particularly when working with interpreters.17–19 Individuals who are navigating temporary visas, student visas or awaiting refugee determinations may have fears regarding how disclosing abuse will affect them legally, or whether their clinical information will be shared with government authorities. Particularly within small communities, it may be prudent to avoid culturally congruent referrals (refer to section titled ‘Education and referral’) in case family or social networks intersect.

It is important to understand that consent is understood differently by different cultures. Some cultures understand consent as a community issue, not an individual issue – for example, a patient may be reluctant to disclose issues that they feel could bring shame to their community. Therefore, clarifying the patient’s view on consent may be prudent.15,20

Intuitive practice

GPs’ suspicion of FAV is often triggered by patient behaviour or physical evidence of violence (eg traumatic injury) (refer to Chapter 2: Intimate partner abuse and violence: Identification and initial response ).19,21 Suspicion of abuse should prompt an inquiry about abuse; if denied, ask again in subsequent visits. GPs may need to apportion extra time to their consultations, as patients may not readily disclose their experiences.

Careful use of language about family violence

GPs may need to modify their language when discussing FAV with migrant and refugee people. For example, common comorbid conditions such as depression, trauma or anxiety may be associated with stigma or shame.22–24 In some countries, there is no direct translation or word equivalent for ‘depression’.

In some communities, FAV might be normalised, or it might be taboo, meaning some individuals will not acknowledge abuse. This requires the GP to prompt or ask directly about abuse, for example: ‘Has your partner ever beaten you, ever forced you to have sex with them, ever threatened to get you deported, or violently or constantly been jealous of you?’

Considerations when assessing patients of migrant and refugee backgrounds

Victims may be experiencing abuse from multiple family members, including their in-laws (mother, father or brother-in-law).9,25,26 Ask if anyone else is abusing them.

Some people, especially refugees, may have witnessed or experienced serious violence before their arrival, and continuing violence within the home can add to the pre-migration trauma experiences and the acculturative stress issues.14

For younger people, especially students and migrant workers on temporary visas, fears about immigration status may affect their comfort to disclose. Women, those on spousal visas and those with dependants or children may also feel particularly apprehensive about the repercussions of disclosure.

If the patient is in an abusive LGBTIQA+ relationship, fears about confidentiality and stigma may be stronger, especially if they are from countries where same-sex relationships are illegal.

Visa considerations

Individuals may be reluctant to leave an abusive situation for fear of the impact on their immigration status.13 Navigating the migration and legal pathways creates a high degree of stress; mental illness improves once a visa is obtained.27

It is valuable for GPs to have a basic understanding of migration pathways. This includes the variable eligibility for support services, healthcare (Medicare or state hospital services), income support and working rights.

Individuals on skilled migrant visas have conditional access to health services and limited work rights.14

Asylum-seekers may hold one of many different temporary visa types, including bridging visas, temporary protection visas, or safe haven enterprise visas. Not all temporary visa-holders have the right to work, and access to Medicare may lapse when a visa expires. An individual may be applying for their next visa and experience delays while reapplying for Medicare.

Individuals who arrive on other visas, such as tourist visas or student visas, do not have access to Medicare or income support, and have restricted work rights.

Information about visa types and support services can be found from:

Awareness of how patients may disclose family abuse and violence

Patients from migrant and refugee backgrounds could disclose less explicit experiences of abuse, such as forced termination of pregnancy, or family members prohibiting the use of contraception.21,28

GPs may uncover neglect of a patient by the family members or caregivers.21

Some patients may express feeling lonely or being controlled.29 Therefore, GPs can prompt responses by questioning patients about their family situations or situations at home.

Patients may describe their distress through somatic symptoms or use physical terms to describe emotional distress.

Working with interpreters

Using interpreters needs to be foundational to practice policy and part of the work done by front desk staff in their interactions with patients. Practice points for using interpreters in clinical practice, developed by the Migrant and Refugee Women’s Health Partnership, are shown in Box 17.3.

Professionally trained interpreters should always be used – it is inappropriate to place children, family or friends in the role of interpreter, particularly when FAV is an issue. Practices should institute speaker phones, have readily available access codes for telephone interpreting services and have translated instructions to explain to patients how to access telephone interpreting services.

Improper use of interpreters, such as dialect mismatches, using a non-professionally accredited interpreter, or disregarding a patient’s gender preference for the interpreter, can result in communication failures that may impair safety planning or inadvertently expose confidential information and risk potential retribution.

Specific recommendations for interpreter use in the context of FAV include:

  • use interpreters who are trained in FAV, if available
  • consider using a pseudonym to ensure confidentiality (in smaller communities there is a risk of interpreters being socially connected to the patient)
  • monitor non-verbal cues to determine if the patient is comfortable with the interpreter (be conscious that there may be a discriminatory interaction between interpreter and patient)
  • implement a code-word in cases where the patient wants to terminate the consultation abruptly
  • if there is a risk of interpreters being socially connected to the patient, consider using an interstate interpreter, or if the patient is multi-lingual, a language other than that of their primary community.

Box 17.3. Practice points for working with interpreters in a healthcare setting30

  • Where possible, GP informs interpreters about the nature of the consultation before it begins, recognising the need to assist the interpreter to prepare for the consultation.
  • GP introduces the interpreter to the patient and explains that the interpreter is a non-clinical member of the healthcare team who will facilitate effective communication in the consultation through accurate interpretation, is bound by confidentiality and maintains impartiality.
  • When working with an onsite interpreter, GP interacts directly with the patient, using direct speech, and maintains appropriate body language and facial expressions.
  • When working with a telephone interpreter, GP uses a speakerphone or a hands-free telephone.
  • When working with a telephone or video interpreter, GP interacts directly with the patient, ensures they manage turn-taking, and uses adequate descriptive language.
  • GP speaks clearly, uses plain English and explains complex concepts and terms to enhance the patient’s understanding.
  • GP speaks at a reasonable speed, with appropriate pauses, and avoids overlapping speech, to enable the interpreter to interpret.
  • In a multidisciplinary team consultation, GP ensures adequate speech rate, pauses and turn-taking for all parties to facilitate good-quality and accurate communication with the patient.
  • When possible and appropriate, GP and interpreter may debrief and exchange feedback following a consultation.

Adapted with permission from: Migrant and Refugee Women's Health Partnership. Guide for clinicians working with interpreters in healthcare settings. Canberra: Migrant and Refugee Women's Health Partnership, 2019.

Risk assessment

Following disclosure, assessing risk for a migrant or refugee person experiencing FAV requires consideration of specific factors that may affect their ability to safely stay or leave their situation (refer to ‘Assess risk’ in Figure 17.2). These factors also influence whether someone has the capacity to navigate wider systems. Language, literacy and marginalisation impose barriers to accessing financial, occupational and health services

Safety planning

Planning a safe pathway for migrant individuals requires additional care, as social and community isolation can be extreme. The caseworker or a GP may be their only safe contact.

Identification documents including passports, immigration paperwork or birth certificates may not be available. Advice from an immigration-specific lawyer may be prudent, to advise on how to manage if these documents are not available.

Access to interpreters is critical to enable people to contact Centrelink, or access legal and medical assistance. Educating patients on how to access telephone interpreting services independently is an essential part of safety planning.

Daisy app by 1800 RESPECT provides links to local support services for FAV and is available in 28 languages.

Refer to safety and risk assessment in Chapter 3: First-line response to intimate partner abuse and violence: Safety and risk assessment.

Refer to ‘Case study: Josephine’ for an example of safety planning.

Education and referral

GPs are well positioned to educate individuals that what they are experiencing is not acceptable and does not need to be tolerated. Education may also include advising of available services, such as emergency shelters or free legal services. For migrant communities, there is frequently a reliance on welfare and acute crisis response, as there may be no family members to assist.

Choosing the appropriate community service can be challenging, and considering whether to use a culturally congruent community service versus an alternative service may require sensitive inquiry. Individuals may be wary of approaching community elders because they fear that they will advise them according to cultural norms, such as acceptance or submission.

In some cultures, divorce may require public disclosure, or approval from community leaders or extended family. Avoid assumptions about social structures, and actively seek to gain an understanding of what influence family and community leaders have on situations of family separation. The first line of inquiry may be the individual themselves and their perception of those structures. It may also be valuable to meet with community leaders or bicultural workers to inquire in a general way, taking care to protect the confidentiality of the individual patient.

The Status Resolution Support Services program (SRSS) is an Australian Government program for non-citizens awaiting immigration resolution, including those released from detention, those in community detention and some asylum seekers. SRSS providers are appropriate points of first contact for individuals in need of casework and income support (Table 17.1).

In general, people deemed to be managing a crisis, such as domestic violence, would be eligible for SRSS. However, individuals who have had a negative determination at the Immigration Assessment Authority may no longer be eligible for SRSS, putting them in a potentially precarious situation. In some cases, state or territory governments may provide emergency housing and healthcare access. Multicultural FAV services, such as inTouch, include immigration and FAV casework, legal and financial support with30 FAV-specific interpreting services.

Be aware that many clients will require letters of support from their GPs, as these may be used as evidence through their legal pathway.

You may access a current summary of who is eligible to access the SRSS, and what services asylum-seekers are eligible for.

Table 17.1. Status Resolution Support Services program providers in each state or territory

Australian Capital Territory/New South Wales

Life Without Barriers

Settlement Services International

Northern Territory

Life Without Barriers

Queensland

Access Community Services Ltd (Access)

Multicultural Australia

South Australia

Australian Migrant Resource Centre

Life Without Barriers

Tasmania

CatholicCare Tasmania

Victoria

AMES Australia (AMES)

Life Without Barriers

Western Australia

MercyCare


More information about the SRSS can be found here.

Box 17.4. Practice tips

  • A culturally attuned general practice response to FAV for patients of migrant and refugee backgrounds needs to include targeted actions by individuals and the whole of practice. These include policy priorities, budget allocation, training and efficient service provision.
  • Primary care providers and practices should frequently self-assess their cultural competency in providing culturally appropriate FAV care.
  • GPs need to actively create a safe environment for disclosure of FAV by ensuring confidentiality, engaging intuitive practice and through the careful use of language. They should be aware of the different ways migrant and refugee people may intimate about abuse.
  • Professional interpreter services should be routinely used, and practice staff and GPs should be competent with using them in the context of FAV.
  • Risk assessment in migrant and refugee people needs to assess language proficiency, immigration status and the individual’s eligibility for support services. Many will experience marginalisation from the wider community through racism, as well as dislocation from their ethno-cultural heritage.
  • Safety planning should include education about how to independently access telephone interpreting services.
  • Ensure individuals understand that abuse does not need to be tolerated and there are alternative pathways available to them. GPs should consider referrals to migrant legal services and SRSS. Consider carefully whether culturally congruent community services are the safest option for the individual, or whether alternative services are required.

Sylvia is a 70-year-old Italian-Australian woman. Her family is well known to her GP after Franco, Sylvia’s husband, passed away last year following a long struggle with bowel cancer. Sylvia’s eldest son, Giorgio, has moved into the family home with his wife. When Franco was alive, he would attend appointments with Sylvia and translate for Sylvia, because her English is limited.

Sylvia comes to her GP with back pain, requesting painkillers. Without Franco there to translate, her GP realises she has never seen Sylvia alone. She uses a telephone interpreter and asks Sylvia how she is coping with Franco's death. Sylvia immediately begins to cry.

Sylvia discloses that throughout their 40 years of marriage, Franco physically abused her. She never said anything, as she believed that these were issues between husband and wife. Now her son and daughter-in-law have begun abusing her, both physically and mentally, since moving in with her. Giorgio is like his father and often shouts at Sylvia, calling her names. Sylvia is depressed, doesn’t eat much and has lost weight. She says that she stays in her room most of the time and cries.

Sylvia and Franco left Italy for Melbourne in 1972. Franco worked in a box factory for 40 years and Sylvia stayed home to raise their five children. Franco controlled all their finances and Sylvia doesn’t know what her rights are now that he has died. Since Giorgio arrived, he and his wife have taken control of the house and finances. They give Sylvia some money, but they don’t like her to leave the house. She has a sister who lives in another state, but Sylvia is ashamed to tell her sister about her problems.

The GP connects Sylvia with an Italian-Australian community organisation that facilitates access to Commonwealth Home Support and coordinates social activities. Building a social network enhances Sylvia’s independence and through this, she finds the confidence to seek advice from a social worker to take back control of her finances.

Key points

This case highlights the importance of culturally competent care (refer to Figure 17.1 and Box 17.2). Rather than using family members to translate, culturally competent care involves engaging a professional interpreter. As part of regular self-assessment of her own cultural competence, the GP might also have reflected on any personal assumptions about marital ideals or conventions and actively facilitated appointments where Sylvia could attend alone.

At a practice level, recording Sylvia’s preferred language and educating Sylvia about how to book her own appointments, using telephone interpreting services, would enable reception staff to pre-book interpreters and Sylvia to attend the clinic independently. This may have provided an earlier opportunity for her to disclose IPAV.

  • Use professional interpreters and not family members.
  • Frequently assess cultural competency at a GP and practice level (Box 17.1, Box 17.2).
  • Challenge personal biases and understand the unique ethno-cultural context of the individual.
  • Develop a network of local providers who provide culturally specific services and understand how to collaborate with or refer to them.

Geetu is a 17-year-old high school student. She lives with her parents and one brother. Geetu's parents moved from Nepal for a better life for the children.

Geetu comes to see you at the clinic and tells you that her parents are forcing her to get married and leave her studies. However, Geetu loves school and has dreams of becoming a doctor to help others. She feels trapped and doesn’t know what to do.

Geetu already has a boyfriend that her parents are not aware of and who doesn’t understand what she's going through. Her friends don’t either. They don’t understand her culture and think her parents are weird.

The engagement is in a couple of months and a dowry has already been paid. This upsets Geetu. Her parents keep badgering her about the engagement, which angers her. She feels nauseous and headachy.

‘I feel sick,’ she says. ‘I feel nauseous all the time, I’m irritated and lose my temper a lot.’

She doesn’t sleep and is anxious about the future.

This is a relatively common situation for people from many cultures and religious backgrounds. What appears to be customary or a socio-cultural norm may belie coercive, oppressive and potentially violent activity.

Creating a safe environment for disclosure may take a longer consultation than initially planned (refer to Box 17.3). It may not be clear to Geetu that her situation is type of FAV. Alternatively, she may be acutely aware that refusing the marriage will put her, or her family, at great risk, either financially, or potentially at risk of violent retribution. Listening to and reaffirming Geetu’s concerns are paramount. Targeted questions may be required to fully understand Geetu’s home situation and the risks for her should she either go against her parents plans or enter a forced marriage.

You arrange a time to speak with the school counsellor, with Geetu’s consent. The counsellor works closely with Geetu in managing her symptoms of distress and anxiety. With time, Geetu decides that she will speak to her parents about her concerns.

Key points

  • Create a safe environment for disclosure by apportioning extra time to consultations.
  • Use directive questioning to assess risk (refer to ‘Creating a safe environment for disclosure’ earlier in this chapter).
  • Be conscious of how people may intimate abuse, including presenting with somatic symptoms or expressing feelings of being controlled or not being understood (Box 17.3).
  • Consider risks that may be specific to your patient’s ethno-cultural context. The financial implications of losing a dowry, or the risk of going against the community’s norms, or the risk to a woman entering a forced marriage – all need to be explored carefully (refer to ‘Risk assessment’, earlier in this chapter).

Zahara is a 35-year-old Somalin woman. Her husband, Fahad, arrived in Australia through a United Nations refugee program in 2015, via a refugee camp in Kenya. Zahara and their children arrived only recently. Fahad is completing his professional recognition as a researcher.

You first meet Zahara and Fahad for their son's catch-up immunisations. They ask if there is free childcare available to them, because Zahara is having seizures. When you finish taking a history and examining Zahara, you wonder whether the seizures may have been aggravated by stress. Regardless, you refer Zahara to a neurologist for a second opinion and arrange some tests. A week later, Zahara returns alone to check her test results. She asks you directly if you think the seizures might be caused by stress.

Zahara tells you that Fahad left Somalia soon after she gave birth to their second child. While he was away, Zahara stayed with her parents, completed her studies in history and worked part time in an office. Zahara loved working and was reluctant to leave Somalia, but wanted her children to be reunited with their father. Since arriving in Australia, Fahad has not wanted her to work and he believes that a woman’s role is at home. He frequently shouts at her or speaks to her as though she’s a servant. Leaving him is not an option, since Zahara has a temporary partner visa. This means that if they separate, she will need to return to Somalia and may never see her children again. On one occasion, when Zahara tried to leave the house, Fahad threatened to report her to the Department of Immigration so that she would be deported. She also explains to you that leaving a marriage is frowned upon in her culture and that her parents, while relatively open-minded, would never accept her back to their home.

After Zahara’s visit, you spend some time reflecting on your personal cultural competency. You have not had many patients from Somalia and have not developed any stereotypes or cultural biases. You do work in a community with a high number of refugee people and have had experience working with women in FAV situations, particularly across linguistically diverse groups. Zahara felt confident to disclose her situation to you, after you established a good rapport during your first meeting.

You consider the factors that contribute to FAV risk in migrant communities. For Fahad, these might include marginalisation, dislocation from his cultural heritage and acculturative stress. For Zahara these also include financial and visa dependency, her children and a lack of social, or family support.

You refer Zahara to the Refugee Council of Australia and the Australian Red Cross, both of which can provide case work and support services regardless of refugee status. You also make a referral to inTouch<<link to https://intouch.org.au/>>, a Victorian service that works specifically with FAV and migrant people and offer case work, legal services and financial support. Refer to the Domestic Violence Resource Centre Victoria website to find services by state.

Key management issues

  • Assess individual cultural competency and screen for personal bias or assumptions (Box 17.2).
  • Build rapport and trust to help create a safe environment for disclosing FAV (Box 17.3).
  • Consider the specific risks faced by individuals from migrant and refugee backgrounds (Figure 17.2).
  • Be aware of migrant/refugee and FAV-specific services.

Josephine is a 22-year-old Papua New Guinean woman. She frequently misses her appointments, so you are surprised to see her in your waiting room. She is particularly withdrawn and keeps her eyes lowered. You ask her gently what she needs today. She tells you that she has had stomach pain for the last few weeks.

After a thorough history and examination, you are unable to come to a clear diagnosis. As part of a review of systems, you ask whether she has been sleeping well. Josephine says that she has not slept well for years and that she rarely feels like eating. Stress is overwhelming her, and she frequently has nightmares. Gradually, she discloses the full extent of her worries.

Josephine left Papua New Guinea (PNG) eight months ago, using money that she had been hiding away. She knew that she needed to leave her husband, who had been physically and sexually abusing her. They were married when she was 16 years old and immediately moved from her family’s province to Port Moresby. At first, she thought he was a quiet and reserved man, but quickly she realised that he was cruel and violent. On several occasions, Josephine tried to get help from the police, the pastor at her church and her cousin who also lived in Port Moresby. Nobody believed her. After the first year of marriage, Josephine gave birth to a baby girl. That was when she knew that she had to leave and find a better life for her daughter.

What distresses Josephine the most is being separated from her daughter. She could not afford to bring her to Australia and so she came alone, applying for the visa after arriving in Australia. The lawyer who is helping her with her visa application has told her that it may take years for her determination to be finalised. At present, her daughter is safe and staying with her parents in their home province. However, her husband has sent them threatening messages and she worries that he will try to hurt her family to punish her.

You ask Josephine if she would prefer to speak with PNG-Australian people that run local support groups, but she says she would rather not. With Josephine’s consent, you instead contact Access Community Services and speak to an intake worker. They advise you that with Josephine’s current visa, she can access SRSS and they will arrange a case worker to help her navigate the visa process and find safe housing. They link her with a local women’s sewing group.

Six months later, Josephine’s visa conditions have changed: she is no longer eligible for SRSS, and her case worker contacts you asking for assistance. You speak to the local tertiary hospital to see what they can offer. While they have GPs and specialists that can provide medical advice, they have limited allied health services and no case workers. Eventually, you find a non-government community health clinic, World Wellness Group, that can see people pro-bono and they offer psychologist support for Josephine. The local Catholic church group arranges some short-term financial assistance.

A year later, Josephine contacts you for a letter of support for the Department of Immigration to bring her daughter to Australia.

Key management issues

  • Social isolation can be profound, and the GP may be the only support person available.
  • It is important to clarify with the individual whether they would prefer to work with a culturally congruent service, or an alternative. Consider whether there may be stigmatisation, judgement or unwanted intrusion by leaders, or other members of the same community.
  • Precarious immigration status and visa conditions can create challenges for GPs to find support services that their patients can utilise. Consider non-government, independent and charitable health services, or community groups.
  • The Refugee Council’s service directory – provides location-based search for settlement services, English classes, case management, legal services, domestic violence support and community support groups.
  • Refugee health guide directory – for state-based, refugee-specific contacts including domestic violence counselling and advice service.
  • Ask Izzy – a national database of location-specific services that enables search for domestic violence organisations specific to the client’s individual circumstances, including LGBTIQA+, CALD, and asylum-seeker groups.
  • Refugee and Immigration Legal Service – provides free legal advice for disadvantaged, refugee and migrant communities.
  • AMES Australia – offers support services including English language courses, migration legal agents, youth services, workforce-ready programs, Humanitarian Settlement Program (Victoria, South Australia, Tasmania), immigration Status Resolution Support Services and refugee mentoring program.
  • 1800 RESPECT – has developed the Daisy app to connect people experiencing violence and abuse to services in their local area. This is available in 28 languages. 1800 RESPECT also has an app, Sunny, for women with disability who are experiencing violence and abuse.
  • Australian Red Cross – provides support for refugees, asylum seekers and migrants who are vulnerable; visa status does not determine eligibility.
  • InTouch – a family and domestic violence specialist organisation that provides financial, legal and other support services to women of immigrant and refugee backgrounds experiencing family violence. 

State/territory support services

Australian Capital Territory

  • Migrant and Refugee Settlement Services – provides casework, homelessness services, emergency relief and community development programs including learning to drive and English language classes.

New South Wales

Northern Territory

Queensland

South Australia

Tasmania

Victoria

Western Australia

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