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
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
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.
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.
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
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.
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.