If your patient identifies as being Aboriginal or Torres Strait Islander, is under the age of 45, lives in any location in Australia and is presenting with indications of being a victim of violence, you should attempt to raise the issue with the patient. For ways of asking about violence and ways of responding to disclosure refer to Chapter 2, Chapter 3, and Chapter 4.
At a community level, GPs need to show leadership, for example through local primary healthcare organisations and other local organisations, by advocating for provision of services that meet the needs of Aboriginal and Torres Strait Islander peoples. The case study below provides an insight into the experience of family violence in an Aboriginal and Torres Strait Islander context and identifies some key issues to be mindful of in your interaction with an Aboriginal or Torres Strait Islander survivor of abuse.
Case study: Lisa
Lisa, a 24-year-old Aboriginal woman with three children aged 6 months, 20 months and 3 and a half years, presents to the emergency department of a regional hospital at the weekend. This is the fourth time in 18 months. She has injuries related to family violence. You have a follow-up visit with her at your clinic in your small regional town of 2000 people, 30% of whom are of Aboriginal or Torres Strait Islander descent. As you review her file you note that this is not her first presentation at the emergency department, or indeed at the practice, for injuries consistent with family violence. The first was about 2 years ago and included a broken nose and facial bruising. Other presentations have included:
- a broken wrist
- facial bruising
- broken ribs
On this occasion she has had more broken ribs, and extensive bruising down one side of her body from being repeatedly kicked. She has come in today because the hospital told her she needed to see her GP on Monday to follow-up on the tests they did in the hospital last Friday night.
As you are reviewing Lisa’s notes you are thinking about what you know about Lisa, her partner, her broader family and the community in which she lives. This is a community that has had a significant history of dispossession and cultural dislocation and many of the families, including Lisa’s, have had aunts, uncles, brothers and sisters forcibly removed both as a policy of the Stolen Generation but also as a consequence of recent Child Protection involvement.
This is a community and family who have not had opportunities to heal from the hurts they have suffered and they struggle with day-to-day living. You know this because you have seen the high incidence of chronic illness, alcoholism and mental health issues in some sectors of the community and it is not unusual for you to be patching up patients who have borne the brunt of violence.
There are also many related issues that confound the problems faced by these community members. These include the high unemployment in the area, because of seasonal work, and the low educational attainment levels related to the racism experienced at the local school. Further, the high turnover of staff at schools and community centres, and more broadly the high levels of both financial and personal stress experienced by most community members, also confound the problems.
It is not unusual for members to be attending funerals at least once a month and this can have a great effect on individuals’ feelings of unresolved grief and powerlessness over their own circumstances.
As you reflect on this context, you think about how you can draw on available resources to support Lisa and her children, to provide them with safety and then to begin the road to healing.
Lisa comes in with her sister Ella, whom she is staying with at the moment. Ella is well known in the community and works as an Aboriginal GP. She will be a great asset to you as you work with Lisa in developing both a safety and care plan for her.
Lisa’s children also attend the appointment. They have no obvious injuries and Lisa says that Rob has never hit them. The children, however, appear withdrawn – they are very quiet, appear scared, and are clingy to both their mum and their aunty.
Lisa says she hasn’t seen Rob since he got angry in the emergency department and they called security on him.
Rob will also need help. This should be provided by another GP, to assist with maintaining confidentiality. At this time the GPs responsibility is to Lisa and the children (refer to Chapter 3. Safety and risk assessment, and Chapter 5. Dealing with perpetrators in clinical practice).
You may wish to discuss with Lisa and her sister what options are available to ensure her immediate safety. These might include:
- staying with a family member or in a refuge – if available, a refuge specifically for Aboriginal and Torres Strait Islander women. Finding a refuge that has space can be challenging. Call the domestic violence line in your state
- police assistance through the domestic violence liaison – remembering that many Aboriginal and Torres Strait Islander peoples have had bad experiences with the police
- an Aboriginal Family Violence Prevention Legal Centre to obtain help or assistance with an intervention order.
If you are referring Lisa to the women’s refuge, or shelter, it is worth noting that they are in high demand, may not be able to cater for the number of children and can have quite strict rules that may be unsettling for Aboriginal and Torres Strait Islander clients. So the ‘fit’ may not always be the best option. It is, however, still worth trying.
Services for men
In terms of Lisa’s partner Rob, the number of Aboriginal and Torres Strait Islander men’s programs has grown significantly over the past decade, but there are still considerably fewer services available to address men’s needs than are available for women. GPs need to understand the context of Aboriginal and Torres Strait Islander men’s use of violence. Many men speak of their anger being related to colonisation. Colonisation, through its policies and practices, including dispossession and dislocation – for example, through the period of the Stolen Generations – often ‘constrain the control which people experience in their lives, and limit their personal choices under stress’.
Men’s ways of managing their trauma are too often, as Maggie White explains, seen as ‘bad’ or sometimes ‘mad’, but rarely as ‘sad’.296 Men are quickly seen as perpetrators but rarely as victims. Rex Wild and Pat Anderson’s Little Children are Sacred report of 2007 sheds more light on this underlying issue of men’s trauma and the intergenerational abuse that takes place in some communities as a consequence of little or no intervention for abused children.280 They provide the example of HG, reproduced here to exemplify Maggie White’s comments:
HG was born in a remote Barkly community in 1960. In 1972, he was twice anally raped by an older Aboriginal man. He didn’t report it because of shame and embarrassment. He never told anyone about it until 2006 when he was seeking release from prison where he had been confined for many years as a dangerous sex offender. In 1980 and 1990, he had attempted to have sex with young girls. In 1993, he anally raped a 10-year-old girl and, in 1997, an 8-year-old boy (ZH). In 2004, ZH anally raped a 5 year-old boy in the same community. Who will ensure that in years to come that little boy will not himself become an offender?
The above example clearly illustrates that Aboriginal men’s ways of coping tend to bring them into contact with the justice system and it is here that they may get their first court-ordered behavioural change type program, whether this occurs while incarcerated or on some form of bail or community-based order. In the event that no such program is ordered or offered through the criminal justice process, the GP may be in a unique position to offer other referrals to Rob should he visit your practice and this can be broached without confidentiality being breached (refer to Chapter 5 ). This will require some research in terms of what is available locally within Aboriginal and Torres Strait Islander medical services, via men’s groups or, again, via the Aboriginal Family Violence Prevention Legal Centres which may be able to refer you to legal service providers engaged in this work.
Addressing the needs of children
It would be worth keeping a watchful eye on Lisa’s children. In this chapter, the significant concern of the intergenerational transmission of violence and the need to break this cycle in these communities was discussed. Lisa’s children are very young but have potentially already witnessed a lot in their short lives. They will need to be monitored to ensure that their development is appropriate and that they do not continue to be exposed to violence. In the event that the latter occurs, as a GP you would need to carefully consider your mandatory reporting requirements and how you were going to communicate them to Lisa ( refer to Chapter 6 ).
If available in your area, specific services for children experiencing family violence can be very helpful. A discussion with the family and a referral for Lisa and the children may help to deal with what has happened and contribute to their safety.