Many GPs can think that their gender or ethnicity is perceived as a barrier to disclosure by a victimised patient from a migrant or refugee background. But if a patient is reassured empathically, and if they perceive their GP to be listening, trustworthy and understanding, then empathy within the therapeutic relationship can overcome stereotypes of gender and culture. Feder et al6 found near unanimity among over 800 victimised women’s views about the need for GPs to be empathic and non-judgemental in their care. When developing healing relationships with our patients, Scott et al 228 established that trust, hope and a sense of being known were the important things identified by patients.
In order to address the cultural diversity of patients who present, the GP needs to:
- be mindful of their own personal beliefs and assumptions
- respect and appreciate the values and beliefs of all patients
- be informed of cultural issues relevant to their patient, including their migrant and refugee patients.
In many migrant communities, doctors are highly regarded authoritative figures. It is therefore a very powerful message for a GP to suggest that the survivor’s symptoms are related to their partner’s or other family members’ abuse. A clear message from the GP stating that the abusive behaviour is not acceptable is valuable for the patient, especially when pathways to help and support the survivors and their families are identified. Ensuring the patient understands the connection between the violence and health, including the health of their children and other family members, is important.
It is good practice to reassure any abused patient that the consultation – subject to legal and mandatory reporting requirements – is strictly confidential, but for migrant and refugee patients it is vital to convey clearly that you will NOT reveal information gathered during the consultation to anyone else. This may be very important if you are a member of the same community and language community. It is also important to assure the patient that trained interpreters are also bound by these rules of confidentiality. Even where this information has been provided, confidentiality can be a difficult concept to relay within a cross-cultural environment and it may take some time for the patient to engage with this understanding.
The importance of culturally appropriate language
Members of many communities find that language barriers pose a significant problem in their efforts to access healthcare. When the GP and patient do not speak the same language it can lead to a loss of important information – for example, misunderstandings can occur regarding the presentation of illness and instructions for the use of medications. Abuse and violence identification and intervention can be especially difficult without proper linguistic tools. In many states, there are specific domestic violence services for migrant and refugee communities and they can provide secondary consultations and sometimes interpreting services if organised ahead of time (refer to Resources). It is important that any interpreter has been vetted for sensitivity to family or partner violence, as domestic violence services report anecdotally that interpreters from mainstream interpreting agencies may not always be confidential.
Professionally trained interpreters from mainstream agencies should always be used (refer to Resources). It is inappropriate to place children, family members or friends in the role of interpreter, particularly when abuse and violence is an issue. Table 17 outlines recommended guidelines for working with interpreters.
Guidelines for interpreters 311
Take a careful history
If a patient has disclosed, you need to take a careful history (refer to Chapter 2 ) and ask questions about:
- all those who are abusing the patient
- the safety and situation of the patient and any children or young people, including access to weapons. This may be more likely if the family is living in a rural area – regardless, it should always be explored (refer to Chapter 2 for questions relating to safety)
- any pressure to maintain family harmony, irrespective of the safety of the victim and any children
- any financial dependence, visa or migration status issues that complicate the relationship with the abuser and vulnerability of the abuser
- other financial abuse – for example, gambling or drug abuse funding
- religious or spiritual abuse
- if you have the patient’s trust, consider asking about sexual abuse and coercion.
Safety planning and referral
After informing a patient that abusive behaviour is unacceptable and damaging to their health and that they are not to blame, it is appropriate to discuss:
- what their perspective and preferences are and whether they wish to take any action
- discuss their comfort to be referred for support – for example, to a mainstream or ethno-specific agency
- assess their risk and safety and make a safety plan ( refer to Chapter 3 ) that may include hiding copies of all important papers and documents, including passports, visas, birth and marriage certificates if appropriate
- the law and rights and support services in Australia ( refer to Chapter 13 ). For example, women from overseas who have married Australian men need to know that their visa application will be given special consideration if there has been domestic violence. The GP may be able to provide documentation that can assist this process
- the role of police, intervention orders and courts in Australia. This may be very different to the individual’s country of origin. This can be especially important if the individual is in a rural community and the perpetrator has access to weapons.
Services for men
If the abusive partner is seen separately and will accept help, you could suggest referral or access to Mensline or No to violence. As outlined in Chapter 5, it is important that the abusive male partner be seen by another GP to maintain confidentiality and safety for the victim.