Family violence among patients from multicultural backgrounds: How GPs can help

Neelima Choahan

4/06/2018 3:33:04 PM

newsGP spoke to three experienced healthcare professionals about how GPs can respond to patients from immigrant/refugee backgrounds who are experiencing family violence.

Protecting identity and maintaining confidentiality can be vital steps in helping people who are experiencing family violence.
Protecting identity and maintaining confidentiality can be vital steps in helping people who are experiencing family violence.

There are many factors that stop women who are experiencing family violence from seeking help, especially if they come from an immigrant or refugee background.
newsGP spoke to three experts about how GPs can help.
Dr Joanne Gardiner
A GP of 25 years, Dr Gardiner has been working with migrant and refugee women for most of her career. She also works at Cohealth Collingwood, formally Collingwood Community Centre and The Victorian Foundation for Survivors of Torture, Foundation House.
Potential indicators
Dr Gardiner said she remains aware of the social context and potential risk factors of the patient when considering the possibility of family violence. These potential risk factors include a couple reuniting after prolonged separation and a history of trauma, or a woman who has arrived on spousal visa and is isolated in a new country.
‘I remember seeing a newly arrived refugee family from a part of Africa’, Dr Gardiner said.
‘At some point, the nurse came and took the husband and the two kids out of the room to do  heights and weights, and I remember the minute the door was shut the mother – who had been very quiet – turned to me and immediately said … “I need a separate house from that man, he abused me for the 17 years we were married. It only stopped in the camp because he took a second wife and I am desperate to get out of that relationship because now I am here, I am afraid it will start again”.
‘She had not had the opportunity to say that to anybody. She had only been interviewed in the context of her husband. 
‘That was a lightbulb moment and I thought to myself, “Right, this is really what you have got to do: forget about culture, just look at the potential risk factors and just make sure that you are open to the possibility of finding out of what might be going on”.’
Build a rapport with the family
Dr Gardiner said if she is worried about a patient, she will make an effort to see the family regularly.
‘It might be to check their blood pressure or to do blood tests and check results or something,’ she said.
‘I would make arrangements to see them on a regular basis and hopefully get rapport.’
Engage an interpreter
Dr Gardiner said it is very important that a doctor uses a trained professional interpreter, preferably a woman, and not rely on a family member to interpret when dealing with people from a multicultural background. She makes an effort to dissuade family members from insisting on interpreting.
‘First of all I would say that I am obliged to use a professional trained interpreter, but the husband is welcome to remain in the room to support his partner,’ she said.
‘I would then try to suggest the husband leave of the room, having established a rapport and trust. 
‘I would then say, “I have to do a women’s health check and we have to discuss women’s business”.’
However, Dr Gardiner has found it is also vital to ensure the right professional interpreter for the patient is used.
‘I was dealing with a young woman who had fled from her boyfriend and I was talking with her,’ she said.
‘The male professional on-site interpreter was the only one I could have for that language and I could see the young woman was growing increasingly uncomfortable.
‘The consultation ended and the young woman went home and told her case worker that while I was briefly out of the room the interpreter had demanded her phone number so he could ring her boyfriend and let him know where she was.’
Protect identity and maintain confidentiality
Dr Gardiner said there are couple of ways to ensure the confidentiality and safety of the woman if using a telephone interpreter.
‘One is to request an interpreter in another state,’ she said. ‘You don’t have to spell out the name of the client to the language interpreting service. You can say the woman’s name is confidential.
‘The other way is to give her a false name.’
Make the time
Dr Gardiner said it is important for patients to be able to access help when they need it.
‘If you are a busy GP and you are booked up for weeks ahead it can be very difficult for people to get in touch with you and sometimes a woman needs to get in touch and speak [immediately],’ she said.
‘So making sure the practice is arranged or that your availability is somehow such that if the patient needs to see you, they actually get to see you.’
Dr Manjula O’Connor
Dr O’Connor is an Indian-born psychiatrist who campaigns against dowry-related domestic violence. She believes both the patient and the doctor experience barriers in the process of asking for and giving help.
Dr O’Connor said it is important that GPs need to have ‘cultural competence’ and be conscious and aware of the way a person would perceive their illness and problems through their cultural lens.
‘Most women from ethnic groups will not want to talk about ethnic violence because this is something that is private and you don’t make it public,’ Dr O’Connor said.
‘The women may not be able to conceptualise what is happening to them is domestic violence. They often don’t know their rights and what services are available for victims of family violence.’
Potential indicators
Dr O’Connor said practitioners should aware of instances in which a patient presents with multiple physical illnesses and symptoms like headaches, insomnia and depression. The woman may also suffer from malnutrition.  
She said a partner attending every appointment and never leaving the woman alone can also be an indicator. 
‘I have heard of stories where the husband has said to the woman “You don’t open your mouth, I will answer all the questions”,’ Dr O’Connor said.
‘For example, a woman will present with menstrual problems or urinary tract infection, but the husband will give answer for the woman. It is very important for the GP at that point to become suspicious.’
Dr O’Connor said spontaneous miscarriage or premature labour can also be signs of family violence.
Dr O’Connor said if a man presents with an issue of alcohol or substance abuse, or there is a sense of marital conflict, he could be at risk of being a perpetrator of family violence.
‘The perpetrator often presents with depression,’ she said.
Raising the issue
Dr O’Connor said it is not appropriate to immediately ask blunt questions like, ‘Are you being beaten at home?’ or ‘Are you being abused at home?’ when meeting a patient. It must be in the context of the assessment of family background.
‘You first ask general questions: “Who is at home? How long have you been in Australia? How is your relationship with your husband? Who are the other members in the family? How does the household generally run? What do you feel about what’s happening? Is there something you’d like to tell me that is concerning you?”’ Dr O’Connor said.
‘Most often she will say, “It’s all good, it’s perfect, no need to worry”. Then [the practitioner] can say, “That’s fine, but if there is anything let me know, because I am here to help”.’
What steps can GPs take?
Dr O’Connor said it is beneficial for GPs to first build trust with the patient. And if the patient discloses any instances of family violence, it is important that GPs take notes and keep a record as it might become into a medico-legal issue, especially if the woman seeks court orders, including intervention.
Maintaining 100% confidentiality upon gaining trust is also vital.
‘Not even a slight amount of information should leak from a doctor’s office,’ Dr O’Connor said.
Some practitioners might find it hard to broach the subject, especially if they are not from a multicultural background. But, Dr O’Connor said, questions should approached from a position of understanding and empathy.
‘You don’t ask the question from the positon of “my culture is better than yours”,’ she said. ‘We are not saying that every single immigrant woman who comes is suffering domestic violence.
‘What we are saying is that you need to be aware that when they suffer domestic violence it could be a silent problem and it’s not to blame their culture, it’s just to be aware and to be respectful towards them at all times.’
Dr O’Connor suggests not continuing to treat both the victim and the perpetrator, as this situation might raise a conflict of interest.
‘If the GP is seeing the husband and the wife that can become problematic,’ she said.
‘The GP wants to do the best by their patient. If they are seeing both the perpetrator and the victim, then who do they do the best for? So the best thing for the GP is to refer one of them to their colleagues.’
Dr O’Connor said it is important for GPs are trained in family violence and appropriate referral pathways, and that they could also call the police if they feel a patient is at risk.
Professor Kelsey Hegarty
Professor Hegarty is a GP and the Chair of Family Violence Prevention at the University of Melbourne and the Royal Women’s Hospital. She is also co-Chair of the RACGP’s Abuse and Violence Specific Interests network and a clinical editor of Abuse and violence: Working with our patients in general practice (White Book).
Professor Hegarty has found GPs can lack confidence to probe about family violence, especially in the case of people from a multicultural community. Part of that, she said, likely stems from a lack of knowledge about the best way to ask and respond, and to where they can refer the patient.
‘Maybe not knowing the legal rights of someone who doesn’t have permanent residency [is also a barrier],’ Professor Hegarty said.
‘I spend a lot of time reassuring GPs that … they just need to be able to ask in an empathic way, believe the woman, validate her experience, phone someone for advice and support.’
Professor Hegarty said GPs can refer the patient to sexual assault, domestic and family violence counselling and information referral service.
Professor Hegarty said extended family can also be a vital area of support, or a potential barrier if they are condoning the violence.
GP resources

1800RESPECT or 1800 737 732
  • The national sexual assault, domestic and family violence counselling service provides support for people experiencing, or at risk of experiencing, sexual assault, domestic or family violence
  • It also supports workers and professionals who are supporting someone experiencing, or at risk of experiencing sexual assault, domestic or family violence
  • Daisy App – designed to support patients and includes tips on the safe use of phones in an abusive situation
  • The Multicultural Centre Against Family Violence is a state-wide accredited service that provides programs and responses to issues of family violence in migrant and refugee communities. It can be contacted on 03 9413 6500 or 1800 755 988.

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Dr Peter Strickland   5/06/2018 12:26:30 PM

I worked in one of Australia's biggest ethnic diverse areas in Australia who were always fighting between themselves, until I informed a lot of them that they came from the same ethnic origin, e.g Italians, Greeks, Slavs etc. which made them think about their behaviour and attitudes. Behaviour is directly related to beliefs in human beings -absolutely!

Michael Fasher   8/06/2018 6:36:04 PM

Excellent stuff! It is important to get it right with individuals
The bigger challenge is for organised general practice to reduce DV at the population level