GPs can be key in helping multicultural women who are experiencing family violence

Neelima Choahan

31/05/2018 3:31:04 PM

Women from multicultural communities face many barriers in dealing with family violence, but GPs can help.

There are many barriers that inhibit healthcare professionals from helping women who are experiencing family violence.
There are many barriers that inhibit healthcare professionals from helping women who are experiencing family violence.

Seven months after Sabrina* left India to join her new husband in Australia, the abuse started.
Forbidden from leaving the house or working, the 26-year-old was verbally abused, slapped and choked.
Isolated in a strange country, the young woman had no one to ask for help. The only regular contact with someone outside the family was the GP.
‘My husband always accompanied me to the GP,’ Sabrina told newsGP
‘I had headaches, bad digestion, my periods had stopped due to the stress.
‘I used to sometimes cry in front of the GP, but he never asked me about the domestic violence.’
According to the Australian Bureau of Statistics Personal Safety, Australia 2016 survey, about one in six women experience physical violence by a partner from the age of 15.
Dr Manjula O’Connor, an Indian-born psychiatrist who campaigns against dowry-related domestic violence, told newsGP that GPs are an incredibly important first-line response.
But, she said, there are many barriers that inhibit GPs from discerning whether someone is a victim of family violence. And these barriers, she said, are particularly worse for women from a multicultural background.
‘Women who have been brought up in Australia … know that domestic violence is an abuse of human rights,’ Dr O’Connor said.
‘Whereas, immigrant women don’t conceptualise these behaviours as domestic violence. They will accept that they are being beaten, abused or humiliated, disrespected or called vulgar names, but they don’t categorise it, don’t label it as domestic violence.’

OConnor-manjula-Article.jpgPsychiatrist Dr Manjula O’Connor believes, despite the inherent difficulty in raising the issue, most women who are immigrants will likely appreciate being asked about family violence by their GP.
Dr O’Connor said she is aware of situations in which a practitioner’s own attitudes stopped them from asking further questions.
‘I have known times where the doctors have not even recorded the conversation and where the patients have shown me evidence that they have been to the doctor so many times and spoken about the bruises,’ she said.
Dr O’Connor believes developing cultural competence, an ability to understand and appropriately respond to the health beliefs and practices of a diverse group, could help GPs get the true picture.
‘You try to be conscious and aware of the way that person would perceive their illness and their problem through their cultural schema,’ she said.
‘Most women from ethnic groups will not want to talk about domestic violence … so the patient will present with symptoms like headaches, insomnia, depression, suicidal ideation, multiple physical illnesses and often malnutrition.
‘So GPs have to be aware of all these issues when they are talking to the women knowing that it is a sensitive area and yet it could be hiding something serious.’
A 2005 research on Patients’ advice to physicians about intervening in family conflict, published in the US National Institutes of Health, showed that nearly all of the respondents believed physicians should ask about family conflict.
Dr O’Connor said most women who are immigrants appreciate being asked about family violence.
‘They want to tell the doctor, they have nobody here, the doctor is their best friend,’ she said. ‘But the thing is, how do you go about it?
‘You can’t throw a question, “Are you being beaten at home?” or “Are you being abused at home?” first off when you meet a patient.’
Dr O’Connor said GPs need to develop trust with the patient, but also educate themselves about what exactly constitutes domestic violence. 
‘I think the RACGP needs to be constantly pushing for GPs to learn the knowledge around domestic violence and also the referral pathways,’ she said.
‘And also to know that every patient of domestic violence that comes across their desk is effectively a medico-legal patient – that they are presenting with a health problem, but they are likely to have legal problems later on and they will need the doctor’s support.
‘And that it is important the doctor provides that support for the woman because their safety is at risk.’
Professor Kelsey Hegarty is a GP and Chair of Family Violence Prevention at the University of Melbourne and the Royal Women’s Hospital. 
She said there is a lack of training in medical courses on how to identify and respond to patients experiencing family violence.
‘I did a study that showed that, on average, medical students learnt about two hours [on domestic violence] in their whole course,’ Professor Hegarty said.
‘At a continuing professional level … there is not systematised training. Certainly there has been a dramatic increase in the training available for domestic violence from RACGP in the last 10 years, in particular.
‘But the problems is most GPs are not accessing those modules and therefore they feel they lack the confidence and skills to ask the questions … and there may be more hesitations in particular cultural groups.’

Kelsey-Hegarty-Article.jpgProfessor Kelsey Hegarty, Chair of Family Violence Prevention at the University of Melbourne and the Royal Women’s Hospital, has found there is a relative lack of medical training in how to identify and respond to patients experiencing family violence. 
However, Professor Hegarty said training is just one of the barriers, and systemic changes are required to better support GPs in dealing with women experiencing family violence.
‘I think that there needs to be a system and an infrastructure that assists GPs that might include providing them with more time to do it,’ she said.
‘There has been some discussion about getting a medical item number for a family safety plan that would allow them to do what is quite complex work.
‘It’s not about the money, but a recognition that it takes some time and requires infrastructure such as that.’
Though her regular GP did not pick up any signs of family violence, another GP, who Sabrina visited once, suspected that something was wrong.
‘The GP asked my husband to step out, but he said there was no problem and told me to reassure the GP,’ she said.
‘So I told the GP everything was okay. He gave me some forms on stress to fill out for the next visit, but my husband never went back to the same doctor.’
Dr Joanne Gardiner, a GP of 25 years, has been working with migrant and refugee women for most of her career.
She said one of the ways to speak to the woman alone is to build rapport with the family before getting the husband to agree to leave the room without being suspicious.  
‘There are a few situations where if I know that there is a particular social context I keep a very close look out for,’ Dr Gardiner said.
‘So the context would often be: a husband and wife where one reunites with the other … where there has been prolonged separation and a history of trauma. Another context would frequently be a woman arriving on spousal visa where they may be socially isolated.’
Dr Gardiner said, despite being vigilant, GPs can still miss the warning signs.
‘I had been seeing an Indian couple,’ she said.
‘Young, in their 20s, they were both professionals who had migrated here, so they were different to the people I often see.
‘I got a sense that they were both unhappy, and for quite a long time I thought it was just social isolation and missing family and difficulty settling.’
Dr Gardiner said it took her a long time to discover the wife was being abused.
‘I moved practice at some point … the wife was seeing me for a little while. She disclosed she had left her husband because of what he was doing, and I remember being quite shocked that I hadn’t realised it,’ she said.
But Dr Gardiner said there were also instances where she had made the mistake of assuming someone was experiencing family violence just because of their background.
‘The only thing you can do is, do your best,’ she said.
‘We can’t do any more than our best whether it is treating a broken leg or trying to discern domestic violence, and I think doing your best hopefully gets better with time and experience.’
Now separated from her husband, Sabrina said things would have been different had she known her rights and the Australian law.
‘I wish the GP had made an excuse and tried to talk to me on my own,’ she said.
‘I used to think that if I leave my husband, where will I live? I wish they had told me that there was help available.
‘If they had, then maybe I wouldn’t have wasted so many years with my husband and maybe would have been spared some of the beatings.’
* Name has been changed to protect identity.

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