CULTURAL CONSIDERATIONS IN SCREENING AND TREATMENT OF INTIMATE PARTNER VIOLENCE
Sudha Prathikanti, MD UCSF Psychiatry
Leigh Kimberg, MD UCSF Medicine
WHAT IS INTIMATE PARTNER VIOLENCE?
Pattern of abusive behaviors …including physical, sexual, verbal, emotional, economic, and/or psychological abuse …used by adults or adolescents …against (current or former) intimate partners, and sometimes against other family members.
IPV IS PAN-CULTURAL
Culture includes
– – – – – – – – – Race/ethnicity Migration Status Gender Sexual Orientation Age Religion Education Socioeconomic Status Disability Status
CAVEAT RE: CULTURE
Every person is in certain respects: Like all other persons Like some other persons Like no other person
-Kluckholn & Murray 1954
IPV PREVALENCE
COMMUNITY PREVALENCE IN USA – WOMEN LIFETIME PREVALENCE: 24.8% – MEN LIFETIME PREVALENCE: 7.8% CLINIC PREVALENCE – WOMEN CURRENT: 5.5-22.7% – WOMEN LIFETIME: 28-66% – HOMOSEXUAL MEN: ED-as high as women INTERNATIONAL PREVALENCE – WOMEN LIFETIME: 10-69% – WOMEN 12 MONTH: 3-52%
IPV PREVALENCE BY ETHNICITY
Women in U.S. experiencing physical assault by intimate partner at least once during their lifetime:
Asian and Pacific Islander (12.8%) Hispanic, of any race (21.2%) White (21.3%) African-American (26.3%) Mixed race (27.0%) American Indian and Alaskan Native (30.7%)
ETIOLOGY OF IPV
Appears rooted in power differential Influenced by individual, relationship, community and society
Graphic: Ecological Model
SOME COMMONALITIES IN SUFFERING OF SURVIVORS
Sense of fear and humiliation Isolation Loss of self-worth Self-blame Feeling of being trapped
SOME CULTURE-BASED DIFFERENCES IN VIEWS OF RELATIONSHIP
Relationship as Dyadic vs. Communal Relationship as Romance vs. Duty Relationship as Normative vs. Taboo
SOME CULTURE-BASED DIFFERENCES IN PATTERNS OF VIOLENCE
IPV is not an isolated act of aggression but a pattern of recurring abuse Patterns of abuse reflect the cultural milieu of perpetrator and survivor
Walker Cycle
Coiled Spring
SOME CULTURE-BASED DIFFERENCES IN EXERTING CONTROL
Aim of IPV is for abuser to intimidate and control the victim Means of control available to abuser can vary depending on cultural milieu
Wheel of Control
CULTURE: A DOUBLE-EDGED SWORD
Religion Social
Norms Minority Status
SOME CULTURE-SPECIFIC INTERVENTION STRATEGIES
Autonomy vs. Alternate Family Crisis Services vs. Ongoing Services Legal Remedies vs. Social Remedies
TAKE HOME POINT
Every
culture has archetypes for enduring versus rejecting intimate partner violence
TAKE HOME POINT
Culturally
competent care allows a person to reject violence but also maintain cultural identity
CULTURALLY COMPETENT IPV INTERVIEW:
LEARN GENERALITIES ABOUT FAMILY AND RELATIONSHIP DYNAMICS IN DIFFERENT CULTURES
INDIVIDUAL PATIENT PERSPECTIVE
CULTURALLY COMPETENT IPV INTERVIEW:
LISTEN CAREFULLY WATCH FOR NON-VERBAL CLUES BE CURIOUS (NOT JUDGEMENTAL) USE BEHAVIORAL TERMS NORMALIZE SHAMEFUL ADMISSIONS (FRAMING QUESTIONS) EXPLAIN LIMITS OF CONFIDENTIALITY
SCREENING:
“IT IS MY IMPRESSION THAT SOME WOMEN HAVE BEEN WAITING THEIR WHOLE LIVES FOR SOMEONE TO ASK”
-Flavia d’Oliveria, Brazilian physician
SCREENING: FRAMING QUESTIONS
“I AM CONCERNED ABOUT MY PATIENTS’ HEALTH AND SAFETY, SO I ASK ALL MY PATIENTS. . .” “BECAUSE VIOLENCE AND THREATS ARE SO COMMON IN RELATIONSHIPS, I ASK ALL MY PATIENTS. . .”
SCREENING: DIRECT QUESTIONS
“HAS YOUR PARTNER EVER HIT YOU OR HURT YOU OR THREATENED YOU?” “HAS YOUR PARTNER EVER FORCED YOU TO HAVE SEX WHEN YOU DIDN’T WANT TO?” “I SEE YOU HAVE A BRUISE. I AM CONCERNED THAT SOMEONE HIT YOU. DID SOMEONE HIT YOU?” AVOID VALUE-LADEN TERMS LIKE “ABUSE” OR “RAPE”
SCREENING: DIRECT QUESTIONS
“HOW DOES YOUR PARTNER TREAT YOU?” “ARE YOU FRIGHTENED OF YOUR PARTNER?”
TRANSLATION
DO NOT USE FAMILY, FRIENDS, OR ACQUAINTANCES FOR TRANSLATION IPV TRAINING FOR TRANSLATORS ACKNOWLEDGE TABOO ASPECT OF DISCUSSING IPV TO TRANSLATOR USE FRAMING QUESTIONS INSIST UPON THE USE OF DIRECT, BEHAVIORAL TERMS USE THE “BLAME ME” APPROACH LOOK EMPATHICALLY AT THE PATIENT!! RE-TRAIN IF NO POSITIVE RESPONSES
PATIENT’S PERSPECTIVE— Relevant topics:
LIFETIME HISTORY OF ABUSE HISTORY OF THE RELATIONSHIP PATIENT’S THEORY OF IPV LEVEL OF ISOLATION (Family/Friends) EFFECTS ON CHILDREN PATIENT’S CULTURAL IDENTIFICATION PATIENT’S LANGUAGE/LITERACY ECONOMICS PATIENT’S ASSESSMENT OF DANGEROUSNESS PATIENT’S READINESS FOR CHANGE
CULTURALLY COMPETENT INTERVENTION:
NONJUDGEMENTAL MESSAGES OF SUPPORT ARE THE MOST IMPORTANT INTERVENTION!! EMPHASIZE PERSONAL, FAMILY AND COMMUNITY STRENGTHS UTILIZE CULTURALLY SPECIFIC SERVICES (On site or community agency) UTILIZE CULTURALLY APPROPRIATE MATERIALS (Literacy level, Language, Cultural perspective)
VAWA: LEGAL IMMIGRATION
UNDER VAWA, A BATTERED SPOUSE CAN APPLY FOR CITIZENSHIP INDEPENDENT OF A PERPETRATOR SPECIALIZED LEGAL ASSISTANCE IS NECESSARY, BURDEN OF PROOF OF ABUSE MAY BE HIGH
TAKE HOME POINTS:
VIOLENCE IS NOT ACCEPTABLE IN ANY CULTURE HEALTH CARE PROVIDERS ARE WELL POSITIONED TO ASSIST WITH IPV
TAKE HOME POINT:
Obvious compassion and concern build bridges across even the most widely separated cultures. Health care staff can build these bridges to deliver hope and support to an abused and isolated patient.