CULTURAL CONSIDERATIONS IN SCREENING AND TREATMENT OF INTIMATE PARTNER VIOLENCE Sudha Prathikanti, MDUCSF 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 INEXERTING 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

ReligionSocial NormsMinority 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.