CULTURAL CONSIDERATIONS IN SCREENING AND TREATMENT OF INTIMATE PARTNER VIOLENCE

1. CULTURAL CONSIDERATIONS IN SCREENING AND TREATMENT OF INTIMATE PARTNER VIOLENCE Sudha Prathikanti, MD UCSF Psychiatry Leigh Kimberg, MD UCSF Medicine

2. 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.

3. IPV IS PAN-CULTURAL • Culture includes • Race/ethnicity • Migration Status • Gender • Sexual Orientation • Age • Religion • Education • Socioeconomic Status • Disability Status

4. CAVEAT RE: CULTURE Every person is in certain respects: Like all other persons Like some other persons Like no other person -Kluckholn & Murray 1954

5. 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%

6. 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%)

7. ETIOLOGY OF IPV • Appears rooted in power differential • Influenced by individual, relationship, community and society

8. Graphic: Ecological Model

9. SOME COMMONALITIES IN SUFFERING OF SURVIVORS • Sense of fear and humiliation • Isolation • Loss of self-worth • Self-blame • Feeling of being trapped

10. SOME CULTURE-BASED DIFFERENCES IN VIEWS OF RELATIONSHIP • Relationship as Dyadic vs. Communal • Relationship as Romance vs. Duty • Relationship as Normative vs. Taboo

11. 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

12. Walker Cycle

13. Coiled Spring

14. 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

15. Wheel of Control

16. CULTURE: A DOUBLE-EDGED SWORD • Religion • Social Norms • Minority Status

17. SOME CULTURE-SPECIFIC INTERVENTION STRATEGIES • Autonomy vs. Alternate Family • Crisis Services vs. Ongoing Services • Legal Remedies vs. Social Remedies

18. TAKE HOME POINT • Every culture has archetypes for enduring versus rejecting intimate partner violence

19. TAKE HOME POINT • Culturally competent care allows a person to reject violence but also maintain cultural identity

20. CULTURALLY COMPETENT IPV INTERVIEW: • LEARN GENERALITIES ABOUT FAMILY AND RELATIONSHIP DYNAMICS IN DIFFERENT CULTURES • INDIVIDUAL PATIENT PERSPECTIVE

21. 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

22. SCREENING: “IT IS MY IMPRESSION THAT SOME WOMEN HAVE BEEN WAITING THEIR WHOLE LIVES FOR SOMEONE TO ASK” -Flavia d’Oliveria, Brazilian physician

23. 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. . .”

24. 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”

25. SCREENING: DIRECT QUESTIONS • “HOW DOES YOUR PARTNER TREAT YOU?” • “ARE YOU FRIGHTENED OF YOUR PARTNER?”

26. 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 • LOOKEMPATHICALLY AT THE PATIENT!! • RE-TRAIN IF NO POSITIVE RESPONSES

27. 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

28. 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)

29. 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

30. TAKE HOME POINTS: • VIOLENCE IS NOT ACCEPTABLE IN ANY CULTURE • HEALTH CARE PROVIDERS ARE WELL POSITIONED TO ASSIST WITH IPV

31. 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.