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: %
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 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

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
LOOK EMPATHICALLY 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.