Clinical considerations
Service considerations
Refugee women seen in clinics may have high rates of PTSD caused by gender-based violence, and often this trauma has not been previously addressed in a clinical setting. As discussed earlier in this module, rates of depression among immigrant women are comparable to Canadian women, but may be higher in pregnant or postpartum immigrant and refugee women (Pottie et al., 2011). It is important for providers to keep in mind that exploring the history or consequences of sexual violence requires great clinical sensitivity and should always be guided by the client's needs and comfort (Kirmayer et al., 2011).
The evidence-based Canadian Guidelines for Immigrant Health indicate that routine screening for depression should be done in integrated treatment programs; however, routine screening for PTSD or IPV is not recommended (Pottie et al., 2011). Rather, providers should be alert for potential signs and symptoms related to such violence, as with all clients, and should perform more in-depth assessments if a reasonable suspicion develops or if a client discloses an incident. Being open and empathic is essential, but pushing for disclosure of traumatic events may result in more harm than good (Ibid.).
Creating a safe space for clients to speak about intimate partner violence
With Vanessa Wright (Nurse Practitioner, The Crossroads Clinic, Women's College Hospital)
If my suspicion is high that a patient has been subject to intimate partner violence, there are several areas that I could address. The first being: I would want to let them know that the clinic is a very safe space. It's confidential and it's safe. And they can tell me, or a variety of providers, anything in confidence, now or in the future. Over time, if my relationship was stronger with the patient and I felt I could ask a very direct question, I probably would. I would say: “Have you been a subject of violence? Has anybody hurt you?” And directly: “Do you feel unsafe?” I wouldn't want to ask directly: “Who has hurt you?” But I would definitely want to open the door if the relationship warranted that and if I felt that the client or patient felt that the space was very safe. I think that door definitely is open if you do suspect that the patient is unsafe in any way to ask.
It is important to keep the following in mind:
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Women will rarely identify themselves as a survivor of sexual trauma.
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Information about the country of origin will contextualize and help establish the likelihood of exposure to sexual trauma.
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Sociocultural factors strongly influence women's responses and their willingness to talk about sexual health; what is taboo for some may not be so for others.
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Cultural and language factors may influence how a woman speaks about her symptoms and experiences, and traditional assessments may not provide accurate information. It is important to use culturally appropriate assessments intended for specific populations. (Bartelson & Sutherland, 2018)
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Linking immigrant and refugee women with services, resources and support networks can help them reconstruct healthy relationships with others, increase social connections and gain social support. (Salt, Costantino, Dotson, & Paper, 2017)
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Here are some organizations throughout Canada that offer services to immigrant and refugee women:
Ontario: Newcomer Women's Services Toronto
Manitoba: Immigration Partnership Winnipeg
British Columbia: Pacific Immigrant Resources Society
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When working with pregnant immigrant and refugee women, provide information about depression numerous times throughout pregnancy and postpartum. (Iliadou, et al., 2019)
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Engagement in the labour force and financial independence are important facilitators of improved mental health. (Alvi et al., 2012; Hyman et al., 2011)