CLINICAL PRACTICE health Health care of refugee women series

BACKGROUND Women have endured major and poverty in their countries of origin or countries of displacement. This has had a major impact on their physical and psychological health. The experience of resettlement places a further burden on their health. Daniela Costa OBJECTIVE MBBS, FRACGP, FPFA, is senior This article aims to provide a simple approach to the health assessment and management of women refugees, taking medical practitioner, Womens into account specific issues related to migration and resettlement. Health Statewide, North Adelaide, and visiting senior DISCUSSION medical practitioner, Migrant Because of the complexities of their realities related to gender, social and economic status, and premigration and Health Service, Adelaide, resettlement experiences, women refugees need a multiplicity of health interventions. The identification of the major South Australia. danielac@ physical and psychological health issues with consideration of gender issues and premigration and resettlement chariot.net.au experiences, represents more adequate basis for the assessment and management of the health care of women refugees.

The complex experiences of women refugees in their Health issues – physical countries of origin and in refugee settings have a • Chronic diseases including , major impact on their health. In recent years, primary and heart disease health care services in Australia and other countries of • Infectious and parasitic diseases such as resettlement have addressed the specific health care and C, tuberculosis, and schistosomiasis needs of women refugees. The aspects of assessment • Nutritional deficiencies such as folate, iron and and management described in this article are based vitamin D deficiency on the experience of these services including the • Anaemia – which threatens women more than experience of a state funded medical service for men because of chronic and endemic women refugees in South Australia.1–5 deprivation. Common causes are: –  due to chronic blood loss caused This article incorporates some of the procedures by intestinal parasitic , menstruation, developed by the service, a collaborative initiative malabsorption, multiple pregnancies close together between Women’s Health Statewide and the Migrant and concurrent, prolonged breastfeeding Health Service, started in 1994. –  folate deficiency – hemoglobinopathies, commonly thalassaemias and Health issues sickle cell anaemia During life in their country of displacement, and in refugee • issues12,13 camps where they may have spent protracted periods, – high rates of poor pregnancy outcomes (miscarriage, women refugees have been routinely exposed to violence preterm labour, low birth weight babies), unsafe and extreme poverty. Furthermore, access to basic needs abortions such as adequate food and water, education, and income – complications from gynaecological surgery generating and resettlement opportunities would have – complications of female genital circumcision including been limited. These factors, together with the relative lack vulval scarring and chronic vulva and pelvic pain, of gender specific health care, have had a major impact on urinary tract , menstrual problems and their physical and psychological health.6–10 complications during pregnancy and childbirth At their point of entry in countries of resettlement • Sequelae of gender based violence women, like men, are likely to experience a large number – physical effects – mutilation and deformities leading of acute and chronic health problems.11 to chronic musculoskeletal problems, sexually

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transmitted infections (STIs), notably HIV, interpreter and adequate allocation of •  history including: , and gonorrhoea. time. The interpreter’s role as the woman’s – details of experience of PTSD, , – psychological effects – post-traumatic ‘voice’, in the background, and bound, , grief and loss and somatic stress disorder (PTSD), anxiety, depression, like the practitioner, by absolute respect of symptoms (see Case study 2). low self esteem, relationship difficulties; confidentiality must be stressed. The constant Physical examination somatic symptoms of fatigue, headaches, focus of the consultation must be between insomnia, generalised pain and anorexia the practitioner and the woman. The request to It is important to consider that many women • General conditions including dental involve a family member, in particular a spouse, are unfamiliar with their anatomy, in particular problems and incomplete immunisation. often presents a cultural challenge. While sometimes it may be appropriate initially Health issues – mental Case study 1 to do so, it is important to point out that Mrs B migrated to Australia with Resettlement stress arises from dealing with accurate diagnosis and management her husband and five children pressing needs such as housing, transport, require the language skills of a qualified after having spent 4 years in a in Guinea. They finances, social security and immigration. interpreter who should be booked for lived in Liberia until the war broke Increasingly, women head many newly arrived future consultations. out in 1996. She was assaulted African families. Adjusting to a new culture Time has a cultural meaning. The time to and sustained major injuries to brings about change in roles and the dynamic greet, smile and involve family members can the pelvis and legs. Her son and of relationships within the family, which open new paths in developing trust and rapport. brother were killed. The family was taken to the Ivory Coast by can often become strained. As a result History taking peacekeeping forces. In 2002, many women become more vulnerable to when another war erupted, while family violence. • History of health problems and treatment fleeing to Guinea, they become Grief is experienced because of the loss of before migration separated from the two older children. Soon after their arrival to or traumatic separation from their loved ones • Migration and resettlement history Australia, the Red Cross located whose whereabouts are often unknown. Women detailing life in country of origin, country of the children in a refugee camp may also be in constant fear for the safety of their displacement other host countries, or time in Kenya. With the support of the relatives left behind in the countries still stricken spent in refugee camps. Australian Refugee Association, she applies for a resident visa for by conflict, or in refugee camps. As a result the It is also important to enquire about the her children and patiently engages memories of past trauma are kept alive.5,14 woman's circumstances of seeking refuge with the immigration department. and with whom she migrated, time separated Health assessment from family, family left behind and if she is in Assessment and management require touch with them, the current composition of Case study 2 understanding of the impact of culture and her family, relationships and adjustment, how Mrs D and her two teenage of migration and resettlement on the health she deals with multiple resettlement demands, daughters are refugees from of women refugees. The explanatory model and links with her own community and support Afghanistan. The Talibans killed approach proposed by Kleinman has provided agencies (see Case study 1). her husband 7 years ago. For the past 12 months she has a suitable framework to establish a culturally • Reproductive health history including: been suffering from constant sensitive therapeutic relationship.15 –  obstetric and gynaecological history with headaches, generalised body The model emphasises a patient centred specific attention to complications during aches, intermittent episodes of left approach to explore the influence of culture on pregnancy, delivery, abortion and menstrual sided chest pain, palpitations and shortness of breath. Apart from health, on the perceived causes of illness and on problems mild hypertension, no causes are therapeutic relationships. Therefore, by following – contraceptive history found for her symptoms. Since the woman’s narrative of her presenting – sexual history including past history of coming to Australia, her appetite problem, the practitioner gains insight into how STIs and level of awareness of safer sexual and sleep have been poor. She constantly thinks about her two the woman ‘understands, feels, perceives, practices sons left behind in Pakistan and and responds’ to the problem and also what – female genital circumcision and related spends most of her time at home, is at stake for her family and community. The complications. As many women may not as she has stopped attending model also provides the practitioner with self find it appropriate to talk directly about this English classes because of monitoring tools to critically reflect on the issue, it is useful to start by enquiring about difficulties with concentration. Above all, she fears that if she dies impact of his/her belief system and practices. cultural/family practices. This issue may be suddenly there will be no-one to Important elements of the therapeutic further addressed as part of the preventive look after her daughters. encounter are the use of a qualified female health examination (see Resources)

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their reproductive organs, and might never have test if pelvic examination is not appropriate), and motherhood in high regard and as a result have had a physical, breast or internal examination screening mammography where indicated. short spacing between births. In discussing performed. Many women experience contraception it is preferable to explore attitudes embarrassment when asked to uncover their Management and birth spacing practices rather than raising bodies, even in front of a woman practitioner The management plan needs to be developed directly the issue of contraception. (see Case study 3). with consideration of the individual woman’s A discussion about contraceptive options needs and the practical, financial and cultural needs to take into account the woman's general Investigations issues that impact on her life in the initial physical state, as well as practical, financial In addition to routine screening tests to detect stage of resettlement. It must clearly outline and cultural considerations. For example the anaemia, nutritional deficiencies, and acute and practical aspects such as prescribing and follow use of barrier methods such as condoms chronic diseases,11 it is necessary to perform u p p l a n s a n d r e f e r r a l s . L i a s i n g can be difficult because of lack of access or preventive health screening tests including a with migrant health and support services knowledge about condom use as well as cultural Pap test, vaginal swabs for STIs (urine test for facilitates the woman's introduction to the attitudes about women negotiating safer sex. chlamydia may be a useful preliminary screening Australian health care system. Slow release long term contraception (such as The management plan should include depot-medroxyprogesterone) tends to decrease treatment of conditions found in the assessment menstrual flow and may be suitable for anaemic Case study 3 phase. The complex interplay between nutritional women. Combined oral contraceptives are safe Mrs G, 53 years of age, has deficiencies, poorly treated chronic conditions, and effective in women undergoing treatment recently arrived from Iran with and anaemia requires prompt attention, for malaria and schistosomiasis and are her husband and three children. She is postmenopausal and has particularly in pregnancy. For example, pregnant preferable to intrauterine devices for women been treated in Iran for type 2 women suffering from malaria, especially during suffering from sickle cell anaemia.16 diabetes for the past 3 years. their first pregnancy, are more vulnerable to the In providing oral contraception it is important She has never had a Pap test most severe manifestations and complications of to give simple, clear information on pill or mammography screening. 16 She presents accompanied by this disease because of decreased immunity; taking, and to arrange for further visits to her eldest daughter who has and addressing reproductive health issues and review the effectiveness and suitability of the persuaded her to seek treatment choices. This may include discussions about contraceptive options. for a longstanding problem of sexuality, body perception and cultural attitudes The management of blood borne and STIs vaginal pain and discharge. Mrs G 17 discloses her embarrassment and toward fertility and family size. requires a sensitive approach. Explanations is agreeable to having a vaginal Many African women have never received about how infection is spread, assurance examination. family planning counselling and contraception regarding confidentiality, preparedness to deal information. They tend to hold fertility and with the uncovering of trauma and violence, clear explanation about treatment and outcome, and counselling regarding safer sexual practices Table 1. Resources – women affected by female genital mutilation are all important aspects of the consultation. Information Women who have undergone female genital • Female genital mutilation: information for Australian health professionals produced circumcision need specific care if they suffer by the National Education Program on Female Genital Mutilation (FGM) and from complications associated with this practice published by The Royal Australian College of Obstetricians and Gynaecologists especially during pregnancy (Table 1). Available at www.ranzcog.edu.au/publications/pdfs/FGM-booklet-sept2001.pdf • Female genital mutilation: a self directed learning package for counsellors produced Early intervention for mental health issues by the NSW Education Program on Female Genital Mutilation. Copies are available Through the woman’s narrative of her presenting by contacting the Area Multicultural Health Unit, Cumberland Hospital, Locked Bag 7118, Parramatta BC 2150. Phone 9840 3910, fax 9840 3755 problem and her journey, it is possible to explore the depth of her suffering, and develop Programs therapeutic interventions and partnerships with Victoria: FARREP (Family And Reproductive Rights Education Program). Program specialist services. designed to support, advocate for, and inform African women and those affected by female genital mutilation attending the Royal Women’s Hospital. Referrals are Preventive health accepted from women, GPs, hospital and other community agencies. Phone 9344 2211 South Australia: Female Genital Mutilation Program includes education programs Preventive health and health promotion and resources for service providers. For information contact Women’s Health interventions include: Statewide on 08 8239 9600 or www.whs.sa.gov.au • Pap test – before taking a cervical smear it is useful to explain, possibly with the aid

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of a pelvic model or other visual material, Conclusion Desktop guide to caring for refugee patients in general practice. 2nd ed, 2002. about anatomy and to demonstrate the A management plan for the health care of a 3. Victorian Foundation for Survivors of Torture and Trauma. process and the purpose for taking a smear refugee woman presents significant challenges and refugee women from West and • Breast examination and, during the for the general practitioner. However, there are Central . Available at www.survivorsvic.org.au perimenopausal and postmenopausal increasing resources through the advocacy and [Accessed September 2006]. 4. New Zealand Ministry of Health. Refugee health care: period, mammography commitment to quality of care of professional a handbook for health professionals. Available at www. • Dietary and nutrition advice – for many bodies (see Resources). The recently introduced moh.govt.nz [Accessed September 2006]. newly arrived women finding traditional, Medicare Benefit Schedule items 714 and 5. Costa D. Women’s health clinics: the many faces of empowerment. In: Proceedings 4th International Women’s affordable food can be difficult initially. This, 716 for health assessment of refugees and Health Conference. Adelaide: Australian Women’s Health in conjunction with eating disturbances humanitarian entrants will also assist GPs in this Network Publisher, 2001. linked with depression or PTSD can prolong challenging task. 6. Pittaway E, Bartolomei L. Refugees, race, and gender: the multiple against refugee women. Refuge nutritional deficiencies and anaemia, and Resources 2001;19:21–32. lead to constipation and pain. Other women • Medicare Benefit Schedule Items 714 and 716 for 7. Ward J, Vann B. Gender based violence in refugee set- need to be alerted about the cardiovascular health assessments for refugees and other humani- tings. Lancet 2002;360(Suppl):s13–4. 8. LaMont-Gregory E, Matenge MN. Violence and inter- and metabolic risks of switching to a tarian entrants: www.health.gov.au/mbs/ nally displaced women and adolescent girls. Lancet diet rich in simple carbohydrates and • The RACGP Refugee and Asylum Seeker Resource 2002;359:1782. sugars, in particular soft drinks. Women Centre: www.racgp.org.au/refugeehealth/ 9. Moszynski P. Women and girls are still victims of violence • Translating and Interpreting Service: 131 450, Doctor’s of childbearing age should be counselled in Darfur. BMJ 2005;331:654. Priority Line 1300 131 450, www.immi.gov.au/tis/ 10. Burnett A, Peel M. Asylum seekers and refugees in regarding folic acid supplementation • Agencies providing integrated humanitarian Britain: health needs of asylum seekers and refugees. • Provision of immunisation settlement services: www.refugeecouncil.org.au/ BMJ 2001;322:544–7. • Referral for further investigations and docs/general/IHSS_providers_0506.pdf 11. Harris M, Zwar N. Refugee health. Aust Fam Physician 2005;34:825–9. specialist services are often required. In the • The Victorian Foundation for Survivors of Torture and Trauma Inc: Phone 03 9388 0022, www.foundation- 12. Krause SK, Otieno M, Lee C. Reproductive health for initial stage it is crucial to provide assistance refugees. Lancet 2002;360(Suppl):s15–6. house.org.au email [email protected] with making appointments and linking with 13. McGinn T. Reproductive health of war affected popu- • Queensland Program of Assistance to Survivors of support resettlement agencies. Support lations: what do we know? Int Fam Plan Perspect Torture and Trauma: www.qpastt.org.au 2000;26:174–80. may also be necessary for emergency • Service for the Treatment and Rehabilitation of 14. McMichael C. Sadness, displacement, resettlement: housing, immigration and social security Torture and Trauma Survivors in New South Wales: Somali refugee women in Melbourne. In: Barnes D, issues (see Case study 4). www.startts.org editor. Asylum seekers and refugees in Australia: issues • Multicultural Mental Health Australia: www.mmha. of mental health and wellbeing. Sydney: Transcultural org.au/ Mental Health Centre, 2003. • Multicultural Health Resources – women’s health: 15. Kleinman A, Benson P. Anthropology in the clinic: the www.health.qld.gov.au/multicultural/cultdiv/ problem of cultural competency and how to fix it. Case study 4 Available at www.plosmedicine.org [Accessed November womens_health.asp Mrs C, 55 years of age, and her 2006]. three children are the only family • Refugee Council of Australia: www.refugeecouncil. 16. Otieno-Nyunya B. Tropical diseases can harm pregnancy. survivors from the Burundi 1993 org.au/ Network 1999;19:5–7. war. They first migrate from a • Australian Refugee Association: www.ausref.net/ 17. Rademakers J, Mouthaan I, De Neef M. Diversity in camp in Tanzania, where they • New South Wales Refugee Health Service: www. sexual health: problems and dilemmas. Eur J Contracept lived for 13 years, to Darwin. refugeehealth.org.au Reprod Health Care 2005;10:207–11. There, the children are frequently • Migrant Health Service (SA): Phone 08 8237 3900. harassed. Mrs C develops severe shoulder pain following a fractured Conflict of interest: none declared. arm for which she received only emergency treatment. The family Acknowledgments move to Adelaide where they Thanks to Bernadette Roberts from Women Health contact a resettlement service Statewide (SA) for her support and advice on the that provides the assistance of an development of the assessment protocols, and Jane African community worker who Williams from Migrant Health Service (SA) for her con- brings her to the migrant health service. The worker assists to attend tinuous support in the development of health services medical appointments and trauma to refugee women. counselling, orientation with the References public transport system, application 1. Allotey P, Manderson L, Baho S, Demian L. Reproductive for priority housing, communicating health for resettling refugee and migrant women? Health with Centrelink, and initially with Issues 2004;78:12–7. English home tutoring. 2. Victorian Foundation for Survivors of Torture and Trauma CORRESPONDENCE email: [email protected] Western Melbourne Division for General Practice.

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