Gillian Singleton, Jan Williams, Georgia Paxton
- Offer women standard preventive screening, taking into account individual risk factors for chronic diseases, bowel, breast and cervical cancer.340
- Offer women antenatal/perinatal care consistent with Australian guidelines.352
- Consider pregnancy and breastfeeding in women of childbearing age when planning immunisation, post-arrival screening, and treating positive screening test results.
- Offer appropriate life-stage advice and education, including contraceptive advice where needed, to all women, including female adolescents.
- Women and girls are vulnerable to sexual violence during civil conflict and subsequent displacement. Be aware and sensitive to the possibility of a history of sexual violence and/or sexual abuse and associated physical and mental health consequences.353
- Intimate partner violence (IPV) is more common in countries experiencing war, conflict or social upheaval. As with any women presenting for care in Australia, the possibility of IPV should always be considered, sensitively explored, level of safety assessed and managed empathically.354,355
- Practitioners should be aware of clinical issues, terminology and legislation related to female genital mutilation/cutting (FGM/C) and forced marriage.356,357
- Always define confidentiality, and attempt to integrate women’s preferences regarding gender concordant care, including gender preference for interpreters.
Female adolescents and women from refugee-like backgrounds may have had limited access to women’s healthcare services prior to arrival in Australia, either due to lack of availability in their countries of origin and transit or because of prolonged periods spent in transit camps. Depending on their country of origin, the concept of women’s health screening and perinatal care may be unfamiliar, and the rationale, benefits and processes thus may need to be explained with a professional interpreter to enable informed consent.
A comprehensive women’s health assessment should be offered respectfully and sensitively. This is an opportunity to build trust and to create a safe environment. Similar to other communities, sensitive aspects of history may not be volunteered by patients until rapport is established, and may not be raised in the presence of other family members. Interpreter rapport is a further factor in building trust in the consultation. It is essential to clearly define the routine role of confidentiality in consultations, including defining interpreter confidentiality. Female adolescents should be seen alone for part of their health consultations once rapport is established. Explaining this is routine in the Australian healthcare system and seeking permission from both the adolescent and her parent/carers is helpful to facilitate this aspect of adolescent healthcare.
It is rarely necessary to perform a breast or pelvic examination at the first visit, unless there is an issue of immediate concern to the patient. It may be appropriate to see the patient over several visits in order to establish trust, to adequately explain the reason for women’s health screening and to ensure understanding and informed consent. Practitioners should always offer and provide a female interpreter, or, if requested by the individual, a chaperone for these consultations.
Cultural pressures and expectations as well as additional vulnerabilities related to migration status may influence the health consultation. As an example, women who are seeking asylum who are victims of IPV, as well as facing the many barriers common to all women who are victims of family violence, may struggle to disclose their traumatic experiences because of concerns about potential impacts on their asylum claim.
Confidentiality within the consultation should be emphasised as well as the fact that resources and support are available if violence is disclosed.355 Re-establishing trust is essential to emotional recovery for women who have experienced pre and/or post-migration trauma. Development of a quality therapeutic relationship with a primary care provider can be an important part of this recovery process.
Many women from refugee-like backgrounds are unfamiliar with pap smears and mammography, as well as other aspects of preventive health. Women with a first language other than English in Australia have been found to have lower health screening access rates and poorer quality of health outcomes compared to English speakers.358,359
Explain the benefit and mechanism of these investigations to ensure an informed choice. Use health promotion material such as multilingual patient information sheets, flip charts, anatomical models and diagrams to explain screening tests, basic anatomy and physical functions such as menstruation.360
Women from refugee-like backgrounds may be at increased risk of osteoporosis due to prolonged poor nutrition and/or low vitamin D levels. Standard national guidelines apply for chronic disease (such as type 2 diabetes, ischaemic heart disease and osteoporosis), cervical, breast and bowel cancer screening.340
Screening for STIs also needs to be considered for women at risk, particularly for women who have come from a high-risk environment for, or disclosed exposure to sexual violence or unprotected sex (See Sexually Transmissible Infections).
Fertility and contraceptive choices
A comprehensive contraceptive and obstetric history is essential. Avoid making assumptions when providing sexual and reproductive healthcare. Some women may have limited knowledge and experience of contraception and are consequently at greater risk of unplanned pregnancy.361
Contraceptive choices may be a responsibility shared by both partners. Offer information sensitively and clarify and enhance existing knowledge of emergency, reversible and irreversible contraception. Multilingual resources are available.362
Avoidance of assumptions is particularly pertinent to the management of unplanned pregnancy. Some women may decline a termination of pregnancy for religious and/or cultural reasons, others will make use of the opportunity; in any case, information regarding referral and clinical options, including medical abortion, should be provided so women can make an informed choice.
Female genital mutilation/cutting
Female genital mutilation/cutting363 is practised in many humanitarian source countries, although there are no prevalence data on how many women have undergone the procedure prior to arrival in Australia. It is estimated that over 125 million women worldwide have been affected by FGM/C,364 and in some countries the prevalence in women is up to 90%.
FGM/C involves removing normal, healthy genital tissue. The procedure is typically performed in young girls, from infancy to 15 years of age. It is medically unnecessary and has many potential physical and psychological consequences. The risks are related to the type of FGM/C that a woman has undergone. It is important that all primary care providers who see women from countries where this practice is performed are aware of the facts on the procedure, and potential consequences for women and girls.
It is important to be aware that use of the term FGM/C can be offensive to women. This issue should be explored respectfully, ascertaining what term the patient prefers. Other suggested terms such as ‘female circumcision’, ‘traditional cutting’ or ‘female ritual surgery’ may be perceived as being more respectful.363 For many women, FGM/C is a normal part of their life experience and thus they may be surprised when concerns are raised. Adolescent girls may not be aware that they have undergone the procedure.
There are four different types of FGM/C, ranging from excision of the prepuce to removal of the majority of the external genitalia and narrowing of the introitus (infibulation).363 Potential consequences depend on the type of FGM/C performed. Many women do not experience difficulties; however some may suffer from difficulty voiding, frequent UTIs, obstructed urinary flow, incontinence, sexual difficulties, urinary and/or faecal fistulae, obstruction during miscarriage and childbirth, intra-partum vaginal and perineal damage, chronic pain and psychological sequelae. Refer to an experienced female GP or sexual health nurse for gynaecological examination, including for pap smears. If women request de-infibulation (surgical opening of a narrowed introitus), facilitate expert gynaecological review – this is considered an urgent rather than routine referral.
Respectful, non-judgemental explanation of medical concerns about risks of FGM/C is important, particularly during pregnancy. Women and their families need to be aware of Australian law concerning FGM/C. It is particularly important that women understand that it is illegal in Australia for their daughters or other female relatives or friends to have this procedure, either in Australia or while overseas. Some families may want their daughters to undergo FGM/C and may wish to take them out of Australia to facilitate the procedure, this is an issue to consider when families seek travel advice for other reasons. Mandatory child protection reporting is required if there is any concern that girls aged less than 18 years of age are at risk of undergoing FGM/C.365 Education programmes to inform and support communities about the negative health consequences of FGM/C are available in several states in Australia.366
Women who have a positive pregnancy test or who are planning pregnancy should be offered screening consistent with Australian antenatal care guidelines.352
Pregnancy planning, preferably in the prenatal period, is very important in women who have had FGM/C, to ensure that health outcomes of both mother and baby are optimised. Assess the type of FGM/C and refer appropriately to ascertain if de-infibulation is required. The external appearance of genitalia is not necessarily an accurate representation of internal narrowing due to the procedure, which may complicate labour. Understanding and managing expectations, which may be divergent from obstetric practice in Australia, such as expectation of re-infibulation following delivery, is important; these concerns should be recognised and addressed as soon as they arise.
Many women from refugee-like backgrounds come from countries where there are high fertility rates and poor access to antenatal and prenatal care. Consequently, pregnancy complications and fetal loss are not uncommon.367 The sense of loss experienced by women from refugee-like backgrounds may increase during pregnancy. Many women are distressed at not being able to follow their traditional cultural practices at this time, where supporting women through pregnancy and childbirth, and raising children is a shared responsibility. Women often feel the absence of relatives acutely and some studies suggest a higher risk of postnatal depression.368
Menopause should be considered when taking a history from women aged over 40 years. Menopausal symptoms may be masked by, or attributed to the difficulties of resettlement. Prolonged periods of amenorrhoea due to malnutrition or stress may be mistaken for premature menopause, or mask a slowly returning and/or unexpected fertility. This presentation provides a good opportunity to talk about contraception and preventive health, including the importance of weight-bearing exercise.
Intimate partner violence355
Refugee women often lack knowledge of laws about IPV in Australia, particularly knowledge of what constitutes family violence, and how to access help for this issue. Women can face multiple barriers to disclosing their experience of violence.
Family violence in Australia is not confined to particular socioeconomic or cultural groups – it is pervasive.369 Recognised correlating factors for risk of violence in women include exposure to child abuse or violence as a child, alcohol or drug dependency issues, financial or personal stress and lack of social support. IPV is more common in countries experiencing war, conflict or social upheaval. Some women are more vulnerable to violence, or less able to leave violent relationships, based on factors such as age, rural and remote location, disability, ethnicity, English language ability and being pregnant.
As is the case with any women presenting for healthcare in Australia, the possibility of IPV should always be considered in women from refugee-like backgrounds, sensitively explored, level of safety assessed and managed empathically.354,355
It is useful to screen discreetly for family wellbeing and to interview the woman separately from her partner where possible, giving her an opportunity to raise concerns. Useful questions include: ‘Is there a lot of tension in your relationship at the moment?’, ‘How do you solve arguments if they happen?’, ‘Do arguments ever get physical at home?’, ‘Do you feel safe at home?’. Assessing safety is important, as is providing support to develop a safety plan for women and children at risk.
The majority of women who are victims of IPV do not readily disclose their traumatic experiences due to a number of factors including:
- fear of reprisal/worsening violence
- social isolation and financial dependence
- poor self-esteem as a consequence of the violence
- emotional dependence
- being unable to recognise the cycle of abuse/self-blame
- fear of loss of custody of children.
For women from refugee-like backgrounds, disclosure rates are believed to be lower than the rest of the population, and they may face additional complexities such as concerns about potential impact on immigration status, and cultural and religious factors, including risk of social ostracism if disclosure occurs.370,371
Healthcare providers need to be aware of these issues, to approach concerns about IPV sensitively and to review regularly and invest time in the therapeutic relationship as the development of trust is imperative. When a woman is ready, referral to culturally appropriate advocacy, support and legal services can be facilitated.
Australian antenatal guidelines (contains information on culturally sensitive care and on specific needs of women from refugee-like backgrounds)
Women from culturally and linguistically diverse backgrounds