Fleeing one’s country to seek a new life is already a scary undertaking. But doing so as a victim of violence adds another layer of uncertainty, confusion and sometimes, fear. This is often the case for refugee and asylum-seeking women.
The Immigrant and Refugee Health Center (IRHC) at Boston Medical Center frequently cares for victims of violence, with offenses ranging from female genital cutting (FGC)—the nonmedical practice of removing, partially or totally, the external genitalia of females—to persecution and abuse because of a woman’s sexual orientation. The beauty of the IRHC is it exists as a service across all disciplines and is not limited to one brick and mortar clinic. Its wide reach allows providers from different departments to collaborate to deliver the best care possible to patients whose history of abuse is complicated and not well understood.
Boston Medical Center recently sat down with three experts in treating refugee and asylum-seeking women who are victims of violence. Nicolette Oleng, MD, a primary care physician, has seen dozens of women visit BMC’s Women’s Health Clinic seeking guidance on how to handle violent situations within their homes. Wan-Ju Wu, MD, obstetrician and gynecologist, and Anissa Dickerson, CNM, a midwife in OBGYN, are co-directors of the Refugee Women’s Health Clinic and have treated the wide array of clinical, psychological and social manifestations of FGC. All three share insights on how they respectively address violence among this patient population in a culturally competent manner.
Boston Medical Center: How do refugee and asylum-seeking women who are victims of violence present in your clinics?
Nicolette Oleng, MD: There are a variety of scenarios you see in clinic at BMC—women who’ve been abused in police detention centers, women escaping war zones and rape victims. But lately, we’ve been seeing a lot of women who are victims of violence because they identify with the LGBTQ community. And most of the time it’s women who are abused by their family members because of this. These women identify as lesbian, but they are forced into a heterosexual marriage against their will. Sometimes this can turn into physical violence and physical assault from other family members as well as perpetual sexual assault from their current intimate partner.
Anissa Dickerson, CNM: The most typical case we see is a woman seeking asylum with a history of female genital cutting, and often, it’s part of the reason they’re seeking asylum in United States. They come to our clinics usually for prenatal care and are having issues like painful menses or other problems. And sometimes, this is the first time a provider has asked them about [FGC]—it’s the first time they’ve had an exam.
BMC: How do you care for this patient population?
Wan-Ju Wu, MD: I think part of what we do is work across clinics. We help by working with others—other groups of providers like the IRHC to understand how to care for the patient. We create an environment where a patient can talk about their history with FGC, but also receive the [routine] care they need like a pap smear. We also work with clinics on referrals for medical and social issues. Many women don’t realize there are care plans like pelvic floor physical therapy we can refer them to that helps with symptoms [of chronic pelvic pain].
NO: As someone’s medical provider, I am able to diagnose and serve as an advocate. What’s unique about BMC, aside from working across multiple disciplines like psychiatry and social work, is we have partners within the community where these patients live. We work with those partners to support the patients—so we could work with resettlement agencies or local lawyers to ease frustrations with legal systems and help women get the care they need.
AD: Trauma-informed care is also an important part of our model. We really attempt to provide trauma-informed care to women and all patients we see. We must do all we can to decrease the risk and trauma for the woman, especially for a mother expecting, as well as treat their history with trauma.
BMC: How does cultural competency play an important role in caring for this patient population?
WW: FGC is a variable term because for a lot of these women, when you refer to it, it is a natural part of their childhood. Growing up, all women around them also had a similar procedure done so it’s what they know. It’s important we recognize that culture plays an important part of this, and we must do our best not to stigmatize because our experience with and knowledge of the procedure is different. We learn from them, while also teaching them more about [the potential harms of] FGC so hopefully knowing these things would make them not want their daughters to undergo the procedure.
NO: I’m not here to tell a patient about cultural norms because these women have very different experiences than me, but I can help a patient understand how her [abuse] is linked to the physical ailments she might be experiencing. In doing so, I can inform her and empower her to own her body and her rights as a woman.
BMC: What does the future hold for caring for this patient population? Where do you see improvement?
NO: The chronic conditions and the constant living in fear can take a toll on a person. These are really expensive to manage long-term, so we have to pay attention. We also have to train physicians on how to provide care to this community. Passing down the knowledge of culturally informed health care is what’s really important—we need to continue to teach providers to be empathetic when treating people who have dealt with unimaginable issues.
AD: It’s important we continue to destigmatize what these women experience in their countries of origin, and provide comprehensive counseling.
WW: More so, we need to work closer with community members and leaders within the community to help, creating a community advisory board to inform the community about what we do and work with them to address these issues in their community.