Dilemma: Honour-based violence
Your patient, a 20-year-old Muslim Pakistani woman, reveals that her older brother has threatened her with violence because her boyfriend is white and of a different faith. She has attended with low mood and anxiety. How would you respond to her worries?
Explain that this situation is not her fault, she is not to blame and that it is never acceptable to be threatened with violence
It is important to be sensitive in this case as the patient may be frightened of the consequences of anyone finding out about her disclosure. Firstly reassure her that anything we talk about is strictly confidential and that we are not allowed to break that confidentiality unless her or someone else’s life is in danger. Therefore one must also take care when contacting by phone or in writing, to not discuss with family members or others from the same community present and avoid using family or friends as interpreters.
One must recognise that she is at risk of honour based violence and/or forced marriage. It is important to risk assess her situation. This will give an indication of what needs to happen next and with what level of urgency.
I would assess her clinically regarding her mental health and treat appropriately, for instance with talking therapy and/or medication.
It is important to explain that this situation is not her fault, she is not to blame and that it is never acceptable to be threatened with violence in any circumstances. I would talk through the options available – speaking to an organisation that can offer confidential help and support (such as Karma Nirvana, 0800 5 999 247, or the National Domestic Violence helpline, 0808 2000 247), speaking to the police or social services especially if she is in immediate danger, finding a safe place to stay if needed.
Dr Iram Sattar is a board member of the Muslim Women’s Network UK and a GP in Wandsworth.
Talk to her on her own, reassure her and book a follow-up next week
I would first ensure that I am able to talk with her on her own. When talking about possible violence or the threat of violence from a partner or family member, even the presence of a child can be dangerous in that they may give some account of the conversation to the perpetrator. If the patient does not speak English it is important to use a professional interpreter not known to the patient (or Language Line).
I would then say that she is brave to disclose this information to me and that it must be difficult for her. I would say that even the threat of violence is unacceptable and illegal and ask for more detail about the nature of the threat and whether she is also at risk from any other family member. I would also ask about emotional abuse.
If she lives with her brother I would check whether it is actually safe for her to go home. I would then offer her the option of directly contacting a local domestic violence advocacy organisation (e.g. Womens Aid), giving her the contact details and the use of a phone in the practice. Furthermore, if there were an immediate risk, I would encourage her to contact the police. I would give her an appointment with me in the coming week to check how she is doing and to address her symptoms of low mood and anxiety, although I do not think anxiolytics or antidepressants have a role in this case.
Professor Gene Feder is a professor of Primary Care and a GP in Bristol.
The patient should feel that the GP understands and shares her concerns
It is imperative that the patient is not made to feel judged or condemned by the GP as this may be one of the patients biggest fears and may inhibit her ability to disclose more information indicative to risk posed by the brother. It is not uncommon that where a threat like this has been made that it is carried out, sometimes leading to fatal consequences.
The patient should feel that the GP understands and shares her concerns. This will empower the patient to feel that the actions of her brother are wrong as very often a patient in this scenario is made to feel like a perpetrator. The patient should be advised that as a 20 year old woman she has the ability to make her own decisions and choices and that the threat of violence from her brother is simply unacceptable. The patient should be advised that she has a range of options available to her and that she can contact the national charity Karma Nirvana confidentially to discuss these. It is advisable that the GP allows the patient to use the phone in the surgery as the patient may not be able to ring at home due to the controlling family dynamics.
Natasha Rattu is a helpline advisor for Karma Nirvana.