Violence & migrationA review of the literature

Pierre Chauvin & Sophie LesieurInserm & Sorbonne Universités, Paris, France

Fegegergerger

Domestic programs meeting

Amsterdam 2015

Violence & migration

Essentially international referenced journals +/- position papers and international reports

Approx. 100 references

Limits: no grey literature collected (no national reports)

A scientific literature (in medicine, epidemiology, public health and human/social sciences) Mainly normative (policy papers, guidelines) Far less empirical (surveys data) Almost never evidence-based, particularly in primary care

Summary

Introduction

Medical aspects: consequences, screening and care in primary care medicine

Some data from different surveys

Ethical aspects

Survey tools & questionnaires

Introduction

From psychological point of view, the different steps of the migration process is requiring from people a constant adaptation of their behaviours, habits, expectations that is a source of stress, anxiety and desorientation Particularly when they are alone or with children

The loss or the constantly change of factors such as language, relatives, friends, cultural habits, social norms, all things that participate in building self identity and keeping self autonomy may have traumatic cumulative effects

Migration is a violent experience by itself

Bhugra D. Migration and mental health. Acta Psychiatr Scand 2004; 109: 243-58.

Migration and exposure to violence

At the different steps of their trip, migrants (and particularly clandestine migrants or those in the most precarious situations) are exposed to many dangers and life-threatened risks that have psychological, physical and social consequences

In most countries, no systematic public health surveillance system of these morbidities

in Paris (France): Comede, which has systematically screened that kinds of psychotrauma for years, shows that they are the most frequent health troubles (among 20;000 arriving migrants)

Same result observed in some German and Swiss surveys

Which violence are we talking about?

What? Physical violence Psychological violence Sexual violence Torture Psychosocial violence

discriminations hunger Administrative harassment Forced relocation

Secondary violence Not being listened or

believed Refusal of care Administrative detention

Where? In public space Group violence Family violence Domestic, conjugal

By who? Security forces Trafficking networks Criminals Civils Relatives, partner

Medical aspects

Medical consequences

Injuries (including tympanic, internal ear, genital, perineal, dysuria) Peripheral neuropathy, epilepsy, memory troubles, concentration

problems Distress, shame, guilt, withdrawal (inward-looking attitudes): "for

many people, restoration of their normal life can be an effective promoter of mental health"

Self neglect (inobservance, no adherence to care) Depression, anxiety, suicidal ideation, phobia, PTSD HIV, STDs, sexual troubles An endless list of psychosomatic symptoms: fatigue, headache,

stomach and digestive pain, back pain, etc +++

Burnette A, Peel P. The health of survivors of torture and organised violence. BMJ 2001; 322: 606-9.

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Urgently HIV PEP in 72h Urgent contraception Vaccination (HBV, tetanus) STDs screening and

treatment Psychological support Legal protection Medical certificate Legal support

At distance VTP HIV, HBV, STDs confirmation

screenings Screening and care

depression anxiety PTSD

Social and legal protection

Caring the psychological consequences of violence

A basic care can prevent further severe mental health problems Make victims talk about it and listen to them +++ Face to face consultations or support group Create a secure space where people can talk confidentially and

share their experiences, fears, distress, frustrations, problems and preoccupations

In order to recover their sense of control, to manage their emotions, to copy with them

The "trauma–informed care » approach

"Trauma-informed care involves recognizing the impact of traumatic experiences on an individual’s life and behaviour"

The goal is to ensure that all care is: adapted to the individual’s needs supportive and avoids judgmental statements or actions integrated and holistic, treating the person as a whole, not just a

list of clinical symptoms empowering, ensuring that the patient’s rights to information respecting privacy, bodily integrity and participation in decision-

making supportive of healing and recovery through a patient-centred

treatment planZimmerman C, Borland R. Caring for trafficked persones. Guidance for health providers. Geneva: IOM, 2009.

Some elements of consensus

Victims do NOT open up spontaneously, or rarely The health professionals must address these issues themselves

Violence screening should de systematic Among vulnerable migrants and asylum seekers Among all women (including in the general population*)

*domestic violence = 10% in the last 12 months, only 10% are reported, life long prevalence = 15-70% according to the countries

The systematic screening is well accepted by patients These are the doctors, never the patients, who feel uncomfortable +++

It requires a response that rests mostly with primary care, at least at the first step

Prévalence de la violence conjugale

Garcia-Moreno C, Pallitto C, et al. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva: WHO, 2013

Some surveys data

Asylum seekers in Denmark

N= 142 new asylum seekers (Amnesty International Danish Medical Group) from 33 different countries (Afghanistan, Iraq, Iran, Syria)

45% had been tortured (1/3 during the year before arrival) A majority had witnessed armed conflicts, had been persecuted and/or in jail Twice as physical symptoms and 3 times as psychological symptoms as non

victim asylum seekers 63% with a PTDS 30-40% had anxiety syndromes (vs. 5-10% of the non victims) 42% had physical injuries directed linked to torture

Masmas TN, Moller E, Buhman C, et aL. Asylum seekers in Denmark. A study of health status and grade of traumatizationof newly arrived asylum seekers. Torture 2008; 18: 77-86.

Health and social needs of traumatized refugees and asylum seekers in the Netherlands

Strijk PJM, Van Meijel B, Gamel GL. Health and Social Needs of Traumatized Refugees and Asylum Seekers: An Exploratory Study. Perspectives Psychiatric Care 2011; 47: 48–55.

Sexual and gender-based violence in refugees, asylum seekers and undocumented migrants in Belgium & the NL

Keygnaerta I, Vettenburgb N, Temmermana M. Hidden violence is silent rape: sexual and gender-based violence in refugees, asylum seekers and undocumented migrants in Belgium and the Netherlands. Culture, Health & Sexuality 2012; 14: 505–20.

223 in-depth interviews were conducted with refugees, asylum seekers and undocumented migrants in Belgium and the Netherlands.

The majority of the respondents were either personally victimised or knew of a closepeer being victimised since their arrival in the European Union.

A total of 332 experiences of SGBV were reported, mostly afflicted on them by (ex-)partners or asylum professionals.

More than half of the reported violent experiences comprised sexual violence, including rape and sexual exploitation.

Violences sexuelles et de genre chez les réfugiés, et les sans papiers en Belgique et aux Pays-Bas

Long term impact of violence on Kurdish and Bosnian migrants health in Switzerland

A survey in primary care

Among migrants who were living in Switzeralnd for 6-9 years in average

Confirms the results of previous American studies that observed the long term consequences of violence, many years after the experience It is crucial for doctors to question the violence history among

immigrants

Gilgen D, Salis Gross C, Maeusezahl D, Frey C, Tanner M, Weiss MG, Hatz C. Impact of Organized Violence on Illness Experience of Turkish/Kurdish and Bosnian Migrant Patients in Primary Care. J Travel Med 2002; 9: 236–43.

Sub-saharian African illegal migrants in Morocco

63% reported violence (2/3 par Morocco security forces and 20% by des criminal bands)

42% of people received by MSF had violence-related injuries 35% of the victims of sexual violence were victims of trafficking The main obstacles to care :

Fear of being arrested (25%)

No perceived need for medical care (25%)

Collectif. Violences, Vulnerabilite et Migration : Bloques aux Portes de l’Europe. Un Rapport sur les Migrants Subsahariens en Situation Irreguliere au Maroc. MSF, mars 2013.

Ethic in research on violence

An exemple: "Putting Women First", a good practices guideline for the research on violence against womenIn order to avoid low quality data (under reporting)To prevent « damage for nothing » Security and confidentiality Methodological standarts Training of interviewers Refering and support

Garcia-Moreno C, ed. Priorite aux femmes. Principes d'ethique et de securite recommandes pour les recherches sur les actes de violence familiale à l'egard des femmes. Genève: OMS, Département Genre et santé de la femme, Groupe Santé familiale et communautaire, 2001.

Some survey tools and questionnaire

Not to talk about specific scientific surveys, far too much detailed exemple : ENVEFF, Harvard Trauma Questionnaire

No standart or harmonized questionnaire (yet), neither in epidemiology nor in medicine « During your life, have you ever been exposed to violence? »

Paris hospital free clinic (PASS) among SSA migrants (68% women) Sensibility = 47% (H) and 78% (F), Spcificity = 100%

But many references on some specific violence Mainly domestic violence (women and witness children)

No consensus about what kind of events to collect

Weine S, Bahromov M, Loue S, Owens L. Trauma Exposure, PTSD, and HIV Sexual Risk Behaviors among Labor Migrants from Tajikistan. AIDS Behav 2012; 16: 1659–1669.

A useful tool…

PTSD Screening Instrument (PC-PTSD Screen)

Can be self-administered

Sensibility = 91%, Specificity = 80 % (cut-off=3)

4 items Reexperiencing: nightmares or having thought about traumatic event(s)

when you didn't want to Avoidance: having tried hard not to think about it Hyperarousal: being alert, careful, frightened Numbness: felt numb or detached from others, activities, surroundings.

Conclusion

A major medical problem among vulnerable migrants Frequent With major health consequences Which needs a systematic screening and support in primary care

Recognized as a good practice in primary care In many migrants health guidelines

Apart domestic violence, the way of surveying these violence are still quite « open » An opportunity for NGOs

A lever for changing prejudices about immigration and advocating migrants needs With a rich corpus of international normative references