4.1 The GPs’ Experiences with Harmful Cultural Practices
Table 1
|
General practitioner
|
|
1
|
2
|
3
|
4
|
5
|
6
|
7
|
8
|
9
|
10
|
11
|
12
|
13
|
14
|
|
|
Marriage pressure
|
+
|
+
|
+
|
+
|
+
|
-
|
+
|
+
|
+
|
+
|
-
|
-
|
+
|
-
|
10
|
Family violence not honor related
|
+
|
+
|
+
|
+
|
+
|
-
|
-
|
-
|
+
|
-
|
-
|
-
|
+
|
+
|
8
|
Honor‐related violence
|
+
|
+
|
+
|
+
|
+
|
+
|
+
|
+
|
+
|
+
|
-
|
-
|
-
|
-
|
10
|
Honor‐related repudiation after rape
|
+
|
+
|
-
|
-
|
+
|
-
|
+
|
-
|
+
|
-
|
-
|
-
|
-
|
+
|
6
|
Virginity Certificate
|
+
|
+
|
+
|
+
|
+
|
-
|
+
|
-
|
+
|
-
|
+
|
-
|
+
|
+
|
10
|
Hymen ‘repair’
|
-
|
+
|
+
|
+
|
-
|
-
|
-
|
-
|
+
|
+
|
-
|
+
|
-
|
-
|
6
|
Female Genital Cutting
|
-
|
+
|
+
|
+
|
+
|
+
|
+
|
+
|
+
|
+
|
-
|
-
|
+
|
+
|
11
|
Forced Abortion/give up the child
|
-
|
-
|
+
|
-
|
-
|
+
|
-
|
-
|
-
|
-
|
+
|
+
|
+
|
+
|
6
|
No control over own fertility
|
-
|
+
|
-
|
+
|
-
|
-
|
+
|
-
|
+
|
+
|
-
|
-
|
-
|
-
|
5
|
Non- acceptance of Homosexuality
|
-
|
+
|
-
|
-
|
-
|
-
|
-
|
-
|
-
|
-
|
-
|
-
|
+
|
+
|
3
|
Overview of the main cases mentioned by the GPs.
When mentioning female genital cutting the GPs meant they had adult patients in their practice who had been cut in their youth. The GPs were asked to treat physical complaints, like uterine infections, but otherwise did not have conversations with their patients about FGC, although some GPs tried. Some GPs suspected that the women avoided the subject, because they know that FGC is forbidden in the Netherlands, but it may also mean that the doctors have difficulty in addressing the subject in a way that does not scare the women, as is confirmed by other research (Allwood, 2017).
Ten GPs had patients who had experienced marriage pressure. For nine this included also patients who had successfully escaped an unwanted marriage, often by running away from home.
The background to honor related violence was that the victim was suspected of transgressing codes of proper female sexual conduct. The cases included threats of violence, but patients also came with injuries and two GPs had lost patients who had become the victim of an honor killing. Six GPs had had patients who were repudiated by their husband and families after they had ‘confessed’ that in the past they had been raped.
Requests for virginity certificates were made by young women, often accompanied by their mother, because the daughter’s reputation was at stake. Five GPs had experienced that a young unmarried woman was forced to have an abortion and one that the woman was forced to give up her child for adoption. Hymen repair refers to cases in which young women who had had premarital sex asked for surgery to (re)construct their hymen. When the interviews were done, GPs could refer patients to public hospitals and private clinics that perform hymen ‘repair’. Since February 2020 hymen repair is discouraged in the Netherlands. Five GPs described cases in which married female patients had no control over their own fertility. They had no say in the use of contraceptives or the timing and number of pregnancies. Two GPs had male patients, who they suspected struggled with their homosexuality and one GP told about patients of hers, whose marriage had been arranged to, as she suspected, a homosexual man.
Beside the practices in the table, the GPs had encountered various other forms of harmful practices. Several GPs had had female patients who were send back against their will to the country of origin. Women came to surgery with psychosomatic complaints and depression. The underlying cause was in many cases that they were overly controlled by their family. Some examples that were given: GP4 had a Hindustani patient who was locked up in the house for three months by her husband. She discovered this because the woman did not show up at an appointment. GP6 had a Sri Lankan young woman among her patients who had tried to commit suicide, because she was not allowed to marry the man she loved. HP2 had a female patient who had caught a sexually transmitted disease (STD) from her husband but did not dare to confront him with that. A preliminary conclusion we can draw is that the majority of cases is related to the regulation of sexuality.
4.2 Interventions
4.2.1 Limited Space for Intervention
When patients come to them with social problems the GPs normal routine is to offer a listening ear and if patients are open to it give advice or organize help. This was also their course of action when patients explained to them their complaints related to harmful practices. Regularly, there was little room for intervention. Patients disappeared from their practice and only later they learned that a young woman was send back to the country of origin or was married to someone abroad or the patient would not disclose the cause of the medical complaint or accept intervention. Men, who the doctors suspected struggled with their homosexuality, were unwilling to discuss this. Women did not dare to leave a violent husband because of considerations regarding family honor. Illustrative is what GP2 related about a patient of hers of Turkish origin. The young woman ran away from home with a Turkish boyfriend to show up only three weeks later. She married the young man, but it turned out that he maltreated her. GP2:
Father and brothers never wanted to see her again and that is still the case now, six years later … and the mother and her sister couldn’t bear to watch it. And they were very angry at me at that time, that I did not do anything, but I did not know what I should do. … They were desperate. And now … mother and sister secretly have contact with that girl and the father more or less knows this, but the brothers absolutely not, because they are still furious with her, because the honor is so tarnished by what she did…. The daughter [at home, xx/yy] is even more in a fix [than the parents], because she sees her parents suffering, whom she loves very much, and about whom she feels very clearly that they cannot act otherwise, and on the other hand she says “It is terrible what is happening, we have to help my sister”.
The maltreated sister did not dare to divorce, because she had harmed her family’s honor already so much by running away with a boyfriend, that she could not on top of that divorce. The GP had started conversations with the parents and the daughters. She had also suggested to call in social services, which they refused, but apparently, the family expected her to do more. Looking back at this case and others, she remarked: ‘You see someone in need and there is nothing you can do. I find it the hardest to deal with that powerlessness. That is what I sometimes take home’.
4.2.2. Cultural Normativity and Intervention
GPs’ interventions are also dependent on their willingness to be normative. This becomes clear from how the GPs deal with arranged marriages. GP13 always asks further when he suspects marriage pressure, but takes care not to sound judgmental. Thus, he regularly discovered that young women were going to get married, because of the pressure by the family, while they themselves did not want this marriage. About his own role he said: ‘I always try to confirm them: “That as little as possible things happen to you, that you don’t want to happen to you”.’ GP3, herself of Turkish origin, is more directive. She had a young man who came to consult her because he wanted to marry a woman whom the parents did not find acceptable. Later, she invited the parents for a conversation and told them: ‘If he is happy with her… We live in 2016. You have to move with the times. You don’t marry her, your son does.’ GPs hence vary in their willingness to be normative and this impacts how they intervene. For majority-Dutch GPs decisions on intervention are complicated because they find it difficult to judge other cultures. Illustrative is GP13’s attitude in an encounter with family violence in a Syrian refugee family. The husband was extremely violent and controlling. The wife was hardly allowed to leave the house. The GP discussed the case in the team - he works in a health center – and they decided to report the case to the complaints-office for family violence. Yet, the wife begged him ‘literally on her knees’, according to GP13, not do so. Eventually, the case was not reported. Looking back, the GP13’s explanation is:
With Dutch families your conversation is more as equals. (I would say): “This just cannot be, if you don’t want to listen, I am going to report it.” Then I am harder. With this Syrian family I could not do this.
He suspected war trauma and very unequal gender relations and found it difficult to assess the consequences of reporting for the family. Hence, the cultural difference made him doubt about the right course of action.
Their attitude to refrain from moral judgment and from intervention when it concerns patients of migrant background sharply contrasts with their attitude towards Dutch patients, usually young women, who ask for labiaplasty. Then the GPs usually entered a conversation to discourage the patient, because after inspection almost always it turned out that it was for cosmetic reasons only. They felt little inhibition to speak their minds towards the patient.
With male circumcision, which is in the Netherlands mainly practiced by Jews and Muslims, they are again not inclined to intervene. Male and female GPs felt that it is a practice that is so commonly accepted by their Islamic and Jewish patients that a conversation has no use, nor did they experience it themselves as a very controversial subject. Only GP3, herself of Turkish origin, was outspoken: ‘It is … a cultural thing, not a religious thing.’ Still, she also said: ‘It is so deeply rooted … It is not open to discussion.’ And so, she too, refrained from raising the subject with her patients.
4.2.3 Patients’ Autonomy and Intervention
Another main reason why GPs may be cautious to intervene are considerations regarding their patients’ autonomy. Illustrative is how they advise women of migrant background who are abused. Their common way of responding to family violence is to have a conversation with the patient and if she agrees, to invite the husband and call in other social services. For GP9 the limit is if the abuse is structural. In particular if there are children who witness the violence, she tries to steer women towards a divorce by cautiously asking ‘Have you ever considered to divorce?’ She has noticed that over the past twenty years a divorce has become more accepted in the Moroccan and Turkish communities and divorced women do not necessarily become social outcasts. Still, she said, she always tries to find out:
Is this on? (a divorce, xx/yy) Will you be able to get by on your own? The family of your husband will of course no longer accept you, but what if you are not accepted by your own family? Then you have a big problem as a divorced woman in this community, so (my advice) is dependent on the situation.
For similar reasons GP1 too is cautious to advise women with a migration background to leave their husband:
These women must in a short time-span develop a form of autonomy, they did not have before. They are raised as dependent wife and then, all of a sudden, they must continue on their own with their children, and cast out, often also by their own family and other people in their immediate environment. … Sometimes, it is better to continue with a difficult husband.
At the same time, she said not to make a difference with native Dutch women: ‘The same goes for them. You must not go faster than the person herself.’ GP3 also takes into account the cultural background, but has different considerations:
This option of leaving is with Dutch people easier to discuss, the decision is easier to take. But I do discuss it, because they (migrant women, xx/yy) come to me for advice: “You can stay with him, but then realize that then probably nothing will change in your situation, or you can leave him, a divorce.” I do not take this decision, but I present you with the possibilities. O, that gives them something of a shock, because at that moment they had not yet considered that as a solution and they hear that from me, your GP … Often, they also think: “But if I leave him, I have no house, no income, how about my children?” Because often, they also believe that if there is family violence, the children will be taken from them, that child protection services will be called in and the children be placed in care. They think: “I am dependent on him, so I have to stay with him.” So, if you discuss this, it works clarifying. Yet, I always say: “It is your decision.”
Hence, while the first two GPs believe that her cultural background may restrict a woman’s capacity for autonomy, which makes them cautious to suggest women to leave their violent husband, the last GP, herself of Turkish origin, sees among the women lack of knowledge of their rights and of practical assistance available in the Netherlands, which makes them stay in an abusive marriage.
Yet, the GPs’ restraint to intervene was also based on another consideration regarding autonomy. GPs generally felt intervention as an intrusion in other people’s lives that was only justified if patients explicitly consented with or requested the intervention. As GP1 explained, with reference to a patient, who had been forced to marry and who visited her because she became depressive, and for whom she actually did intervene: ‘It is a meddling in other people’s lives, about which you ask yourself ‘Is this my role? Do I know enough of it (their culture, xx/yy)?’ Her general viewpoint is:
It is not up to me to interfere in people’s lives. Except when they ask me to, then I might do it, but not of my own accord. It is up to people themselves to live their lives. And in my eyes young people are sometimes the victim of their parents’ culture, but it is also up to them to struggle out of that. ….. So, my idea is that one has to have patience and believe that the next generation will do it differently.
Another example is given by GP10. When women tell her that they do not want to become pregnant again, and if to discuss this with the husband is no option, she is willing to secretly provide contraceptives. Yet, she adds:
But I do not actively seek it out. In the end, I find it a matter of self-determination. People also have to choose or decide in this themselves. I understand that there are many hindrances, and that those barriers and hindrances are bigger than in Dutch culture, but still I believe that as GP it is not my task to play mothers and fathers for my patients. I work more demand-driven.
Even GP3, one of the doctors most prone to intervention, found it important to stress that it must be the patient, who decides.
4.2.4 Trespassing the Boundaries of Bioethics?
While the GPs were cautious to intervene if not requested by the patient, this is different when patients ask for help. Yet, this was not without moral dilemmas. This became most clear in the issue that the GPs experienced as the morally most trying, when they were asked to establish a patient’s virginity. Ten GPs had received requests for virginity testing. The context was usually that the family pressured the young woman to have her virginity confirmed because there were doubts about her chastity. There were threats of sanctions and the doubts could be an obstacle to get married. Four GPs have always complied with the request, two always refused and two have in the course of their practice changed position. The WHO has declared in 2018 virginity testing a harmful practice. The interviews took place in 2017, yet none of the GPs referred to the testing as a harmful practice. Those who refused did so, because they did not consider this as part of their job or believed that by complying, they would strengthen the sexual morality they rejected. Of those who complied, some doctors had in some cases actually performed a vaginal examination, although they knew that there is no necessary relationship between the status of the hymen and virginity and hence it is impossible for doctors to establish whether a woman is still a virgin. More common however was that they sought to have a private conversation with the young woman to hear from her what was the matter, and then to write a virginity certificate or if the family settled for that, to verbally transmit the result of the ‘examination’. Yet, they found it problematic that they thus confirmed a sexual morality they rejected and helped keeping up the myth that all women have a hymen that bleeds upon first penetration. What bothered them professionally is that they were falsely diagnosing a condition. When they wrote that they could not establish that the young woman has lost her virginity, they were well aware these are ‘diplomatic certificates’ as Juth and Lynøe (2014) name them, as the double negation makes that technically they are not lying, but that did not ease their discomfort. GP1 explained: ‘When it comes to virginity, you always do wrong, I find. Either you rape yourself, your values or norms, or you do violence to her, because she may be maltreated or lynched because she is not a virgin anymore.’ GP3 similarly stated:
You are a social worker. You try to be non-judgmental. Sometimes you have to trespass certain boundaries, or, you are not obliged to, but you do what is beneficial for the patient. To protect the patient, you do sometimes things you think of as bullshit.
GP14 therefore called the certificate ‘the nonsense certificate’. GP9 initially did not comply with requests for a virginity certificate. Yet, after she had witnessed what difficulties it caused for young women when their chastity was doubted, she changed her mind. One of her patients for instance was cast out by her family. GP4 on the other hand said that initially, without checking she ‘declared anybody virgin, if this could keep them out of troubles.’ Yet later, she noticed that a virginity certificate might pave the way to other undesirable things, like a marriage with a husband the young woman did not want (as the man demanded proof of his bride’s virginity). She added: ‘Then you think: “I can better not declare anything, because then she will not marry him, let there be disgrace in the family.”’ What bothered her also, was that she had young women in her practice, who were on the pill and of whom she knew they were not virgins, who still asked for a virginity certificate when they were about to marry. She explained her decision to no longer write virginity certificates by saying:
At a certain moment I realized that this is no longer my struggle, my war. If I can help you, by, say, walking in a protest march, I’ll do that, and I am willing to explain [the hymen] to the community, I am willing to do anything, but this is not my war. You really have to do it yourself. It must really come from the inside.