‘And that was her choice’: Dutch general practitioners’ perceptions of the autonomy of patients with non-western migration backgrounds who experience domestic violence

ABSTRACT

Women in the Netherlands with non-western migration backgrounds experience domestic violence at the intersection of culture and gender, and visit their general practitioners (GPs) with health concerns related to the violence. Drawing on semi-structured interviews with GPs, this paper illuminates how GPs navigate the process of decision-making around intervention in domestic violence, with particular attention to the role of autonomy. Patient autonomy is a core principle in Dutch general practice. The term refers to the principle that GPs must respect that competent adults can make autonomous decisions about the care they do and do not want, and that GPs must respect patients’ views, choices, and ways of life. The interview data shows great variation in how GPs respond in situations of domestic violence against women with non-western migration backgrounds. Deploying ‘somatechnics of perception’, this paper explores how GPs’ perceptions of their patients’ autonomy are both the agent and effect of a complex and embodied negotiation of gender, race, culture, ethnicity, medical ethics, and morality. In highlighting how these patients’ autonomy is rendered (un)intelligible and (il)legible in contextually specific ways, this paper sheds light on how GPs in the Netherlands can better assist women with non-western migration backgrounds who experience domestic violence.

KEYWORDS:

• Domestic violence
• autonomy
• somatechnics
• bioethics
• perception

Introduction

In the Netherlands, women with non-western migration backgrounds visit their GPs with direct questions, requests, and needs directly related to domestic violence, such as physical injuries, anxiety, and stress, but also with somatic health needs, such as headaches and stomach aches (Prosman et al., 2014) or general symptoms of depression that mask domestic violence-related care needs (Saharso & Dekker, 2022, Van Bergen & Saharso 2016). In this article, we explore how GPs navigate the process of decision-making around intervention when women with non-western migration backgrounds visit them with domestic violence-related care needs.

The Royal Dutch Medical Association (KNMG) defines domestic violence as:

(threats of) violence, in any location, by someone in the domestic circle, where violence means the physical, sexual, or psychological assault on the victim's personal integrity, including partner violence, honour-related violence, and elder abuse. The domestic circle includes: a family member, a housemate, a spouse or former spouse including a (registered) partner, and an informal caregiver. (2018, p. 15)

While research into the prevalence of domestic violence in the Netherlands has found no differences in rates of victimisation based on migration status (Akkermans et al., 2023), women with non-western migration backgrounds may nonetheless face different and additional structural barriers that impact their decision to talk about and report the violence, and to leave violent relationships (Valente & Stichting LOS, 2022). These are often related to gender norms that are both internalised and externally enforced. Every year, 2500–3000 cases of violence in which it is suspected honour plays a role are reported to the police (Fier, 2018). It concerns ‘acts of violence and control [that] may be accepted, or even encouraged, if they are seen as a means for restoring honour, fighting shame and valuing shared social norms’ (Lidman & Hong, 2018, p. 262). Such violence, commonly related to strict gender norms, can take the form of (domestic) violence against women (Lidman & Hong, 2018). When domestic violence is culturally accepted or condoned, Tonsing points out, ‘there is greater tolerance for such acts within the community’ (2016: 442). Standing up against abuse, and/or leaving their partners, then, is not merely a matter of individual choice for women, and women must also take the collective into account (Aboulhassan & Brumley, 2019). Women must thus negotatiate the cost of leaving in terms of additional violence, and losing access to their communities. Women’s position regarding leaving a relationship itself may also already be shaped through their socialisation in a context that does not condone divorce or separation and that ties women’s identity to marriage (Ondicho, 2013; Tonsing, 2016). Moreover, norms around women’s and men’s roles impact women’s economic dependence on others in their domestic circle, which can limit women’s ability to stand up against and leave domestic abuse. Female marriage migrants are disproportionally victims of domestic abuse (Valente & Stichting LOS, 2022), with the number of victims without prior residency permits estimated at 70–800 per year (Jongebreur et al., 2017). To qualify for an independent residency permit, victims of domestic abuse who have had a residency permit for fewer than five years must prove domestic abuse in the marriage (IND, 2023) with, for instance, statements from healthcare practitioners, social workers, and the police. Women are, however, often not (sufficiently) informed, at least in part because men withhold information from them, resulting in insufficient evidence and women not reporting, which points to the gendered impact of immigration policies (Roegiers et al., 2023).

Our data shows there is great variation in how, and if, GPs respond in situations of (suspected) domestic violence against women with non-western migration backgrounds. One of the difficulties GPs experience in deciding on the best course of action is weighing up their patient’s autonomy in the context of such constraints (Saharso & Dekker, 2022). On the one hand, (patient) autonomy is a core principle in Dutch general practice while, on the other hand, cultural difference in the Netherlands is read as autonomy-constraining, whereby women with non-western migration backgrounds become culturally coded as inherently oppressed and powerless (Tack, 2023).

Deploying somatechnics of perception as a critical orientation (Sullivan, 2012), in what follows we complicate the medical ethical principle of (patient) autonomy and show that GPs’ perceptions of their patients’ autonomy are both the agent and effect of a complex and embodied negotiation of gender, race, culture, ethnicity, religion, medical ethics, and morality, and highlight how these patients’ autonomy is rendered (un)intelligible and (il)legible in contextually specific ways. In doing so, we argue that a somatechnics approach constitutes a necessary step in developing practical tools for intervention in situations of autonomy in constrained conditions.

Autonomy and somatechnics

Autonomy in general practice

Autonomy means that individuals can live their lives according to the values that matter to them. To pursue a life of their own choosing, they must be free from coercion and informed about possible lifestyle options (Saharso, 2007). Patient autonomy, a core principle in Dutch general practice, is based on this idea. In its 2022 Code of Conduct for Physicians, the KNMG notes that physicians, and thus GPs, must respect the autonomy of patients: people should be able to make decisions free from pressure and coercion from others about the (health) care they do and do not need. Respect for patient autonomy does not mean, however, that patients should make decisions without help, support, or advice from others. Indeed, conversations with others can help patients to develop their own views and make decisions. GPs must thus invite patients into a shared decision-making process, that is, engage in a conversation with the patient about what they need to be able to make a decision. Informed decision-making is part of this: to make their own decisions, patients need to be informed. This constitutes informed consent. GPs thus provide information that is as complete and clear as possible. They must take into account the lived reality of patients, including cultural patterns, knowledge levels, and language barriers, and respect patients’ views, choices, and ways of life. The KNMG (2022) points out certain limits to patient autonomy: it does not mean that patients will simply be granted the care they request but, rather, that they can refuse care they do not want, and it concerns mentally competent patients.

The autonomy principle is only one of four key ethical pillars in medicine. Reflecting the germinal work of Beauchamp and Childress (2001), the Dutch Physician’s Oath also refers to non-maleficence, or the duty to not do harm; beneficence, the duty to act in the best interest of the patient; and justice, the duty to treat all patients in similar situations equally (NFU et al., 2019). The KNMG (2022) acknowledges that these principles are often at odds with each other in moral dilemmas, and that physicians will need to balance their importance. Physicians are allowed to deviate from ground rules, but must be able to substantiate their decisions. When a physician cannot comply with a patient’s request because it goes against their own conscience, the physician must inform the patient and refer them to a colleague.

The KNMG (2018), furthermore, has a domestic violence reporting code that includes both violence against adults and child abuse, and mentions honour-related violence, forced marriage, and isolation of adults. Since physicians have a right – but not a duty – to report, the code provides a step-by-step guide that assists physicians in deciding when to report. Physicians report to Veilig Thuis (Safe (at) Home), the key advice and reporting body for domestic violence in the Netherlands. When the violence solely concerns adults, physicians should be reluctant to report if the adult does not give permission to do so due to doctor-patient confidentiality. They must, however, take the vulnerability of the victim into account. When children are involved, regardless of whether they are a direct victim, physicians can report earlier. Physicians can report without the consent of their patient if there is serious risk of severe physical or psychological injury or death. The general rule is that they should not share information with other healthcare workers who are not involved in the case, nor with the police.

Autonomy, then, is a guiding theoretical principle for physicians, and emerged as a way to counter paternalism in medicine. That GPs should not report domestic violence unless the patient consents or faces serious danger demonstrates a common approach to autonomy in bioethics, one that considers it to be largely antithetical to paternalism (Sjöstrand et al. 2013), ‘the intentional overriding of one person’s known preferences or actions by another, where the person who overrides justifies the action by the goal of benefiting or avoiding harm to the person whose preferences or actions are overridden’ (Beauchamp & Childress, 2001, p. 178). The reporting code leans towards a rights-based conception of autonomy, which emphasises the patient’s right to make (informed) decisions about their own care, whereby interference in this right constitutes paternalism and should be avoided (Sjöstrand et al., 2013). What such conception fails to take into account, however, is that not every patient is equally capable of autonomy, and so it is less clear how GPs should act when their patient’s autonomy is culturally constrained. A conceptualisation of autonomy that considers it as a value, and thus something to be protected and promoted in healthcare settings, refuses a simplistic understanding of autonomy as the antithesis of paternalism (Sjöstrand et al., 2013). Indeed, there are times when a physician may go against a patient’s decision in order to protect and promote their autonomy.

Bioethicists such as Sjöstrand et al. (2013) argue that while weak paternalism for the sake of autonomy may be justifiable in certain situations, policies that allow strong paternalism are much harder to justify, which leads them to conclude that ‘there are strong reasons to presume that the best means to promote autonomy in healthcare is to respect patients’ autonomous decisions’ (p. 723). Feminist political philosophers such as Chambers (2008), on the other hand, argue that social inequalities and cultural norms can make it rational for individuals to choose practices that are profoundly harmful to them. To protect these people, such practices should not be an option for choice.

In presuming a rational agent who calculates free from external constraints which life best suits them, a rights-based notion of autonomy ‘does not account for important relational or embodied (i.e. non-cognitive) factors that have been shown to affect or constitute one’s capacity for autonomy’ (Lewis, 2023, p. 139). As women are more inclined to consider the interests of signifcant others in deciding over their lives, feminists have proposed a relational model of autonomy that acknowledges that people’s subjectivities are shaped in and through relationships with others and the world, which impacts which decisions they make and how (Mackenzie & Stoljar, 2000). Such different conceptions of autonomy, then, can lead to vastly different types of intervention in domestic violence.

Somatechnics

Guided by the conceptual toolbox of somatechnics, we explore the relational aspect of autonomy in order to gain a better understanding of how GPs frame intervention in domestic violence. Somatechnics is a critical orientation towards being-in-the-world that centres the inextricability of soma, ‘the body as a culturally intelligible construct’, and techné, ‘the techniques in and through which bodies are transformed and positioned’ (Stryker, 2006, p. 12). The term has a double meaning: it is shorthand for the understanding that bodies are always-already rendered intelligible in particular and situated ways through particular operations of power (Pugliese and Stryker, 2009), and it refers to the wide variety of dispositifs, discourses, knowledges, norms, and apparatuses that render bodies (un)intelligible in contextually specific ways. In such approach, perception is not merely a matter of seeing, ‘a neutral process that provides access to empirical objects/facts’ but is, instead, ‘the effect and vehicle of sedimented contextual knowledges’ (Sullivan, 2012, p. 303). Importantly, perceptions are not only ‘constituted by the environment in which they occur’ but are also ‘constitutive, they shape the world and those in it in accordance with dominant ontologies’ (Sullivan, 2012, pp. 303-304). It is not the case, then, that GPs instrumentally apply the principle of (patient) autonomy in their interactions with patients. Rather, GPs’ perceptions of their patients’ autonomy are shaped by a range of somatechnics, that is, knowledges that see through them and whereby both the GP and patient come into being in the encounter with each other and the world, and that shape GPs’ interventions in domestic violence. One thus never simply perceives, but perception and conception are always-already interwined, which we refer to as per/conception (Bruining & Tack, 2022, p. 11). We are interested in the somatechnics that shape GPs’ perceptions of the autonomy of women with non-western migration backgrounds who experience domestic violence, and simultaneously we consider perception as a somatechnic that shapes the subjectivity of both women and GPs in the GP-patient encounter.

Methods

We conducted 18 in-depth interviews with GPs in the Netherlands between November 2022 and May 2023. The GPs were recruited via multiple channels: a university hospital’s GP specialty training’s mailing list for GP trainers, newsletters of intermediary organisations focussed on issues of culture and gender experienced by women with non-western migration backgrounds, organisations that support GPs in disadvantaged areas, and snowball sampling. The interviews were conducted in Dutch. The data was collected as part of a broader study into GPs’ perceptions of and interventions in health needs related to cultural practices experienced by women with non-western migration backgrounds in the Netherlands.

Sixteen of the GPs we interviewed are women and two GPs are men, reflecting the feminisation of general practice in the Netherlands (SBOH, 2021). Twelve GPs are white Dutch, four have non-western migration backgrounds, and two have western migration backgrounds. Most of the GPs were raised Christian but only three are currently practicing, and one GP is Jewish. Nine of the GPs indicate they have a large population of patients with non-western migration backgrounds (+40%), for seven GPs this population is small (10% or less), and for two GPs it is about 30%. The large majority of these patients have migration backgrounds in Morocco and Turkey, but GPs also have patients with backgrounds in Ghana, Surinam, the Antilles, and a small minority with backgrounds in Syria, Eritrea, Algeria, Armenia, and Pakistan.

The nature of the call for participants and the channels through which we advertised meant that GPs self-selected based on having experience with the cultural practices outlined in the call for participants and/or interest in contributing to better healthcare for migrant populations. The GPs who are also GP trainers attend regular training sessions which has likely fostered their reflective skills and enhanced knowledge of regulatory frameworks and diversity.

The interviews each lasted about 60 minutes and were held at GPs’ offices, in their homes, and online. The interviews were audio recorded and transcribed verbatim, and were coded using Atlas-ti. We coded the data on domestic violence for autonomy-related considerations such as ‘support network’, ‘language barrier’, ‘visa’, ‘empower women’, ‘wait for crisis’, ‘practical needs’. In the following coding round we focussed on the ways in which GPs navigate culture and cultural difference.

The study was approved by the Medical Research Ethics Committee of VU University Medical Center (decision date: 03/03/2022, approval number: 2021.0760).

Results

‘What can I do for you?’: patient-directed healthcare

What underpins several GPs’ conversations with patients is the question ‘What can I do for you.’ Thus, GPs expect that patients come to them with a specific, well-defined healthcare related question. This question functions as a mechanism to avoid paternalism and is a recognition of patient autonomy. GPs perceive the GP-patient encounter through the medical ethical principle of autonomy, then: the patient knows what they need and can express this need. Simultaneously, however, several GPs implicitly acknowledge that patients often cannot answer this question. Most of the GPs indicate that (older) women with non-western migration backgrounds often do not speak the language well enough to be able to have a conversation. GP1 thus mentions that she is unable to have a conversation in situations of domestic violence if the woman in question does not speak Dutch and, as such, the GP resigns herself to being unable to help her patient. Conversely, GP14 takes a direct approach. He demands that his patients learn Dutch:

I think to myself: get out of here, how long have you been here? Twenty years? Get real! That can’t be good? So I tell them, you need to learn to speak Dutch. So I am very prescriptive, because well, it doesn’t work otherwise.

When patients cannot express their needs, both GPs continue to view their patient as autonomous, and consider it the responsibility, and within the capacities, of the patient to learn the language so they can express their needs. Their per/conception of their own role, however, differs: in order to foster autonomy, GP14 is directive and practices weak paternalism, whereas GP1 relies entirely on the personal responsibility and capacity of the patient to learn the language so the patient can direct the patient-GP encounter.

Most of the GPs also point out that older women with non-western migration backgrounds initially present with somatic issues such as headaches and stomach aches, which they point out is a common cultural way for this group to express stress and other psychological issues that can be experienced as a consequence of domestic violence. Their knowledge of different cultural and somatic expressions of non-physical ailments leads GPs to view the patient as not capable of expressing her health needs, and encourages them to ask further questions. However, GP5 notes that when a patient has bruises or when the violence is acute, the patient will bring up domestic violence: ‘People do tell us about it themselves. … When they come to see the doctor they’ll say, I’ve just been beaten by my husband, that’s why I have a bruise.’ GP6 mentions that she has not encountered cases of domestic violence, but later in the interview discusses a case of psychological violence which she, upon further reflection, labelled domestic violence. Conversely, GP8, a white woman with a migration background from a country with high rates of domestic violence, states that many patients do not speak to their GPs about domestic violence because these patients do not think that is what GPs are for. Thus, when GP8 suspects violence, she asks about it: ‘It comes naturally to me. I don’t assume it’s something that rarely happens. I come from a place with shockingly high rates of domestic violence, so that’s a perspective that’s important.’ GP14, after having missed a case of domestic violence for years, has also become more alert. Whether GPs notice and/or watch out for domestic violence depends on their own backgrounds, such as cultural and professional experiences and knowledges. This shapes their (perception of the right kind of) intervention regarding whether they address the topic themselves or wait for the patient to start the conversation. While GPs acknowledge that patients do not or cannot always formulate their specific needs and issues around domestic violence, the general emphasis on the patient’s own healthcare-related question demonstrates that the autonomy principle shapes their perception of the GP-patient encounter.

When asked what they would say if they could offer one piece of advice to new GPs, many of the GPs we interviewed emphasised the importance of non-judgemental, active questioning, and being open and listening to the patient. GP8 says, ‘Stay open and keep asking questions. That is the only way you will find out. Let go of your assumptions.’ GP5 adds, ‘you never know what the situation is as an outsider.’ Thus, GPs are reluctant to, and some specifically point out they cannot, advise women on what to do. They actively ask questions in the context of domestic violence, but do so to help the patient get a clearer sense of what she wants. The encounter, then, and further steps, continue to be perceived from the GPs’ vantage point of (patient) autonomy from which they see the patient as the director of their own life. Their caution not to make assumptions does not extend to the autonomy framework that structures their vision: the GPs are ‘in’ a perspective rather than ‘having’ a perspective: ‘the perspective … precedes the individual (Alcoff, 2006, p. 117) and thus the GPs’ ‘practices of visibility are indeed revealing of significant facts about our cultural ideology’ (Alcoff, 2006, p. 8).

‘And that was her choice’: following the patient’s lead in domestic violence

When the GPs discovered that women with non-western migration backgrounds were victims of domestic violence, many followed the women’s lead. GP4 recounts her experience with a female patient with Turkish background, married to a deeply religious Turkish man. After conversations about the abuse, both physical and psychological, the woman told the GP she could no longer live with her husband and wanted to go to a safe house, upon which the GP contacted relevant organisations. Ultimately, however, the woman changed her mind. GP4 describes the conversation with the patient:

‘I think that in the end it won’t be good for my children if I do this, because then they’ll end up in a situation where they’re being pulled at. So I think I will sacrifice myself, to ensure the wellbeing of my children; and I stay.’ And that has truly been a conscious choice, that she says, I want my children to have a better life than I do now and I think that the safe house and a divorce might not make things better for my children at all. She said that leaving her husband would not be good for her children, so she decided to stay. And that was her choice.

When asked how she saw her own role in this situation, GP4 stated,

I supported her in that choice. … I could understand that choice. While you should obviously not say that something is good or bad, I also said that I think maybe it is best for the children. And of course I can’t ever know, but I do think that, I genuinely understand that choice.

GP4 continued to support this woman: ‘later on I regularly supported her, saying I thought it was really impressive that she did this. So I didn’t tell her, you should do it [leave].’

GP4 also indicates, however, that she had genuine concerns for her patient’s safety. The woman in question visited the GP to ask for contraception since she did not want any more children, but noted her husband would not allow it. The GP and the patient decided that an IUD would be the best option. The GP warned the woman to be careful, since an IUD would show up on an ultrasound should she ever have one. Years later, the woman’s husband visited the GP to discuss fertility issues and ask about fertility testing. The next day, the woman came by, panicking about what might happen if her husband found out about the IUD. The GP promptly removed the IUD because the couple might go to Turkey for fertility testing. When asked if she was ever afraid for her own safety, the GP responded, ‘I was more afraid for her, if he discovered she’d taken this step.’ She, furthermore, said, ‘I saw myself as woman’s protector. That she gets to decide for herself whether she wants children, yes or no.’ Reflecting on the ethics of this intervention, the GP explains that she was informed by the Dutch National Association of General Practitioners that she ‘did not sufficiently inform the husband of the cause of infertility.’ When asked about the role of patient-doctor confidentiality in relation to his wife, the GP explains that she did not sufficiently inform him that both parties should be examined. She points out, however, that she prioritises her own ethics over what she is allowed to do: ‘Our profession is too focussed on rules rather than on humanity.’

The GP’s vantage point is her own ability to understand her patient’s choice. In other words, she places herself in the patient’s position, and sees from the patient’s perspective. However, as Sullivan (2012, 306) notes, ‘it is not possible to simply abandon, throw off, or replace one’s perspective with anOther’s, at will’ (emphasis in original), and the assumption that one can or should constitutes an imperialist act. Instead of seeing from the perspective of the Other, then, it is the GP’s positionality as a GP and a white western woman that shapes her perception of the patient and her situation, and of her own role as a GP and woman. The patient, the GP, and the situation become intelligible and marked in accordance with dominant ontologies that centre women’s rights and empowerment, i.e. putting women’s choices first, regardless of what they are – to stay in a harmful relationship of domestic violence, and the right to reproductive autonomy – is the best course of action. While the domestic violence reporting code allows GPs to report domestic violence sooner if children are involved, this is not a key consideration in this GP’s narrative and can be sacrificed if it means the woman in question can be supported in her choice.

Unlike GP4, GP6 recounts a situation of powerlessness. An Indonesian woman who, in the GP’s view, had married her husband in order to get a Dutch visa, is abused psychologically by her husband. They have children. The woman did not want to leave her husband because that would mean she would lose her visa and have to leave the country. GP6 recounts, ‘I said, see if you can meet another man. Because that was almost … Because she was, in that sense, stuck. To go back to Indonesia, with her children, or to stay with this man. It was complicated.’ Since children were involved, the GP also spoke to the children, to a confidential physician, and to Veilig Thuis,

to see, what can we do. And for her, it was her decision in the end. There wasn’t much more that I could do for her other than listening, and ensuring the children were as safe as possible. The children were getting psychological help, but it was complicated.

In the end, the patient left the practice. When asked if she would respond in the same way if it concerned a white Dutch family, GP6 points out that she believes she is never paternalistic:

I try to help them, to support them, and to look if there is something we can do. But I don’t say: ‘You should do this.’ … But that’s no different from one to the next [Dutch family or family with non-western migration background].

Unlike GP4, GP6 acted in accordance with the regulatory framework for situations that involve children. While for GP4, following her patient’s lead constitutes a tool for empowerment, for GP6, following her patient’s lead means that there is little she can do and as such it is disempowering for both GP and patient. Indeed, her suggestion that the patient should find another man as a possible way out of a hopeless situation constitutes a recommendation that her patient moves from one relationship of dependency to the next. What disappears from the perceptual field in the GP’s account is that steps can be taken in the visa situation. Instead, the patient is marked as inherently dependent and powerless.

Some GPs, such as GP2, point out that they find it frustrating that the patient must be left free in her decision-making, while GP14 clearly intervenes in domestic violence. Accompanied by her neighbour, a female patient with Moroccan background visited the GP to tell him that her husband had left for Morocco without leaving money for rent, utilities, and groceries. She has two children, he notes, who witness what is happening, and she also wears a headscarf, ‘so it’s really obvious that you find yourself in a more strict environment.’ Her neighbour explained that the woman is regularly beaten by her husband, upon which the GP called the police despite knowing that he is not allowed to do so:

I told them, listen, this man is going to return and this woman is severely abused by this man. I don’t think that should be allowed. And you need to do something. … And I told this woman, you need to change the locks, you just need to, that man should not be coming inside anymore. Do you want to continue with this man? Not really. I say, well, then you end it. So I’ve been a little directive.

In addition to calling the police, he explains,

I did say you should, I would go talk to social services. No, look, I’m not going to take people by the hand to do everything for them. But I did call the police myself, because I thought, she doesn’t speak Dutch very well and it’s a complicated situation after all, but it is also a very clear, for me, a very clear situation.

When asked if he would respond in a similar way if a white Dutch woman found herself in a similar situation, he notes that he is stricter when women with non-western migration backgrounds are concerned, since Dutch women usually know where to go, can count on their families to help them, and have more helplines.

GP14 does not merely ‘see’ the headscarf, rather, stereotypes of gender, culture, and religion see through him and mark the woman as oppressed, helpless, and incapable of making decisions and taking action. Whether GP14 is right in these assumptions is less relevant here than the ways in which perception operates to justify a paternalistic intervention that aims to protect the patient’s autonomy but that also contravenes several ethical rules, positions the patient as inherently lacking autonomy, and may ultimately further harm the patient’s safety and autonomy. Yet, simultaneously, the GP’s racialised/ing perception of the patient’s inability to speak Dutch shapes the boundaries of his own professional involvement when it comes to helping the patient get support from social services, and what he expects his patient to be autonomously capable of doing in terms of getting this support.

‘I don’t see colour’: navigating a fear of culturalisation

All GPs, to a greater or lesser degree, acknowledge the specific difficulties their female patients with non-western migration backgrounds face in situations of domestic violence, and some point out that it is important to be alert to the fact that certain problems are more common in certain cultures, and that awareness is key. GP10, for instance, notes, ‘Know that in certain cultures certain problems are more common. Because when you know this, you can consider it. And if you don’t know it, then you won’t think of it, you’ll miss it completely.’ Nevertheless, when asked if they approach situations in which white Dutch women are the victim of domestic violence in the same way as they do when the victim is a woman with a non-western migration background, several GPs state that they do, a small number are more reflective and state that maybe they do or that while they hope they do they might unconsciously treat such situations differently, and a small number firmly state that they do not.

A fear of culturalisation runs through the GPs’ descriptions of how they approach domestic violence. Culturalisation means that causes of domestic violence and the experiences of domestic violence of women with non-western migration backgrounds are reduced to ‘culture’, which ignores that domestic violence is caused and experienced through a range of intersecting issues such as poverty, access to housing, religion, discrimination, and health impacts of violence (Vergaert et al. 2021). The GPs try to mitigate the risk of culturalisation through different mechanisms. Some GPs appear to take pride in mentioning they do not notice their patients’ backgrounds. GP2, for instance, points out that others have noted that there is great variation in the backgrounds of her patients but, ‘in all honesty, more often than not, I don’t see colour.’ In a similar vein, GP10 says, ‘I think I’ve become a little colourblind. … I think I’ve unlearnt it [making assumptions based on skin colour or ethnicity], hopefully.’ Several other GPs focus on the individual patient. GP10 points out, ‘these days I think, we’re making such a big deal out of cultural differences. And that’s silly. Everyone is just, we’re all just people. And everyone has different views and ideas.’ GP8 is aware of cultural differences, but notes that how one relates to one’s culture may vary between families and individuals:

I see everyone for who they are and culture just comes with it. … There is culture, which is the larger group culture, but there’s also how a family approaches it, what a person’s own conviction is, and how strict they are in for instance their faith or other things. … You need to stay open about these things. And that’s why I don’t treat someone with a different culture, different to a native Dutch person, differently. … The only problem is when there is and domestic violence and a language barrier. That’s when things get hard.

Other GPs appear to be concerned about equality. GP12, for instance, believes that everyone should have equal access, and treating patients differently gets in the way of that: ‘Of course I try to let it [culture] play as little of a role as possible because I think it’s important that everyone gets the same access to healthcare.’ Yet, she also realises, ‘there must be bias there. Because you identify more easily with someone and can put yourself in someone’s shoes more easily when you have the same cultural background.’ Other GPs are concerned about Othering. GP2 says: ‘it’s looking for that which binds you, again and again,’ while GP10 points out: ‘these days, I think, we’re making such a big deal out of cultural differences. And that’s silly. Everyone is just, we’re all just people.’ While their views and approaches are different, most of the GPs emphasise the importance of asking open questions in situations of domestic violence, regardless of whether the victim is a white Dutch woman or a woman with a non-western migration background.

The GPs try to mitigate their fear of culturalising through particular – and interconnected – strategies. A first strategy is developing colour-blindness so that they no longer perceive patients’ ethnicities or cultures. Another strategy is highlighting that each patient is different, and that the GP’s principal role is to figure out each patient’s individual situation. Cultural background, here, moves to the background of the GP’s perceptual field. A third strategy is taking equality as a starting point so that cultural difference does not play a role. Each of the three strategies is premised on the notion that one can develop x-ray vision of sorts that allows the GP to step outside of their embodied location and into a ‘view from nowhere’ (Haraway, 1988) from which to see the patient devoid of cultural markers. Conversely, what we have shown here is that the GPs’ perception of what ought to be materialises into the reality from which they operate – equality, which invisibilises perception as a somatechnic.

Discussion and conclusion

While the literature on autonomy in restrictive circumstances largely focuses on women (Khader, 2011), we have sought to complicate the notion of autonomy in GPs’ interventions in domestic violence, and have drawn attention to how GPs’ thinking and acting is also constrained. The interview data shows that (patient) autonomy structures GPs’ responses to victims of domestic violence who are women with non-western migration bacgkrounds. The GPs’ expectation that patients are capable of unambiguously expressing their healthcare-related needs poses the risk that domestic violence goes unnoticed for prolonged periods of time. Furthermore, despite the ethical and regulatory frameworks in which GPs operate, there is great variation in how GPs respond in known situations of domestic violence. Such variation is to be expected in the context of patient-centred healthcare that requires GPs to engage in shared decision-making with their patients and to take into account their patients’ specific circumstances. The GPs we interviewed are all to a greater or lesser degree aware that the women in question face additional barriers that impact their ability to leave the violence in their homes, and engage in open, active questioning in order to get a picture of the women’s situation.

We highlighted the responses of three GPs to stand in for three modes of framing intervention in domestic violence. The first mode aligns with a rights-based conception of autonomy that protects the right of competent adults to know and act upon what is best for them. GPs prioritise the notion of women as autonomous decision-makers, and supporting them in their decisions is a tool for empowerment. The second mode is in line with value-based conception of autonomy in which GPs decide what is best for the patient with the intention of protecting her autonomy, and take steps with the aim of stopping the harm regardless of the woman’s wishes. In the third mode, autonomy is given up on, and a wait-and-see approach is deployed due to the powerlessness GP and patient share about the patient’s limited options for leaving the abuse.

The GPs in our study do not simply apply medical ethical rules, guidelines, and principles but, instead, their decision-making processes are shaped by a wide range of somatechnics, such as (interrelated) knowledges and conceptions of gender, race, culture, ethnicity, equality, medical ethics, and professional guidelines that see through them and render the situation and the patient in front of them, and their own own role as GPs, legible and intelligible in contextually specific ways. A somatechnics approach demonstrates that GPs do not simply deploy their knowledge instrumentally in order to decide on the best course of action, which would imply that GP and knowledge are separate entities. Instead, the GPs’ perceptions are both the ‘vehicle and effect’ (Sullivan, 2012, p. 300) of a particular somatechnic constellation in and through which they perceive the world.

The GPs, furthermore, demonstrate a fear of culturalisation, which creates a disconnect between their recognition of the specific circumstances of women with non-western migration backgrounds, and their ability to see how these shape women’s perceptions of their options. What is insufficiently addressed, then, is that the women in question may not be able to imagine that leaving is an option, or to view themselves as victims of abuse (Prosman et al. 2014). In other words, GPs do not actively acknowledge that the women’s perceptions of what is possible have been shaped by a range of somatechnics so that leaving is not part of their perceptual field. In her account of relational autonomy, Mackenzie (2007) thus points out that autonomy not only requires awareness of the existence of other ways of living, but also that ‘such lives must be not only practically realizable, but also imaginable’ (p. 117). The capacity to imagine alternatives can, however, be closed off in oppressive environments. This includes not only the experience of ongoing domestic abuse more generally, but also the additional barriers related to strict binary gender norms that intersect with socio-economic difficulties, lack of access to housing, fears around immigration status, concerns about exclusion from their families and communities, and the threat of honour-related violence. A consequence of, on the one hand, GPs’ strong reluctance to advise women on possible courses of action so as to not impact their autonomous decision-making and, on the other hand, their interventions on behalf of the women, is that the women’s capacities to imagine alternatives are not sufficiently fostered. Both a decision-making process structured around patient autonomy, and the bioethical literature that frames autonomy issues around weighing up autonomy and paternalism, then, fail to take into account the imaginative capacity aspect of autonomy, or, in other words, how per/conception are inherently entangled.

We propose a reconsideration of ethics in line with what Shildrick (2005) has referred to as a postconventional ethics of the body, which, in Irigarayan terms, frames ‘the ethical relation, not in terms of separation, but as a mode that occurs between subjects’ (in Shildrick, 2005, p. 8). In such intersubjective mode, GPs are aware of the mutually constitutive perceptive processes both they and their patients are engaged in, so that the perceptual fields of both parties can be widened and new ways of imagining, and thus of conceptualising and practicing autonomy, can come into being.

Acknowledgements

We would like to thank the GPs for so generously offering their time and sharing their experiences with us. We would also like to thank the individuals and organisations who helped us reach participants.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by an NWO Open Competition-SSH grant [#406.20.CW.001].