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Clinical Crossroads |

Primary Care Management of Non–English-Speaking Refugees Who Have Experienced Trauma:  A Clinical Review

Sondra S. Crosby, MD, PharmD, Discussant1,2
[+] Author Affiliations
1Associate Professor, Boston University School of Public Health, Boston, Massachusetts
2Associate Professor of Medicine, Boston University School of Medicine, Boston, Massachusetts
JAMA. 2013;310(5):519-528. doi:10.1001/jama.2013.8788.
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Importance  Refugees are a vulnerable class of immigrants who have fled their countries, typically following war, violence, or natural disaster, and who have frequently experienced trauma. In primary care, engaging refugees to develop a positive therapeutic relationship is challenging. Relative to care of other primary care patients, there are important differences in symptom evaluation and developing treatment plans.

Objectives  To discuss the importance of and methods for obtaining refugee trauma histories, to recognize the psychological and physical manifestations of trauma characteristic of refugees, and to explore how cultural differences and limited English proficiency affect the refugee patient–clinician relationship and how to best use interpreters.

Evidence Review  MEDLINE and the Cochrane Library were searched from 1984 to 2012. Additional citations were obtained from lists of references from select research and review articles on this topic.

Findings  Engagement with a refugee patient who has experienced trauma requires an understanding of the trauma history and the trauma-related symptoms. Mental health symptoms and chronic pain are commonly experienced by refugee patients. Successful treatment requires a multidisciplinary approach that is culturally acceptable to the refugee.

Conclusions and Relevance  Refugee patients frequently have experienced trauma requiring a directed history and physical examination, facilitated by an interpreter if necessary. Intervention should be sensitive to the refugee’s cultural mores.

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Figure.
Dermatologic Findings From Cultural Health Practices That May Be Incorrectly Identified as Signs of Torture or Physical Abuse

A, In cupping, circular lesions occur on the skin as a result of the application of cups in which a vacuum has been created by heating the cups prior to application or by mechanical suction. The cups are left in place (stationary) or moved about (gliding). Petechiae and round ecchymotic marks from cupping typically last up to 3 to 7 days but hyperpigmentation can last longer. B, In coining, a smooth object (eg, coin, bone, jade, metal lid) is repeatedly rubbed on a lubricated area of skin until petechiae appear. The resulting skin lesions are typically linear and oriented in a direction away from the heart. The areas most often treated are the chest, back, and torso. Marks readily fade to ecchymosis and generally resolve in several days.

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