Am Fam Physician. 2001 Oct 1;64(7):1142-1148.
to the editor: In general, we agree with the editorial by Dr. Bullock1 concerning the importance of screening by physicians for child and partner abuse in all settings. However, we must object to her “culturally sensitive” endorsement of certain “alternative” practices of medicine that may amount to child abuse. There are certain cultures that practice infanticide of defective infants (sometimes defective only because they are female). Is it culturally insensitive to condemn this? It is considered child abuse to pray over a child instead of operating on his or her perforated appendix. Is this culturally insensitive? Should we refuse to report infant or child clitoridectomy because it's sanctioned by her father's culture?
Similarly, it should be required, not condemned, to criticize and report Caida de Mollera (“fallen fontanelle,” the cultural practice among Latinos of holding a child upside down to correct a depressed fontanella) as described in this editorial.1 We would be uncomfortable calling this anything other than shaken-baby syndrome. This is not an “erroneous” diagnosis; it is the practice itself which is unacceptable, and where possible, should be prevented through anticipatory guidance by the family's physician. When it occurs, it must be reported as child abuse.
1. Bullock K. Child abuse: the physician's role in alleviating a growing problem [Editorial]. Am Fam Physician. 2000;61:2977–80.
in reply: I appreciate Drs. Lamson and Doran's comments. This issue is part of the larger challenge that involves learning how to integrate core cultural competencies within a diverse socioeconomic, multiethnic and multilinguistic practice. The integration of culturally sensitive and competent care is crucial if physicians are to successfully address the health needs and racial/ethnic disparities of their patients. Published guidelines on this topic serve as a good reference.1,2
Physicians must begin by considering the family's social, ecologic and historic background, because health behaviors are influenced by cultural determinants and can be misinterpreted. Cross-cultural medical literature is a relatively new addition to the area of child victimization, and growing attention has been placed on correctly managing children with “nonaccidental”injuries.3 Although authors differ in their responses, consensus exists that folk interventions that produce physical findings should not necessarily all be viewed as child abuse and reported.4
Physicians' capacity to understand cultural factors will help guide the decision—was the purpose of the alternative practice to heal or to harm? Having a knowledge of traditional practices and their physical manifestations, and appropriately evaluating families' interactions, is critical to assessing dysfunction or pathology. What constitutes acceptable folk practices is a question cross-cultural abuse and neglect experts have not answered sufficiently because of the spectrum of negative health outcomes associated with indigenous therapies.5 For example, the minor red circles left by coin rubbing (cao gio) or cupping should not be interpreted or disparaged in the same way as the cultural practice of female genital surgeries or circumcision (legally outlawed in the United States). The treatment for Caida de Mollera that I recorded is an extreme cultural example of managing dehydration with a significant outcome. Other practices for this condition include massage and prayer—benign therapies when performed alongside biomedical management.
If a harmful folk therapy is identified, physicians should determine whether the negative outcome was intentional, unintentional, or accidental. They should sensitively communicate and educate the family about the detrimental effects and seek to replace the current practice with one that is culturally acceptable. If the practice and/or outcome require notification of child protective services, this should be done in a way that does not criminalize the family or create unnecessary conflict. Discussion with the social worker should proceed in a nonpunitive way, with concern for protecting the child and preserving and strengthening the family.
The more important work for physicians is preventive and entails educating parents as to why traditional practices might be harmful. In many cases, the medical community has failed to communicate effectively in this area. More problematic are instances where physicians do not offer appropriate interpreters or patients' families do not understand the medical jargon or the actions taken “in their best interest.” This alienates and polarizes ethnic families and communities against Western medicine.6 Child maltreatment procedures and policies should be expanded to include “best practices” for multicultural children. The goal is to develop what the AAP Committee on Pediatric Workforce identifies as culturally effective pediatric care in these situations.1
1. Culturally effective pediatric care: education and training issues. American Academy of Pediatrics Committee on Pediatric Workforce. Pediatrics. 1999;103:167–70.
2. Like RC, Steiner RP, Rubel AJ. STFM Core Curriculum Guidelines. Recommended core curriculum guidelines on culturally sensitive and competent health care. Fam Med. 1996;28:291–7.
3. Thomas JN. Cultural considerations in assessment and treatment of child sexual abuse: a commentary. Journal of Child Sexual Abuse. 1992;1:129–32.
4. Pachter LM. Culture and clinical care. Folk illness beliefs and behaviors and their implications for health care delivery. JAMA. 1994;271:690–4.
5. Johnson CF. Inflicted injury versus accidental injury. Pediatr Clin North Am. 1990;37:791–814.
6. Fadiman A. The spirit catches you and you fall down: a Hmong child, her American doctors, and the collision of two cultures. 1st ed. New York: Farrar, Straus & Giroux, 1997.
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