Cultural Sensitivity and Childhood Sexual Abuse

What can child sexual abuse support services in the UK do to adapt to British Asian contexts? And why is this even important? Join Sophia in conversation with Dr Anujavahinie Suntharamoorthy, CAMHS psychiatrist and Director of ANBU UK, as they discuss Vietnamese and Eelam Tamil contexts. They touch on intergenerational trauma,  disclosing in cultural contexts, and advice for charities and services. 


ADDITIONAL RESOURCES
ANBU stands for 'Abuse Never Becomes Us', and envisages a future where Tamil people impacted by childhood sexual abuse can find their voice
Find out more about their work on the ANBU Website
Instagram: anbu.uk 

Chapters

• 0:00 Introduction to Tamil and Vietnamese in UK
• 2:39 Intergenerational Trauma, Forced Migration and CSA
• 10:08 Disclosures in British Asian cultural contexts
• 16:30 What can services do to be more culturally sensitive?

Transcript

0:04

That's for your physical health. Imagine your mental health. It's not even a concept. We were practicing mental health and actually it's not the Western world who even brought us into it. No one taught me the word for sex growing up. You can't be loud. I mean, if I stuck to all those things, then I wouldn't be a psychiatrist right now. Hi. Welcome to Secrets Worth Sharing, a series all about having difficult conversations but with serious joy. This episode is specifically about cultural sensitivity in a British Asian context, and we're focusing specifically on Tamil and Vietnamese narratives. I'm joined by the lovely Anuja. Hi everyone. I'm Anuja. I am a doctor in East London and a practicing psychiatrist specializing in child and adolescent mental health services. But more importantly, I’m director of ANBU UK and ANBU UK stands for Abuse Never Becomes Us UK, a nonprofit organization, a UK registered charity that support adult survivors of childhood sexual abuse within the Tamil community. We're going to be talking a lot about ANBU’s work, but specifically also about cultural differences in disclosing, in support services, family narratives and education. Before we start, we just want to describe a little bit about what Tamil and Vietnamese is just for people who aren't really aware of these parts of the world and where the prevalence is in Britain. So did you want to start by explaining a little bit about what Tamil actually is. So Tamil is a language. In terms of our charity predominantly they’re the Tamil diaspora from Eelam Tamils, so from Sri Lanka. Because of the war conflict that was going on in Sri Lanka and the genocide there was forced migration. So that's why a lot of Tamil people then had to move to countries that would allow them to seek asylum, so Canada, Australia, Europe, particularly the UK. That's why there's a lot of Tamil people in London. Different generations are affected in different ways by the war and certain impacts of the trauma has gone down generations. And it's interesting because when we were talking off camera, there was so much similarities with the Vietnamese context as well. Because of the war in Vietnam, a lot of people were forced to migrate. And just for a bit of rough numbers that we know - statistics are never 100% accurate - there's roughly 55,000 Vietnamese people living in the UK and there's roughly 200,000 Eelam Tamils living in the UK as well. So it's quite interesting because even though the numbers are quite different, there's still a lot of those similarities. And obviously being Tamil or Vietnamese living in the UK brings a whole nother dialogue to it as well. The first thing I kind of wanted to touch on was intergenerational trauma, this forced migration and how that can sometimes play out in child sexual abuse. We usually divide it into collective trauma and individual trauma. So there's the collective trauma, which is the impact of the war in Sri Lanka. It's sort of normalized in our identity as Tamil people. Our parents don't talk about it. They were forced to migrate, and actually because they had to try and survive, they did everything they could to try and survive in a country where English isn't their first language, where they're financially struggling, a lot of them don't have degrees, they were trying to get any sort of jobs that they could, etc. So then when someone who has been impacted by childhood sexual abuse then discloses to their parents or their families, they find it difficult to understand how that can impact a child or even an adult survivor of CSA, because to them they had to hear shellings, they had to hear bombs, there’s so many disappearances, unexplained disappearances in Sri Lanka, etc. They dealt with that by internalizing it, compartmentalizing and trying to survive in their host country. So when they now have a disclosure from a survivor, they don't know how they, they don’t understand how they can have mental health difficulties from that and how to have those conversations about CSA. Yeah, this this is really resonating with me as well. I remember when I was first disclosing and someone in the Vietnamese family said, unfortunately, everyone else is just going to see this as a drop of water in an ocean of trauma they’ve already gone through, you know, and at the end of the day, like, you're physically safe, you weren't at risk of dying, you didn't have to, like, cross an ocean to get here, all of these kinds of things, so like even though the thing you went through is bad, like no one's going to see it as that bad, and I think that is a very common thing, especially with a lot of like British Asians who were forced to migrate, is like “Ah, given all the hardships that my families have already gone through am I even going to be validated in what I'm saying?” And a lot of survivors then feel like they're a burden to their families. They don’t want to add to their struggles, especially when in our culture, you don't speak about child abuse or sexual abuse. And so when you start having these conversations and then the response to your disclosure is not a healthy one or not a supportive one, then you feel even more alone than when you initially disclosed. And you also doubt yourself, I think. There's a lot of risk of that because it's like,“Ah, is what I went through even bad? Oh, did I even go through it? Oh, should I even bother telling my family if they're not even going to respond to it very well anyway? Maybe I should keep it silent.” And as we often see, those patterns happen again and again, and actually then it allows the person who's abusing to repeat, repeat, repeat without getting caught. Sometimes the people feel as if it's the perpetrator that has silenced the survivor. And it's not just the perpetrator at times. Sometimes it can be your own family, it can be friends, your community, etc. I’ve personally gone through sexual harassment. I remember one occasion when I was told, don't tell anyone. That's the first line that was said to me when I disclosed. So, you know, you can be silenced even even by the person that you're disclosing to. And that's the thing that we need to avoid, and that's why we need to have these healthy conversations about it. One thing I find in my communities, I don't know if you'll agree, is to have simply the space to think about your abuse, about how you're feeling is such a luxury. Because so much of the time, especially for elders, if you’re second gen, you've been forced to migrate, you've been forced to survive. You don't have time to think about all the bad things that have happened. You don't have time to think how you’re feeling and responding, you just plough on. The side effects of that mean that you don't necessarily 1) register what happened to you and 2) have the time to register how this could emotionally affect others, especially like even that joke, oh, it's only white middle class people that get therapy, when therapy should be for everyone, thinking things through should be for everyone. It is because to have simply the time is a luxury. A lot of people don't want to think about the difficult parts of when they were in their home country. So for example, the shellings, the bombs, etc, the war conflict. They want to think about all the good parts where they were around their community, where they could tend their places of worship easily, where they could have fresh fruit, vegetables, seafood and sun. So they want to think about those times and those memories. So it's also the want to process. And that's why it's really important to promote therapy in a way that actually sometimes when you haven't processed it, it comes out in different ways. And for example, in the Tamil community there is a lot of alcohol dependance. And then from that there's domestic abuse. People are going down the unhealthy coping mechanisms route because they haven't been given that safe space to explore their feelings, to sit with their feelings, to have that safe space where they can talk about how they genuinely feel. So they close up and they they become guarded and they compartmentalize, but actually it's having an effect on their families, it’s having an effect on the next generation and the generation after that. Even when someone makes a disclosure, a lot of people don't know what to say to them. And so sometimes it's just even telling people, actually just saying, I believe you, or just actively listening or being next to someone in itself is therapeutic. Recently we had a research symposium. This was the first time I even saw quite a few South Asian researchers presenting research about the South Asian community. And there was a lot of discussion about honor and shame. And this is again culturally specific. I think, to put it bluntly in a way that loads of people will understand is, we Vietnamese, we have our own health practices. God knows the amount of medicated oil I carry in my bag all the time. We have our own ways of healing. Typically, the route that a lot of people will reach a doctor is a lot later on in their illnesses than other cultures because there is that kind of culture of, oh, well, we didn't have health care systems that were free in our country. So we’re used to like getting that holistic health care, doing our own remedies to delay having to go to the doctor. That's your physical health. Imagine your mental health. It's not even a concept. Sometimes it can feel so, so far away. Actually, we didn't have the words for mental health in the Vietnamese and you know, Eelam Tamil culture, but actually we were practicing mental health because when we were going to a priest in a temple or a church, that was spirituality, that was, you know, we look at Hinduism or Buddhism, mindfulness, yoga, etc., came from sort of religious or cultural backgrounds. So we were practicing mental health. And actually it's not the Western world who even brought us into it. We were doing that. We just didn't call it mental health. It's about actually naming it and saying this is what we were doing. So we were practicing it even back then and it is just about promoting it in a culturally sensitive way. I think it's difficult because I see so much of the Vietnamese response to this as being like joy and smiling through the pain. And I don't know if that - Is a trauma response. Yeah, it is. Because it's survival, right. If you just compartmentalize and, you know, if you just smile through the pain, it's like, fake it till you make it. It's the same concept. It doesn't mean that people aren't spiritual or, you know, mental health is everyone's health, right? So it's just about finding what's right for you. I just wanted to talk a little bit about disclosure itself in different cultural contexts, how this can be made more challenging. I can start by sharing a bit about the Vietnamese community. This notion that if you're telling something so deep and so dark and so shameful, that it should be something that's concealed. And particularly when I was disclosing to Vietnamese people, the first thing they say is, okay, you can forget about it now, and then instantly move on to being like the happy jolly face. Even though that pain was there, they were able to put on this face and ignore it because that's just what you do. I've had questions like, obviously you're going to have the abuser at the wedding, right? What are people going to say? The notion less became of like how to protect me but more how to protect the family reputation. And within that, that instantly meant the abuser who was in the family. And not only that, but when you have disclosures and you're already doubting yourself and you don't have the language for the thing that you went through, it becomes less of a concept that you're thinking about. So your abuse kind of gets invalidated. 100%. There's two things there. So one is the victim blaming culture. And then the second thing is protecting the abuser. And so if we look at victim blaming culture, even within the Tamil community, for example, when I was growing up, I was told sit with your legs together, don't challenge your elders. You can't voice your opinions. You can't be loud. I mean, if I stuck to all those things, then I wouldn't be a psychiatrist right now. So actually it was because I was a loud person and I would challenge people that I went into the career that I did. But imagine someone's potential can really be affected by what the community’s saying to you. For example, when they're telling you how to dress, how to speak, etc, even if the abuse hasn't happened yet, it's already a victim blaming culture that's already been cultivated. Then when someone discloses- don't tell anyone, this will bring shame to the family. Why didn't you say anything at the time? Why didn't you speak out? Why didn't you report it, etc etc comes out and then at the same time, oh yeah, the abusers coming to the wedding, right? Oh, the abuser just got married. Right. Well, even the gaslighting sort of comments such as that didn't happen, or you're lying, I don't believe you. Even that is a defense because parents are in denial sometimes. A lot of the time. It’s the shock. It's the denial. It’s every stage of grief that you could imagine possible because it is a loss. You don't ever want your child to ever, for their boundaries to ever be crossed. And so to accept that and the fact that you couldn't protect them, that is something that's huge. The fact that you couldn't protect your child. And then they may say things that they genuinely don't mean, but unfortunately they said it now. It's such an interesting line as well between respect for elders - Yeah - and then like obviously the elders protecting the children. In a culture which is so steeped in respect and so steeped in like respecting your elders, which in so many ways is very beautiful and something I'm very proud of, that I was brought up in that way. But like, you know, I was used to going to a family party, and it’s like okay, so find the first oldest elder, you bow to them first, or you hug them first, whatever. That is a very huge part of our culture. What it can sometimes create for an abuser’s perspective, is a culture where they are used to always being right and a culture where they are never questioned. Smallest example. I remember one time like an elder in my family left the tap running all night, then found the tap, forgot it was them, told all of us off and then realized it was him but didn't apologize because you don't apologize as an elder, right? So then that creates a culture, like well, whatever I say goes and some abusers can exploit that. If I'm doing something to a child, they won’t dare question me. They won’t dare think, ah, this is something that I can push back against. And it's the same with like ah, go hug your elder. How can that be exploited? And I'm not saying that within the culture is embedded abuse. I'm saying that there are cultural norms which can make it easier for abusers to exploit and things we should watch out for. And then that opens up a whole problem with people worrying about their cultures being judged, especially if your culture is a minority in the UK, at least, then you’re saying, oh, but this is quite common practice, this, that and the other. Then you can get worried that other people who are outsiders are going to judge your culture. And not only is there the worry, the stress and the fear that exists within your own community, there's also the fear of how you should be representing and you don't want to make your community look bad. So then you can't complain about this phenomenon to external people. And therefore you get almost

two vicious cycles of abuse: 14:27

there’s the external cultural judging and the internal cultural confusion, you just add so much to the trauma. One of the things that we say is, for example, if your child does not want to sit on that person's lap, then don't force them to. We start really breaking down consent. And so we talk about safe touch, unsafe touch and actually promoting autonomy in a child as young as four years old to be able to say no. And actually, everyone around that child respecting the fact that that child just said no. And that's why it's from a cultural lens, right? Because when an elder says, come here, give me a hug or kiss me on the cheek, how dare you say anything, how dare you say no? Well, what's kind of innate in our culture, it doesn't come from a bad place, but it does need to be challenged a little. And this is constant throughout our lives, because although we're talking about childhood sexual abuse - sexual harassment, sexual abuse happens every day, whether it's in the workplace, whether it's at home, etc. So it doesn't even just stop as under 18s. Even recently I was asked the question, what do these perpetrators look like? And I was like, It could be anyone. But it's the fact that people actually don't realize it can be anyone. The context was that we were talking about priests who were perpetrators. We were talking about tutors. So tuition masters is how we call them being perpetrators, or a family member being a perpetrator. By saying that I am director of ANBU UK, it starts off these conversations I'm having with the older generation, whether they're in my family, whether they're strangers or other people, where they start learning that actually it could be anyone. People don't realize that CSA, the person in front of you isn't always a child. They can be your grandma who's gone through CSA but actually they dealt with it in a different way because it wasn't so safe to be open about it. And it's about respecting everyone's autonomy. You need to think about actually, if someone does disclose their abuse, that's courage, that's bravery, that's resilience, that's them showing vulnerability is courage. How do you think the services that ANBU provides and counseling and charity services that are provided, how do they have to be culturally sensitive and adjust to these kind of things we're talking about? With ANBU UK, we’re survivor centered and community led. What that actually means is that in terms of the survivor themselves, we ensure that if they're Tamil speaking survivors, that we provide them information in Tamil, that we signpost them to Tamil therapists and Tamil speaking counselors, etc. And that in itself increased accessibility because if there's already a language barrier, then they don't even realize how much support there is available to them, especially in a community that doesn't talk about mental health. And then on top of that, we've gone towards Eastern practice, which is something that we have been practicing for centuries, that now the Western therapy system have really taken on board, such as mindfulness, meditation, yoga. We have a project called Transition and Wellbeing Project where we provide a group of survivors with group talking therapy, as well as group art therapy and group yoga therapy. The therapist, she did something that was really interesting. When they said goodbye on their last session, she asked everyone to bring food and so they had a meal together to commemorate that. That's something that is very cultural to us, but in Western practice there is that client patient sort of relationship. You don't go past that boundary. So the fact that we were able to incorporate that made people feel more comfortable and at home. And I think that's the thing, people so often forget, right - you're not just providing a service in a language. That, of course, is a huge part of it. But you're also culturally translating a lot of difficult issues. How do you even talk about this when there's not even the language for it? Like even if I chose to have therapy in Vietnamese, which I wouldn't, because my Vietnamese isn’t that amazing, but even if I did choose to have that, no one taught me the word for sex, growing up, like I was brought up with my family. They're not going to give you sex ed and they’re certainly not going to talk about sex and certainly not in Vietnamese. So then how do you then even begin to find that word to then backwards communicate, oh, this is what's happened to me. And then similarly with the therapy, you want someone who's able to culturally translate not just the language, but okay, there's a lot of hierarchy within families. So what does it mean if a younger is talking up to an elder and disagreeing with them about how they responded to things, like that's an absolute no go. And I think a lot of the time when I saw English speaking therapy from people who were white, British, a lot of the advice they gave me, I was like, this is not going to apply in my context. This is not helpful to me. And then it kind of puts you off even wanting to seek help in the first place. Exactly. And even working for the NHS, the number of times I have heard people say, well, just get out of that situation or just speak out, culturally it's not something you don't feel safe to do. Your boundaries have already been violated when you've gone through CSA and then on top of that you're being told to stop speaking and there's a lot of gaslighting as well, etc. So what we do is we don't judge them for that and we work with that, and we start asking them, where does that come from? Why do you believe this? And then start changing their perception. I'll give you an example. We went to a temple, we were talking to a parents group. At the beginning, they were basically like, how dare you come to a temple, a holy place, and talk about sex? How dare you talk about abuse? But actually by the end of the workshop, they were so grateful and we did it in such a sensitive way as well, because it's not about judging the older generation, especially when they have gone through so much to even survive in the turmoil they had to in Sri Lanka and here by even migrating. So it's about having no judgment, testing the waters in a way and trying to change their perception. We would do role plays as well. We always have a trained facilitator, whether they’re a counselor or a therapist, those who speak in Tamil as well, who can interpret or translate, so it's as inclusive and as protected and safe as it can be, when we have these conversations. Other times it does take some time to build rapport because they're worried that they may tell the community. So that's why even having someone whose Tamil speak about confidentiality in Tamil or in Tamil context is so important because then they can trust better and they can see actually someone's modeling that behavior when they're in the community and they're talking about confidentiality and they won't speak to anyone else about it. So it's never pinpointing individuals and saying, you're not doing this right, nothing like that. Actually it’s about all of us learning from each other. And even for us, we've learned from the younger generation, we've learned from the older generation. And that's what every generation has been saying as well through all the work that we've done. So it is about learning from one another, not us feeling like we've got all the answers. No, our community does have all the answers, but we need to work with them to try and find them. That's so well said because any time you have a situation of child sexual abuse, there are multiple generations involved. Even if it's child on child abuse, because the people who are responsible for signposting and responding to that are typically from different generations as well. So you need to have at least three generations of dialogue because that's the only way to make it sustainable, is to stop it from happening again as well. We learnt from this by producing MDAG. So MDAG stands for Multidisciplinary Advisory Group and it's all the leads from Tamil organisations that do work regarding mental health, for example, or child abuse. So they may be therapy services, safeguarding leads, forensic psychiatrists, etc, and who share best practices with each other and the challenges that we faced in providing our service. But then we started Open Dialogues and Open Dialogues is about bridging that gap between generations so that we understand our parents better, we understand our grandparents better, etc, but they can also understand us better and improving that communication between generations. It really reminds me because some of the most interesting lessons that I learn the most from are like people in their eighties- shout out to all of you. I learned so much from them about people growing up in an age where this was completely under-talked about, and actually they have so much more experience of navigating the silence than I do for someone who like disclosed when they were in their teens. So it's really interesting to see how that learning is still relevant today for younger people. It's just maybe it's not quite the same language or we have phones now or whatever, but those sentiments are still there. Even with that, it’s so interesting when you divide it between communities. So when you look at the Jewish community, they of course went through a genocide. Ukrainian communities, Syrian communities, Tamil communities. Sometimes we may be a generation behind, but we can see from other generations, from other communities how things can progress and what the challenges can be and what space there is for the work that we do. So we also learn from other communities. The fact that we're saying that there are so many similarities between the Vietnamese community and the Tamil community. And it's realizing that different cultures, different communities, they have got a very different experience and a lot of the time sometimes harder experience than what you might consider the average. And a way to work with

communities is to break down: 23:42

okay, this is the service I provide; this is the advice we typically give in X-Y-Z situations; and you put all those bullet points down, then you take that to the different communities and you say, okay, where might there be a barrier in the advice I give? So for example, we talked about police. If you are to say, okay, the first point of course should be the police, how is that going to be disastrous in a lot of cases to different communities. If you're going to give them advice about how to talk to their family, have you considered hierarchy, have you considered religion? Have you considered all the different ways this might be a barrier for different cultures and communities and make sure that you have those different avenues available, as well as people who speak their language, who look like them, or understand the culture, if not fully available for 1 to 1 service, at least to have them consulting you on the service that you do provide. And that's why focus groups and peer reviews are so important. Because, you know, I wouldn't know everything about the Vietnamese culture. You wouldn’t know everything about the Tamil culture, so the fact that I've learned so much - it's actually just having someone who represents that community or people that represent that community also helping you address such topics. Well, Anuja, you've given us a lot to think about. I just want to say thank you. This is such a safe space because honestly, you and everyone here have made this such a lovely environment to even discuss such a sensitive topic. Oh, thank you. Thanks for bringing your joy as well. Thank you for having a difficult conversation with serious joy, and see you next time. Bye! If you want more bite sized content, we also have a webisode version of this episode called The Secret’s Out, which focuses on more do’s and don'ts for your own conversation. Find us on YouTube or by going to www.secretsworthsharing.com.