CASE 13
Mae Ling Chung
A 22-year-old Chinese woman in an arranged marriage
Educational Objectives
- Describe the custom and marriage practices prevalent in some families within Asian communities.
- Review the issues of arranged marriage, gender roles, and their effect on the physician–patient relationship.
- Appreciate the impact of cultural influences on the choice of contraception.
- Formulate approaches to caring for this patient/couple that maximizes on establishing a sense of trust, autonomy, and independence in making health care decisions.
TACCT Domains: 1, 2, 3, 4
Case Summary, Questions and Answers
Mae Ling Chung is a 22-year-old Chinese woman who immigrated to the U.S. 2 months ago after her family arranged for her to marry Wang Chung, a 30-year-old Chinese American man who has been in the U.S. for the past 12 years. She was an elementary school piano teacher in China but is currently not working. Mr. Chung had made an appointment to see a gynecologist to determine whether his wife is healthy enough to “bear” him children. Dr. Pedro Gonzalez, the physician assigned to see her, enters the room and immediately notices that Mr. Chung is sitting in one of the two chairs facing his desk, whereas Mrs. Chung is seated across the room on the examination table. When Dr. Gonzalez invites her to sit next to her husband, Mr. Chung initially resists saying, “her English is poor.” Despite Dr. Gonzalez’s efforts to speak to Mrs. Chung during the initial interview, Mr. Chung dominates the conversation, answering all the questions directed at Mrs. Chung except for a couple of yes/no questions. He refuses to entertain any questions related to his wife’s past sexual history, indicating that these questions are irrelevant.
Arranged Marriages
An arranged marriage by definition is a marriage in which neither spouse has control over the selection of their future partner. However, both parties give full consent to the marriage. Arranged marriages have been a successful tradition of family life in many cultures for years. Although often considered by Westerners as a lost tradition of the past, arranged marriages still remain an integral facet of life in many cultures today and are an accepted practice in Iraq, Iran, Afghanistan, Africa, Japan, Indonesia, India, and Bangladesh. This also can be seen in Amish communities, appreciated in the role of Jewish matchmaker “shadchan,” and evident in recent immigrants from Yemen and Albania. In China, arranged and semi-arranged marriages are still common, although the Chinese government introduced a new Marriage Law in 1980 setting the legal ages for women (20) and men (22) to marry. The law also confirmed the government’s approval for free-choice marriage, right to divorce, and the elimination of child marriages. Although there are no statistics on the success rate of arranged marriages in a Western context, anecdotal evidence suggests that these relationships often fail when husbands demand total autonomy over their spouses.
1 Why might Mr. Chung be acting in this way?
His behavior could simply reflect discomfort due to an unfamiliar situation or anxiety related to his new relationship and/or his desire to have children. Another possibility is that Mrs. Chung’s status as a very recent immigrant, and his sense of her limited English language proficiency, may have led Mr. Chung to see his wife as very vulnerable and in need of his protection. In addition, issues related to the arranged nature of the relationship may be at work as well. As they have been together for only a few weeks, Mr. and Mrs. Chung may not have actually discussed their past sexual histories with each other. Further, the marriage may have been agreed to based on promises of the virginity of his wife, which Mr. Chung believes to be true, and/or he does not want to hear anything that would question the notion of his wife’s virginity. Mr. Chung’s behavior may also reflect traditional Chinese male–female roles in the family of male dominance and female submission. And certainly, his actions may have nothing to do with any of the above. This may be who he is: a “controlling,” “domineering” individual.
Dr. Gonzalez asks Mr. Chung to leave the room so that he can examine Mrs. Chung, who up until now has not been able to say much. Mr. Chung hesitates but eventually agrees to leave, again requesting that his wife not be asked any questions related to her sexual history.
2 How might Dr. Gonzalez respond to Mr. Chung’s request that questions not be asked about his wife’s sexual history?
Physicians cannot agree to requests that are inconsistent with established standards of care or which are not in the best interest of the patient. Further, to promise not to ask the questions, and then do so, runs the risk of alienating Mr. Chung should he discover that the physician has lied. In this situation, the perceptive physician will realize that s/he will, however, need to take a few minutes to focus on Mr. Chung and begin the process of eliciting and understanding his goals and expectations for the care of his wife. This will aid in the development of trust and will provide information that will enable Dr. Gonzalez to negotiate a way through Mr. Chung’s objections.
3 Given the behavior of Mr. Chung, what other issue should Dr. Gonzalez consider as he evaluates Mrs. Chung?
The controlling behavior of her husband should raise some concern and prompt the physician to consider and potentially screen for intimate partner violence. Although studies specific to Chinese immigrants have been limited, the available data do suggest that domestic violence is a problem in this and other Asian immigrant populations. Although domestic violence is a problem that transcends race/ethnicity or class, there are several features of Asian communities that may increase the occurrence and/or tolerance of partner violence. These include the following:
- traditional cultural norms in which femininity is strongly associated with submissiveness;
- community denial or discounting of the problem;
- a strong emphasis on close family ties and a reluctance to do anything that would disturb the harmony or order of the family;
- fear on the part of the women of jeopardizing their immigration status;
- a lack of an extended family support in the United States;
- pressure to maintain the wider societal image of Asians as the “model minority”;
- domestic relationships in which the women are financially dependent on their husbands;
- limited English proficiency;
- ignorance of (Western) legal rights and available services.
These factors, in addition to more general societal, patriarchal arrangements, cause many immigrant women to stay in abusive relationships and/or be fearful of seeking help. It is therefore essential for health care providers to the take the initiative in exploring the possibility of partner violence when it is suspected for an immigrant patient. In pursuing a suspicion of domestic violence, it is essential to do this in a way and at a time that is safe for the patient.
Indicators of an Abusive Relationship
A series of questions can be asked regarding the patient’s inner thoughts and feeling or which explore the behavior of the partner to determine whether a patient’s relationship with her partner may be abusive.
The Patient’s Inner Thoughts and Feelings
Do you:
- feel afraid of your partner most of the time? [This may be the most significant sign of abuse.]
- feel emotionally numb or helpless?
- wonder if you’re the one who is “crazy?”
- believe that you deserve to be mistreated or hurt?
- avoid certain topics out of fear of angering your partner?
- feel that it is impossible to do anything right for your partner?
The Partner’s Belittling Behavior
Does your partner:
- humiliate, criticize, or shout at you?
- blame you for his own abusive behavior?
- ignore or put down your opinions or accomplishments?
- see you as property or a sex object, rather than as a person?
- treat you so badly that you’re embarrassed for your friends or family to see you?
The Partner’s Controlling Behavior
Does your partner:
- constantly check up on you?
- control where you go or what you do?
- act excessively jealous and possessive?
- prevent you from seeing your family or friends?
- limit your access to the phone, car, or money?
The Partner’s Violent Threats or Behavior
Does your partner:
- have a bad and unpredictable temper?
- hurt you or threaten to hurt or kill you?
- threaten to take your children away or harm them?
- threaten to commit suicide if you leave?
- destroy your belongings?
- force you to have sex?
Adapted from: Davies P., Smith, M., de Benedictis T., Jaffe J and Segal J. Domestic violence and abuse: warning signs and symptoms of abusive relationships. Available at: http://www.helpguide.org/mental/.
As soon as Mr. Chung leaves the room, Mrs. Chung moves closer to Dr. Gonzalez, becoming more animated, smiling, and, surprisingly, speaking English well enough to be understood. She immediately thanks Dr. Gonzalez for giving her an opportunity to speak in private and tells him she is grateful to be able to use the American health care system. She explains that she only met her husband 2 months ago and that their families had arranged the marriage. Although she agreed to the arrangement and is pleased with her husband, she now feels unhappy. She begins crying and explains that she is not ready to have a baby and asks Dr. Gonzalez to prescribe “Bi Yun” (prevent pregnant) birth control. She indicates that she does not want her husband to know about her use of contraception.
4 Why might Mrs. Chung have been willing to tell Dr. Gonzalez, but not her husband, that she was not ready to have a child?
An arranged Chinese marriage is more about an obligation to one’s parents than a romance and more an indication of personal self-worth and achievement for the husband. A common Chinese idiom is “cheng jia iiye,” translated as “get married and start one’s career.” Although Mrs. Chung had accepted her marriage as an obligation to fulfill a traditional Chinese female role, now that she is in the U.S. she no longer wishes to be a dutiful “wife who hums along, while the husband sings” and is not ready to have children. From a Western perspective, steeped in the empowerment of women, this might not be seen as problematic. However, Mrs. Chung’s agreement to the prearranged marriage was a commitment not only to her husband but to their respective families as well. Consistent with cultural norms, this commitment included an expectation by all involved that a child would soon follow their marriage and a family would be started. From the traditional Chinese cultural perspective, a loss of honor and subsequent disgrace results from a failure to keep one’s promises. Thus, in deciding not to have a child at this time, she not only would have to face the disappointment and anger of her husband, she would have to carry the cultural burdens of breaking a promise as well as not having children (at least not immediately) and thus risk being seen as an “old virgin.” Given this, and the newness of the relationship, it is not surprising that she shared her feelings with Dr. Gonzalez but not her husband.
During the visit while her husband was present, Mrs. Chung was unable to speak freely about her ambivalence regarding her prearranged role as wife and her husband’s and their families’ expectations for starting a family as soon as possible. She had come to see this visit as an opportunity to gain support of her desire to postpone pregnancy and was frustrated that she was unable to speak for herself while in the company of her husband. All this would not have come to the light if Dr. Gonzalez had not provided time to be alone with Mrs. Chung. This illustrates the importance of creating opportunities for patients to speak safely and not relying on family members to serve as interpreters. It also emphasizes the role that physicians can play in being advocates for vulnerable patient groups, such as immigrants with limited English proficiency.
5 Is it appropriate to prescribe contraception to this patient?
It is Mrs. Chung’s right to receive all available information on her family planning options and to choose to delay pregnancy or not to become pregnant at all. However, some careful thought and consideration should go into Mrs. Chung’s decision given the cultural dynamics (the immediate expectation of a child) and the nature of their relationship. The first issue is whether she will inform her husband of her intension and plans. It is not surprising, given that her marriage was arranged, that she might feel powerless or fearful to discuss this with her husband, particularly in light of his desire for a child. And such a conversation is made even more difficult by the possible dishonor and disgrace that she could bring her family if she did not have a child immediately. However, given her dependence (financial and otherwise) on her husband and her lack of familiarity with the American health care system, the best approach would be to develop a strategy of informing and including Mr. Chung in this aspect of her care. Moreover, a discussion with her husband is favored because open communication will strengthen their relationship and their marriage. If Mrs. Chung is willing to inform her husband, then Dr. Gonzalez should help her explain her perspective to Mr. Chung.
A decision to not tell her husband is Mrs. Chung’s right but is fraught with risk and not likely to work in the long term. That is, her husband will likely discover that she is using contraception. Has she carefully considered his reaction should he discover that she is employing birth control without his knowledge? Would this, in turn, create issues of safety for her? Will she feel comfortable knowing that she is keeping something from her husband? These are important questions that Mrs. Chung needs to consider. If she decides not to inform her husband, then Dr. Gonzalez should reassure Mrs. Chung that he will act to preserve the confidentiality of her decision.
The second issue is the actual choice of the specific form of birth control to be employed. A complete discussion of contraception should include a description of methods, written (if she reads English) and verbal explanation of pros and cons for each method, and an opportunity for questions related to how each works. There are methods that are culturally less acceptable and/or more problematic, such as condoms and other barrier methods that require cooperation from both partners. If Mrs. Chung chooses not to disclose her use of contraception to her husband, she will need a method such as birth control pills or the Nuva Ring that is reliable but not readily noticed by her partner. However, some of these more private methods may require subsequent physician visits that may make it difficult for Mrs. Chung to conceal her contraception use from her husband.
With her husband waiting outside, the complex nature of the discussion, and Mrs. Chung’s limited English proficiency, it is clear that this decision preferably should not be made after a brief or rushed conversation between the patient and the physician. There is certainly a need for a follow-up visit (in a week or two), ideally with an interpreter present, to ensure that Mrs. Chung is making an informed decision. This would also give her the opportunity to discuss the issue of birth control with her husband if she decides to inform him of her decision.
Chinese Women and Contraception
Since the inception of the Chinese government’s “one-child” policy in 1979, contraception has been widely available in China. Permanent sterilization and intrauterine devices (IUDs) have been the most common forms of contraception, with historically much lower use of condoms and oral contraceptives. In the wake of increasing rates of HIV infection, the Chinese government, however, has begun to promote the use of condoms. The patterns of contraceptive use may be somewhat different in North America. In a study of 40 ethnic Chinese women in Vancouver, Canada, the methods of contraception most frequently employed were condoms (n = 40), rhythm method (n = 20), and withdrawal method (n = 17), typically in combination. For this group of women, only 14 have ever used oral contraceptives and only 3 had used an IUD. None had used a spermicide or an injectable contraceptive such as Depo-Provera. These data are reflective of the fact that the attitudes of ethnic Chinese women (in Canada) toward oral contraceptives are generally negative. Common concerns in this group of women are weight gain, permanent infertility, and fear of being considered promiscuous. A similar distrust of birth control pills has also been detected in ethnic Korean women (see Wiebe et al., 2002, 2004, 2006).
6 Over time, what role can Dr. Gonzalez play to help improve communication for this couple?
Dr. Gonzalez must establish a trusting rapport with Mrs. Chung in order to support and empower her to open channels of communication. He will need to establish an open, unbiased, and safe environment that will include an understanding and appreciation of individual, family, and the sociocultural and economic pressures that are impacting on this couple’s ability to make family planning decisions. Mrs. Chung must struggle with becoming “the virtuous wife and good mother (xianqi liangmu).” She is also likely to face difficulty in obtaining the credentials needed to resume her previous career as a grade school piano teacher. Thus, if she seeks work, she may be forced to accept some form of unskilled employment (e.g. housekeeping or restaurant work). With employment opportunities often being limited and low-paying, many immigrants will have to work long hours and/or have several (part-time) jobs. And when she does have a child, child care may become a particular challenge, given its cost and the lack of support from extended family members, such as grandparents (which she would have back in China). Therefore, discussion over time of issues such as the role of honor, family obligations, work-related frustrations, and acculturation versus individual needs and expectations will be the kind of conversations that will help to establish and strengthen cross-cultural communication. Dr. Gonzalez should not feel that he can or should do this alone, but he should offer Mrs. Chung referrals to a social worker, culturally appropriate support groups, and other support systems.
Respecting and valuing Mrs. Chung’s individuality will enable Dr. Gonzalez to see her needs from the most basic, such as nutrition and sustenance, to the more complex, such as self-actualization. One way of conceptualizing this is through Maslow’s Hierarchy of needs, of which there are five levels that must be fulfilled in order to live a full life and feel happy. Although some of these needs are not absolutely essential, the foundations of Maslow’s pyramid are indispensible, and as one moves toward the apex, more complex needs come into play. Understanding her needs for safety, security, belonging, and self-esteem will help Mrs. Chung as she transitions in this stage of her life.
Another option that is not always appropriate, but which may make sense in this situation, is for Dr. Gonzalez to suggest that he also see Mr. Chung for his health care and attempt to provide culturally sensitive care to both of them. He should try to meet with them separately and together to discuss their perceived family pressures. Physicians who see both partners in a relationship, however, must be very mindful of boundaries and clearly define what are shared topics versus what are individual or private issues.
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