Language is a tool of communication. Communication between two parties in the same language is complicated enough, let alone when it is conducted in more than one language, with multiple parties including an interpreter involved. An interpreter is a qualified professional who ‘transfers a spoken or signed message from one language (the source language) into a spoken or signed message in another language (the target language) for the purpose of communication between people who do not share the same language.’¹ But the effectiveness of this communication process hinges on factors such as cross-cultural issues, interferences from third parties and role boundaries and perceptions. This article attempts to discuss these issues based on the day-to-day interpreting experience of a team of in-house hospital interpreters working in women’s health.

The Royal Women’s Hospital’s Language Services team provides interpreting in more than 70 community languages. Fourteen of the most requested languages – Arabic, Mandarin, Vietnamese, Cantonese, Amharic, Greek, Urdu, Hindi, Oromo, Punjabi, Spanish, Tigrinya, Turkish and Japanese – are spoken by in-house accredited interpreters.

In satisfying the hospital’s commitment to help patients effectively communicate with staff to make their own decisions with informed choices about their healthcare, the Language Services team tries to make their presence and work valuable for overcoming language barriers between patients (who speak little or no English) and health professionals.

Cross-cultural communication

‘Victoria is home to one of the most culturally diverse societies in the world, and is also among the fastest-growing and most diverse states in Australia.’² According to the 2016 census, almost 29% of Victorians were born overseas in over 200 countries, and nearly 50% were either born overseas or born in Australia with at least one parent born overseas. More than a quarter of Victorians spoke a language other than English at home, whilst almost 60% followed one of more than 130 different faiths.³

A language can be spoken in a number of countries and by people from different cultural backgrounds. For example, a Spanish-speaking patient’s country of birth can be Spain or Chile; an Arabic-speaking patient can be from Iraq or Lebanon; Urdu is spoken in India and Pakistan. And practices in each culture may not be observed by all (or even most) of those from the same culture. For example, a patient from Turkey might agree to an internal gynaecological examination while another might refuse because she is unprepared for it and feels she will lose her dignity to show her unshaved pubic hair. Having said that, we also need to allow for changes in their views and thoughts that evolve with age, experiences and other factors after their migration to Australia. A Chinese or Vietnamese patient who has been in Australia for years may not have observed one month of confinement after childbirth, whereas her newly arrived friend from China or Vietnam may have. While we hold certain views about cultures in the following discussion, we have no intention to create any cultural stereotypes.

In some cultures, such as Vietnamese, Chinese, Greek and Turkish, medical professionals are highly respected and considered as acknowledged superior authorities and will be trusted entirely by some people, particularly women. Therefore, when they are told to make choices for their treatment, they get confused and are reluctant because they trust the professionals’ opinion rather than their own. Some do not understand informed consent or are not aware they can refuse recommended treatment. Some even try to seek advice from interpreters.

These drag-on struggles about ‘who should make the decision’ between patients and professionals not only fail to effectively achieve positive outcomes, but also undermine the professionals’ trust in the interpreters’ competence in conveying their messages, and the patients’ trust in the professionals who are seen as unwilling to tell them what to do.

Sometimes a patient’s own misconception, inadequate education or lack of knowledge on human anatomy, may contribute to their hesitation. A few patients from Vietnamese and Turkish backgrounds who could not distinguish between a uterus and female genitals were reluctant to have a hysterectomy because they believed they could no longer have intercourse once their uteri were removed. Vietnamese patients sometimes would be reluctant to have a hormonal Mirena IUD. They implied a woman could not be a complete woman without a monthly period, unless they are menopausal.

From our experience, using drawings, pictures or three-dimensional models such as anatomical pelvic models to illustrate reproductive organs, for example, by health professionals, has proved highly beneficial to patients. A picture is worth a thousand words. Even when medical staff explain in simple English and do not use jargon, visual demonstrations always help to improve and facilitate communication.

Syntax of negative questions

English and some Asian language speakers process negative questions differently. The following example shows how this can lead to misunderstanding, poor interaction and even distrust among all parties involved, including interpreters.

A worrying husband who wished to confirm if his wife’s infection would harm their baby rephrased his question, ‘Doctor, doesn’t it cause the baby any harm?’ Being impatient with his repetition, the doctor just replied with one word, ‘No!’ For her, she meant no, it ‘does not cause any harm’. But for the Chinese, Vietnamese or Japanese speakers, her answer indicated she disagreed to the negative question, which meant the infection ‘does cause harm’. Before the interpreter could interpret, the husband (who spoke some English) felt the doctor contradicted herself and asked again for clarification, which in turn annoyed the doctor more. She raised her voice and said, ‘No, it doesn’t harm the baby.’ Up to this point, all parties became agitated. The couple considered the doctor rude and inconsistent, and the doctor doubted the interpreter’s competence in transferring the message.

In a similar scenario, after responding with a ‘no’ to the negative question, the doctor sensed their patient’s confusion, further elaborated her answer and explained it again in a different way to help the patient understand. We also found if health professionals can closely observe facial expression and body language by maintaining eye contact with patients, it is more likely to achieve a satisfactory communication outcome.

Asking sensitive questions

Women from some cultures are shy, introverted and submissive and tend to refrain from discussing sexual matters. For example, some older women who lost their husbands a very long time ago get offended when asked if they are still sexually active. In one scenario, the interpreter needed to step out of her role and clarify the misunderstanding before the professional could get answers from an angry African widow.

Some women would not speak of their sexual life when their children are present; some if accompanied by their partners would intentionally omit their current or past medical history.

Family members’ interference – acting as interpreters

The presence of family members is good to give patients support and supply extra information especially for elderly patients, but they should not replace interpreters. While patients from some cultures may prefer family members to be their interpreters, failure to use impartial and qualified professional interpreters can give rise to conflicts of interest and intentional misinterpretation.

A patient only found out she was not the cause of their infertility (but her husband was) when his female relative, who had always interpreted for her before, was unavailable and the hospital interpreter service was used. The interpreter recalled how the elated woman glowed with self-confidence when she knew the truth. In some cultures, a divorce or polygamy is warranted if the wife is found infertile.

Family members’ interference – dominant partners

It is not uncommon for partners to interfere in patients’ health affairs, when they speak little English and come from a culture where women’s rights are not respected. Provision of a professional interpreting service empowers those women to speak freely.

One observation made by an interpreter is noteworthy: when patients come without their partners, they are more likely to ask many questions; when partners attend, they can take over the conversation with the health professionals who are satisfied to chat with the partners ‘all in English’. In such a situation, to ensure the patient ‘remains linguistically present’,⁴ the interpreter would offer whispered simultaneous interpreting for her. With all participants talking simultaneously (with the exception of the patient, the supposed focus), the communication is far from satisfactory.

One of the requests commonly made by family members is not to interpret ‘bad news’ to the patients or to avoid the word ‘cancer’ in the interpreted message. While we understand their motive might be love, interpreters must adhere to our responsibility, which is ‘to ensure that the full intent of the communication is conveyed’, and ‘do not soften, strengthen or alter the messages.…’⁵

Similarly, interpreters must also try their best to be accurate, ‘faithful at all times to the meaning of … messages’⁶ and ‘keep the participants informed of any side comments made by any of the parties…’⁷ All parties are advised to refrain from uttering anything that they do not intend to be conveyed in an interpreting session.

Role boundaries and perceptions

Some patients in small tight-knit communities would refuse interpreters from their communities because they do not trust them to abide by confidentiality in the course of their work.

However, on the other end of the spectrum, some patients perceive interpreters as their ‘close allies’ because they speak the same language and may come from the same cultures. They would consult us in their treatment; expect us to remember their medical history and conversations from previous consultations. Interpreters would try to make patients understand that we must ‘maintain professional detachment, impartiality, objectivity and confidentiality’.⁸ In fact, sitting and engaging in conversation with patients in the waiting area is not appropriate because it runs the risk of getting their medical information, which the patient expects the interpreter will later tell the health professional.

However, in-house interpreters working in an institutional setting are wearing two hats, playing the roles as staff members and independent interpreters. In carrying out our professional duties, it is also important to develop good rapport with patients, provide information on the services available and help clear up misunderstandings when appropriate. According to our code of ethics, interpreters are allowed to play a role in addition to interpreting as long as ‘they clearly indicate when they are acting as interpreters and do not switch roles without notice’.⁹ As NAATI accredited interpreters whose credentials need to be recertified regularly like other professions, we perceive ourselves as professionals, not ‘helpers’.

Sometimes we are present ‘on standby’ for patients’ ‘in case’ incomprehension occurs, upon the patients’ requests even though they communicate well in English. Our hands are not bound, but we feel our tongues (both our native and foreign ones) are ‘tied’! Comments made by some professionals such as ‘your job was easy because you didn’t have to do anything’ are even more discouraging. The interpreter does not sit idly, but is listening to every utterance attentively for the entire time to prepare for ‘rescues’ when necessary. However, by and large, interpreters are respected and their work is appreciated in Australia.

‘Learning a language challenges you to see the world from a different and sometimes uncomfortable perspective – it broadens the mind more surely than travel, and at the same time promotes cross-cultural empathy and understanding.’¹⁰ Author and literary translator Linda Jaivin considers access to translation as a ‘sensible corrective’ for those who lack opportunities to learn another language.¹¹ In this sense, interpreters, verbal translators, are also providing this important access.

Our feature articles represent the views of our authors and do not necessarily represent the views of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), who publish O&G Magazine. While we make every effort to ensure that the information we share is accurate, we welcome any comments, suggestions or correction of errors in our comments section below, or by emailing the editor at [email protected].

1. National Accreditation Authority for Translators and Interpreters. Certification Glossary of Terms. 2021. Available from: www.naati.com.au/information-guides/certification-glossary-of-terms/.
2. State Government of Victoria. A snapshot of our diversity. 2021. Available from: www.vic.gov.au/discover-victorias-diverse-population.
3. State Government of Victoria. A snapshot of our diversity. 2021. Available from: www.vic.gov.au/discover-victorias-diverse-population.
4. Australian Institute of Interpreters and Translators. AUSIT Code of Ethics and Code of Conduct. 2012. Available from: ausit.org/wp-content/uploads/2020/02/Code_Of_Ethics_Full.pdf.
5. Australian Institute of Interpreters and Translators. AUSIT Code of Ethics and Code of Conduct. 2012. Available from: ausit.org/wp-content/uploads/2020/02/Code_Of_Ethics_Full.pdf.
6. Australian Institute of Interpreters and Translators. AUSIT Code of Ethics and Code of Conduct. 2012. Available from: ausit.org/wp-content/uploads/2020/02/Code_Of_Ethics_Full.pdf.
7. Australian Institute of Interpreters and Translators. AUSIT Code of Ethics and Code of Conduct. 2012. Available from: ausit.org/wp-content/uploads/2020/02/Code_Of_Ethics_Full.pdf.
8. Australian Institute of Interpreters and Translators. AUSIT Code of Ethics and Code of Conduct. 2012. Available from: ausit.org/wp-content/uploads/2020/02/Code_Of_Ethics_Full.pdf.
9. Australian Institute of Interpreters and Translators. AUSIT Code of Ethics and Code of Conduct. 2012. Available from: ausit.org/wp-content/uploads/2020/02/Code_Of_Ethics_Full.pdf.
10. Linda Jaivin. Quarterly Essay 52 Found in Translation: In Praise of a Plural World. Schwartz Books Pty Ltd. 2013. eBook conversion: Duncan Blachford. Melbourne: Morry Schwartz; The Balance of Trade.
11. Linda Jaivin. Quarterly Essay 52 Found in Translation: In Praise of a Plural World. Schwartz Books Pty Ltd. 2013. eBook conversion: Duncan Blachford. Melbourne: Morry Schwartz; The Balance of Trade.