SITUATING IMMIGRANT WOMEN OF COLOUR

Immigrant women have been the focus of numerous scholarly investigations from diverse disciplinary traditions. Yet, although constructed as a group, the needs, realities and lives of immigrant women are not homogenous nor are they a monolithic group. 'Race' and class are major factors influencing immigrant women's choices and degree of access to shelter, employment, and services (Anderson et al., 1993; Bolaria & Bolaria, 1994; Lee with Harrison, 1999; Ng, 1993). Immigrant women of colour are racialized in terms of their construction as 'others' as well as their subordinate status within Canadian society (Iyer, 1997; Ocran, 1997; Thobani, 1998). Legislation and policies concerning immigration have a tremendous impact on settlement and access to services. Hence, whether a woman immigrates as an 'independent,' a 'sponsored dependent' in the family class, a convention refugee, or has received 'landed status' after serving time as a domestic worker or live-in caregiver, determines her subsequent status and access to services (Thobani, 1998).⁽⁴⁾ The same situation applies to undocumented women, migrant workers, and foreign students whose access to services may be further impaired by the degree of legality ascribed to their status.

Even prior to immigrating, applicants have to demonstrate that they are in good health and will not pose a risk to public health, or impose a burden on the health care system. Should they fail the medical exam on either one of these conditions, they will not be admitted into the country. According to the 'excessive demands' clause, an applicant will not be admitted if their health demands "exceed that of the average Canadian (evaluated as $2,500 per year); if their admission may displace a Canadian resident from obtaining services; or if the required services are not available and/or accessible" (Laroche, 2000:53). The popular perception of immigrants as a drain on the health care system or as endangering public safety has a long history (Beiser 1998).⁽⁵⁾ Historically, the threat of people of colour bringing over strange diseases was used to rationalize their exclusion as citizens and immigrants (Anderson & Kirkham, 1998). That fear still remains and continues to inform policy decisions around screening mechanisms for the detection of diseases among potential immigrants (Beiser, 1998; Shroff, 1996/97).

Many immigrant women come to Canada as dependents of their spouses or as 'sponsored' individuals who are sponsored by families or spouses (Abu-Laban, 1998). In either case, their dependency on the sponsoring spouse is underscored by the legislation (Ng, 1993). As dependents, they have little access to services. The sponsoring spouse or family has to demonstrate they are economically able to support the sponsored person for a period of 10 years. If the sponsorship agreement breaks down, the woman involved can obtain hardship assistance but she would have to verify her changed circumstances and inform the authorities (see Janoviek, 2000). Her status would then be reviewed, and she could potentially risk deportation (Dosanjh et al., 1994). Even if the sponsorship agreement is intact, should the woman's spouse be deported, she will be deported as well. The situation is often complicated by the reality that women are involved in the joint sponsorship of their own and their spouse's extended family members. The coercive pressure to keep the family together compels women to remain in abusive relationships.

The Racialization of Women

According to Citizenship and Immigration Canada, immigrants constitute 17.4% of the population, totaling 4,971,070 individuals. One out of every six Canadians is an immigrant (Kinnon, 1999). Asia and the Pacific constitute the source of 54% of all recent immigrants, followed by Africa and the Middle East (18%), Europe and the UK (18%), and the US, Caribbean, South and Central America (10%). Thus, it is safe to assume that most of the recent immigrants are people of colour or in the terminology of the government, 'visible minorities.' According to Statistics Canada, the 'visible minority' population in Canada totals 3,197,480 and in BC, the figure is 660,545, constituting approximately 18% of the total provincial population (Statistics Canada, 1996).

The identity of groups that are racialized varies according to the particular society being examined and is reflective of a group's social status in a given historical period (Miles, 1989). Within Canada, Aboriginal peoples, people of colour, the Jewish, Irish and Ukrainian peoples have been racialized at various times in the history of the nation. Today, Aboriginal people and people of colour still remain on the outskirts of Canadian society as racialized groups who are visibly identifiable and subject to racism, exploitation, marginalization and criminalization (Bannerji, 1993; Das Gupta, 1996; Henry et al., 1995; Jiwani, 2000).⁽⁶⁾ Racialization refers to the "processes by which meanings are attributed to particular objects, features, and processes, in such a way that the latter are given a special significance and carry or are embodied with a set of additional meanings" (Miles, 1989:70). Women of colour are racialized in the sense that their skin colour serves to demarcate them and imbues their representation with negative valuations. These meanings are grounded in an ideology of racism which Bulhan defines as:

… the generalization, institutionalization, and assignment of values to real and imaginary differences between people in order to justify a state of privilege, aggression and/or violence. Involving more than the cognitive or affective content of prejudice, racism is expressed behaviourally, institutionally, and culturally. The ideas or actions of a person, the goals or practices of an institution and the symbols, myths or structure of a society are racist if (a) imaginary or real differences of race are accentuated; (b) these differences are assumed as absolute and considered in terms of superior, inferior; and (c) these are used to justify inequity, exclusion or domination. (1985:13)

As Bulhan notes, racism can be communicated in a variety of ways and can take different forms in different historical periods. Thus, there may be many 'racisms', and the task at hand is to "[understand] racisms as modes of exclusion, inferiorization, subordination and exploitation that present specific and different characters in different social and historical contexts" (Anthias & Yuval-Davis, 1992:2). The discourse of immigration itself has become racialized. Hence, the term 'immigrant' is popularly constructed as referring to a person of colour (Henry et al., 1995). This point is echoed by Ng (1996) who states:

… technically, the term, 'immigrant women,' refers to women who are landed immigrants in Canada. In everyday life, however, women who are white, educated, and English-speaking are rarely considered to be immigrant women. The term conjures up the image of a woman who does not speak English or who speaks English with an accent; who is from the Third World or a member of a visible minority group; and who has a certain type of job (e.g., a sewing machine operator or a cleaning lady). (cited in Lee & Harrison, 1999:16)⁽⁷⁾

Canadian society has long been described by scholars as a vertical mosaic (Hamilton, R., 1996; Porter, 1965). The description highlights the stratified nature of the society and the ranking of groups within it on the basis of their class and race, as well as the particular structures of domination exerted on the basis of sexuality and ability to maintain the hegemonic power of the elite and reinforce the normative glue of social cohesion. Within this structure, women constitute a subordinated group. Their inequality is defined on the basis of institutionalized economic, socio-cultural and political devaluation, all of which are underpinned by historical and contemporary social forces. Similarly, people of colour are subordinated by institutionalized racism, and largely occupy the lower rungs of the society (Henry et al., 1995). Thus, the very institutions that women look to for protection and services are themselves structured on hierarchies based on race, class, gender, sexuality, age, and ability. These forces are evident also in the organization and structure of the formal health care system in Canada (see Varcoe, 1997).

However, within the category of 'women', a similar hierarchy exists. Class, race, sexuality and ability engender a ranked order and influence women's autonomy, access to services and economic mobility. As Spelman argues, there is no 'universal woman' (Bannerji, 1993; Spelman, 1988). To submit to an essentialist notion of woman is to negate the differences within women and erase the power and privilege exercised by some women over others (Razack, 1998).⁽⁸⁾ It is to erase the impact of racism, classism, heterosexism and ableism in the lives of women.

Immigrant women of colour who have experienced violence are positioned at the juncture of multiple and intersecting systems of domination. Not only are they located in the lower echelons of the social stratification system of the wider society because of their race and gender, but they are also located at in the bottom of the hierarchy of preferred clients of the health care system. Compounding this situation is the reality of their subordinate status within their own communities as a result of patriarchal forces that are heightened by State policies of immigration. As women who are classed and raced, their needs and realities have and continue to remain invisible, and their voices confined to the realm of advocacy and survival.

THE IMMIGRANT EXPERIENCE:
RESILIENCE AND SURVIVAL IN A HIGH RISK CONTEXT

Immigrants come to Canada for a variety of reasons. Principal among these is to secure a better future for themselves and their children. Coming to a western country from a developing nation has always carried connotations of upward mobility, economic betterment and a more secure future. Certainly, the picture that western countries have advanced, through various channels, to the developing worlds of the South is framed in the racially inscribed language of colonialism where the south is constructed as backward, traditional and in need of modernization (read westernization), and the North by contrast is presented as the realm of democracy, economic prosperity, individual freedom and equality. Implicit in this language is the promise of acceptance, integration and equality for those groups migrating to the north. Hence, many immigrants of colour come to Canada expecting that they will be able to participate fully and enjoy the fruits of their labour in economic and social terms. They bring with them their social, cultural and in many cases, economic capital.

The Reality of Racism

Since 1976, many immigrants who were selected on the basis of their qualifications and skill-sets (as determined by the Canadian immigration point system), find themselves, upon arrival, deskilled and devalued (Ervin, 1994; Ng, 1993). Their qualifications are not recognized and they are required to obtain 'Canadian experience' in order to qualify for jobs more suited to their abilities. Not having any Canadian experience because of the lack of accreditation and the reluctance of employers to hire them, they experience downward mobility. For racial minorities, this factor is compounded by the pervasive racism in Canadian society (Billingsley & Muszynski, 1985; Bolaria & Li, 1988; Boyd, 1989; Henry & Ginzberg, 1985; Henry et al., 1995). The overt and covert nature of racism in Canada has been documented extensively by advocates and academics. As Henry & Tator confirm: "In a white dominated society, the colour of your skin is the single most important factor in determining life chances, as well as your dignity, identity, and self-esteem" (cited in Fleras & Elliot, 1996:35). In a context of intense and prevalent anti-immigrant sentiments, the reality of immigrants of colour is one of constant negotiation, adjustment, and retreat into the cultural community. And in the Canadian context where racism is more 'polite' and insidious, the processes of negotiation are more nuanced and confounding leaving many people of colour doubting their own realities. This situation of being a perpetual 'other' exacts its toll on the mental health of immigrants of colour. As one immigrant woman interviewed by MacKinnon & Howard put it:

We are living in the community but it's just like water and oil, you shake the bottle, they mix together, you cannot tell the difference and I say 'Hello, hi Joe, how are you?' and then the bottle settles down, oil and water separates. We don't feel we are really mixed with the neighbours, with the community. (2000:28)

Fanon (1967) and Memmi (1965) have poignantly described the psychological impact of being a perpetual outsider and being 'othered.' Additionally, Black feminist scholars have further elucidated on the psychological and sociological impact of racism (e.g., Davis, 1990; hooks, 1995; Williams, 1991). As people of colour who are also immigrants, the trauma of migration combined with the experience of being 'othered' contributes to a greater sense of alienation and marginalization.

The Impact of Migration

In his study of the Southeast Asian boat people, Beiser (1998) observes that immigrants go through three distinct stages during their process of resettlement in Canada. Initially, they experience a period of euphoria. This is followed by a period of disillusionment during which depression is common. Finally, a period of adaptation follows. These periods accentuate the stresses of migration that mark the lives of all immigrants resulting in a sense of loss, helplessness and alienation (Choi, 1997; Moussa, 1994; Schneller, 1981; Vega et al., 1987; Zulman, 1996). MacKinnon & Howard state that, "Immigration itself is associated with increased morbidity. ... These factors include: language difficulties, multiple responsibilities; financial and employment stressors; lack of acceptance by their host communities; culture conflict; and a perceived lack of social support" (2000:25). For refugees, these stresses are more intense as a result of witnessing or being victimized by violence. However, in the case of immigrants of colour, the harsh reality of racism and its constancy make the settlement process more difficult, if not traumatizing. American studies have underscored the negative health impact of racism (e.g. David & Collins, 1991 as cited in Cameron et al., 1996). Combined with the poverty resulting from deskilling, under-employment and unemployment, the disruption of social ties and the lack of immediate supportive networks, the health impact of migration is more severe for immigrants of colour (Brice-Baker, 1994). A Canadian study indicates a high suicide rate among Asian women (Kinnon, 1999). Anderson (1987) notes that for the immigrant women in her study, loneliness and depression were a daily feature of life.

Multiple Roles

Immigrant women have been identified as a high risk population (Meleis, 1991). Meleis defines their vulnerability as stemming from the multiple roles they are required to play within the home and the external society, as well as the constant negotiation of competing demands that results from their bi-cultural existence. The notion of 'role overload' has been documented in the US, UK, and Canadian literature as one of the defining stressors in the lives of immigrant women (Anderson, 1987; Choi, 1997; Li & May, 1997; MacKinnon with Howard, 2000; MacLeod & Shin, 1990; Rhee, 1977). Some authors have detailed the multiple work that immigrant women do in terms of constructing a transnational community, transmitting cultural knowledge, and providing support to their immediate and extended kin (Alicea, 1997; Lutz, 1995; Ng, 1993). This is in addition to the double load that most women carry with respect to working outside the home and child-rearing and house work. However, the negotiation of multiple roles occurs within a larger social context, and it is the responsiveness of the receiving society which plays a critical role in exacerbating role overload. Part of this responsiveness lies in the kinds of services and programs that are available to immigrant women to facilitate their integration into the economic and cultural spheres. Yet another part deals with the attitudes that are directed at immigrant groups in general and racialized groups in particular (Bald, 1995; Henry et al., 1995). Exclusion from the larger society as a result of racism increases immigrant women's role overload in terms their responsibilities as nurturers providing a space within the home that is affirming and that provides a sense of belonging through cultural continuity. 

Racism & Sexism: Economic Exploitation & Ghettoization

Canadian social policy has tended to view immigrant women as dependents of their spouses or families and to erase their social, economic and cultural contribution to the economy (Thobani, 1999). Despite having higher qualifications, immigrant women are unable to practice in their fields because of language barriers and the lack of accreditation of their qualifications. Further, they are often diverted from language instruction and economic integration programs on the assumption that they are not the principal breadwinners of the family (Ng, 1993; Roberts, 1990). As an evaluation report conducted by the Windsor Occupational Health Information Service (1995) demonstrates, immigrant women are not provided language instruction or education in terms of their employment rights. This renders them a pliant and cheap labour force, which can be easily exploited. Bolaria & Bolaria (1994) note that immigrant women tend to work in occupational areas that are dangerous and hazardous to health. Further, many of these sectors are unprotected by unions, rife with economic exploitation, seasonal or part-time in the kind of work they offer, and render women working within them vulnerable to all forms of violence (Anderson, 1985; 1987; Jiwani, 1994; MacLeod et al., 1994; Philippine Women Centre, 1997; Savary, 1998). Lack of dominant language skills serves to stream women into low paying, low mobility and seasonal jobs (Ng, 1993; Ocran, 1997). This has a direct bearing on the kinds of stresses they experience, their vulnerability to violence, and their ability/inability to access adequate services.

Ghettoized in particular jobs (Iyer, 1997; Ocran, 1997), many of these women also experience gender role dislocation in the family. The deskilling and unemployment of men combined with more rapid employment of women in low paying jobs (Ng, 1993), e.g. domestic work, create additional tensions in the family. In a series of focus groups convened by the MOSAIC immigrant settlement society, women from the Kurdish, Somali, Vietnamese, Polish and Latin American communities in Vancouver discussed the gender shifts in their family and the potential for violence. The focus group participants, "… felt that immigration and the resulting changes in the family roles and expectations, appear to increase men's insecurity in the relationship, and that insecurity, in turn, resulted in dysfunctional behaviour" (1996:4-5).

Legal Status

By far the most common thread cited in the literature dealing with immigrant women who have experienced violence centres on the implications of the legality of their status (e.g., Abraham, 1995; Brice-Baker, 1994; Calvo, 1996; Choi, 1997; Choudry, n.d.; Dosanjh et al., 1994; MacLeod & Shin, 1990; MacLeod et al., 1994; Narayan, 1995; Rasche, 1988; Rhee, 1977). As indicated previously, most immigrant women enter Canada as sponsored spouses. Their dependency on their spouses is underscored by the sponsorship requirements and reinforced by the State. Sponsorship obligations are often used as instruments of power and control by abusive spouses to reinforce their authority within the family (MacLeod & Shin, 1990; Moussa, 1998). In essence, the dependent designation subordinates women in the relationship and accentuates their dependency on sponsors to meet basic needs (Ng, 1993). For women, this translates into a feeling of indebtedness (NAWL Brief, 1999), a fear of deportation, fear of having their children taken away from them, and fear of poverty and destitution should they leave the abusive relationship.

In British Columbia, social assistance policies known as BC Benefits exacerbate the situation by holding the sponsoring spouses accountable for any social assistance given to women. This contributes to a continual harassment of immigrant women by their abusive spouses, who use it to threaten women not to disclose abuse and/or leave the relationship. For many women, the situation is compounded by their lack of knowledge regarding their legal rights. Language barriers, dependency and lack of dominant cultural knowledge, contribute to their inability to access information about their rights or the resources that may be available. Studies focusing on 'mail order' brides are illustrative of the impact of isolation, lack of knowledge of the dominant language and systems, and dependent status as factors contributing to violence (Choi, 1997; Narayan, 1995; Philippine Women Centre & GAATW, 1999).

In addition to their legal and economic dependency, the lack of accreditation of skills and qualifications for both themselves and their spouses contribute to immigrant women being streamed into specific jobs which are 'dead end' (Ng, 1993:289). The decline in their spouse's status leads to the use of other means by which spouses attempt to exert power and control within the home.

Isolation

In describing the situation of immigrant women in the US, Pinn & Chunko (1997) identify isolation as a key risk factor for domestic violence. Social, structural and cultural isolation contribute to women's marginalization and vulnerability to violence. Lack of dominant language skills can in effect make women more dependent on their families and communities to negotiate their survival. The lack of cultural knowledge and frameworks of meaning within the dominant society increases the sense of isolation experienced by many immigrant women (Wiik, 1995). Exclusion from the dominant culture as a function of racism exacerbates the isolation and sense of loneliness they experience (MacLeod et al., 1994; Rasche, 1988; Sidhu, 1996). Many women don't know where to turn when they are victims of violence.

Accessing Services

Existing studies indicate that lack of dominant language skills is a key barrier exacerbating the situation of immigrant women (Calvo, 1996; Chin, 1994; Choudry, n.d.; Dyck, 1992; Easteal, 1996; MacLeod & Shin, 1990; MOSAIC, 1996; Perilla et al., 1994). Inability to communicate in the dominant language permeates interactions with service providers leading to feelings of frustration and heightened dependency on those who can translate. Too often, the interpreters are other immediate members of the family. This serves to compromise confidentiality and can engender feelings of shame and embarrassment (MacLeod & Shin, 1990, 1994; Sasso, 2000). Lack of adequate and appropriate interpretation can lead to misdiagnosis thereby endangering the lives of immigrant women (Sasso, 2000).

However, language barriers are only one of many issues impeding immigrant women's access to services (Anderson & Kirkham, 1998). Given immigrant women's concentration in the lower, unprotected echelons of the labour force and the piecemeal nature of work they are required to perform, women cannot afford to take time off to access services. Should they take the time off, they often have to find transportation and accompaniment by someone who can interpret their request. And further, inability to communicate in the dominant language compounds the difficulties of negotiating with government and health care and social service bureaucracies (Gany & Thiel de Bocanegra, 1996). Thus, aside from language, other barriers also influence immigrant women's access to health care. In her study of immigrant communities and their access to health care, Christensen (2000) found that the inability to speak in the dominant language was mentioned by only 27% of the individuals she surveyed. Similarly, Anderson (1987) found that immigrant women of colour who speak English fluently experienced barriers to services based on the stereotypes that health care providers had of their particular cultural groups.

Silencing Violence

Immigrant women's marginalization in the social, cultural, political and economic spheres of society also contributes to their sense of 'otherness' and lack of belonging. The retreat into their cultural communities exacts a price for immigrant women of colour who experience violence. When the community becomes the only site for a sense of belonging and self-esteem, jeopardizing one's reputation incurs social costs which could amount to stigmatization and exclusion (Dasgupta, 1996; Health Canada, 1994; Huisman, 1996; MacLeod & Shin, 1990; Rasche, 1988; Rhee, 1977; Wiik, 1995). In this sense, the plight of immigrant women who experience violence parallels that of rural women whose only choice in leaving a violent relationship is to leave their community (Jiwani et al., 1998). However, in a racist milieu where men of colour are increasingly criminalized, reporting violence can in effect be construed as 'race treason' (Flynn & Crawford, 1998; see also Davis, 2000; Razack, 1998). Communities are labeled and constructed as being inherently violent resulting in negative social implications for other members and children. Fear of deportation and criminalization leads many immigrant women of colour to avoid authorities and any form of official documentation that could potentially jeopardize their legal status.

Summary

The subordinate status of immigrant women as dependents, combined with their streaming into occupational ghettos that are hazardous, underpaid and unprotected, and their diversion from language classes (and concomitantly occupational and economic mobility), contribute to their inferiorization, isolation and marginalization. Given the racism and sexism they face from the broader society, and the sexism they face from within their own communities into which they retreat in order to maintain a sense of self, immigrant women of colour are indeed in a high risk category. However, as a vulnerable population, their access to services is limited. Their gender, race, and class form a juncture where multiple forces of domination intersect. The negative health effects emanating from the stresses of migration, economic exploitation, stigmatization and marginalization worsen the situation. The negative health effects emanating from spousal abuse are further accentuated by the institutionalized racism and sexism that immigrant women of colour encounter in the formalized health care system, namely at the hands of medical professionals.

WOMEN, VIOLENCE & THE MEDICAL SYSTEM

As a social institution, the health care system is stratified. The system is 'raced, classed, and gendered' in the way in which services and labour are organized. While the janitorial, kitchen and laundry staff occupy the bottom echelons of the system, nurses are located above them, and physicians along with hospital administrators account for the elite. The concentration of people of colour occurs at the lower end of the hierarchy, namely in the cleaning sector. Within this tiered context, there are varying levels of violence perpetrated against those who have relatively little power and control (Varcoe, 1997).

The medical professions' response to women who have been abused has been described as inadequate (Kinnon & Hanvey, 1996). According to studies cited by Kinnon and Hanvey, "medical personnel identify one battered woman in 25" (1996). The absence of an effective response to the screening and treatment of battered women has been attributed to a lack of knowledge about violence among medical personnel, their unease with dealing with issues of violence, the implications of violence in terms of their own experiences of abuse, stereotypes about women, and preconceived notions about woman abuse. Further, identification of abuse tends to depend on the visibility of symptoms and the lack of alternative explanations by which to understand the injuries. For women whose symptoms are not visible, the possibility of effective identification and intervention is further reduced. The political economy of medical care is also undoubtedly an influential variable, given that physicians are paid on the basis of the number of patients they treat. The time required to deal with woman abuse is greater than the time taken to simply prescribe medication.

Health Care Costs of Violence

It has been estimated that the medical and health related costs attributed to violence against women amount to $408,357,042 nationally (Greaves et al., 1995). These include the costs of emergency visits, consultations with doctors, ambulance services, psychiatric ward care, and some treatments. They do not include the costs to patients, e.g., transportation, prescription drugs, time-off from work, child-minding, or anything else that is required to obtain medical services. Nor do they include the entire spectrum of health issues associated with the psychological forms of abuse which may result in self-harm.

In a recent survey conducted by Statistics Canada, 40% of the women who had experienced violence reported being physically injured and requiring medical attention (General Social Survey on Spousal Violence, 1999). The 1993 Statistics Canada Survey on Violence against Women revealed that 45% of the victims of spousal violence had been physically injured (Johnson, 1996). Further, in 21% of the cases, the abuse took place during pregnancy (Varcoe, 1997). Injuries among women who had been abused included burns, cuts, scratches in 33% of the cases, and miscarriages and internal injuries in 10% of the cases (Wilson, 1998). According to Archer, "seventy percent to eighty percent of women who are psychiatric inpatients have a history of physical or sexual abuse. Fifteen to 30 percent of women presenting to emergency rooms have a history of current abuse" (1994:975). The Domestic Violence Program at the Vancouver General Hospital reported a 15% disclosure rate among women presenting to the emergency department (Chambers, 1998). As Chambers notes, most women do not disclose the violence to the police or other authorities. Rather, they tend to confide in friends and family. Nevertheless, the health impact of chronic stress and violence compels many women to seek medical attention.

For women who are experiencing violence, the doctor's office may be the only place they can go unaccompanied, as medical visits tend to be more sanctioned and normalized. It may also be the only place in which they can disclose abuse if asked by a concerned physician. Yet, as a study by Trute et al. (1988) of general practitioners in Manitoba revealed, most physicians do not ask questions about violence. Trute et al. found that physicians who are male and who have been in practice for a long time period were less likely to detect abuse. The Violence against Women Survey (1993) found that 23% of the women who had been injured by a male partner had approached a doctor. Bullock et al. (1989) found that 8.2% of the women who had visited the four planned parenthood sites in their study were victims of physical battering. While hospitals are the sites which women turn to in emergencies, the chances of the family physician being the first line of refuge for an abused immigrant women is much higher. Community-based research underscores this point (e.g. Sidhu, 1996). The role physicians can play in detecting abuse and providing referrals is therefore critical, as is the role of nurses working within clinics and hospitals (Henderson & Eriksen, 1994; Varcoe, 1997). Nevertheless, even in this context, anecdotal and community research suggests that disclosures are not given serious consideration.

Health Effects of Violence

The health effects of violence are manifold and complex. They include Post Traumatic Stress syndrome which groups a range of symptoms (Abbott et al., 1995; Archer, 1994; Argüelles & Rivero, 1993; Chuly, 1996; Ristock et al., 1995); bronchitis and upper respiratory infections (Abbott et al., 1995); depression, anxiety, fear, mood swings and dissociative states (Argüelles & Rivero, 1993); chronic pain, fibromyalgia, chronic pelvic pain, headaches, gastrointestinal disorders, irritable bowel syndrome, and pelvic inflammatory disease (Radomsky, 1995), to name just a few of the more common symptoms. Other mental health issues arising from being victimized by violence include sleep disorders, sexual dysfunction, anxiety disorders, alcohol and substance abuse, low self-esteem, suicide ideation and obsessive-compulsive disorders. Archer (1994) notes that in a study of women who had attempted suicide, 83% had experienced intimate violence. Kurz & Stark (1988) found that women who had experienced intimate violence were five­times more at risk of committing suicide. Women who are sexually assaulted are eight­times more likely to commit suicide, six­times more likely to attempt suicide, and five­times more likely to have a nervous breakdown (Boychuk Duchscher, 1994).

While this list identifies some of the longer term health sequelae of violence, it does not locate these within a socio-ecological model (Perilla et al., 1994) that outlines the intersections and compounding factors of race, class, sexuality and ability/disability, as well as the larger and more immediate social context of the individual and group (Stark et al., 1979). To this end, Ristock et al., note that factors such as "racism, isolation, lack of services, language barriers, geographical barriers, and religious beliefs" can amplify the impact of violence (1995:9). This observation is echoed in other literature focusing on immigrant women in the US (e.g., Bohn, 1993; Brice­Baker, 1994; Champion, 1996; O'Keefe, 1994).

The Medicalization of Violence: Systemic Sexism

As an institution, the health care system reproduces social inequalities by privileging those who have power and subordinating others. In so doing, the health care system draws upon the dominant language of biomedicine to categorize, manage and process patients. Symptoms become the categorical referents which are then organized to generate the 'appropriate' prescriptions. As a system of thought, western biomedicine embraces a Cartesian dualism focusing on the physical manifestation rather than the social, psychological and economic reality of the patient. To some degree, this dualism has been tempered by recent discoveries that point to the links between 'mind' and 'body.' However, in the case of woman abuse, the incorporation of a socio-ecological model which begins with a recognition of patriarchal power and the systemic violence of racism and classism has yet to occur. While Health Canada's population framework model signifies a beginning in its recognition of gender and class as determinants, it has not permeated the dominant medical discourse of the health care system.

In an insightful analysis of the treatment of woman abuse by the health care system, Ahluwalia & MacLean (1988) note that the medical encounter is a hierarchical one in which power inequalities between the patient and the physician are asserted and reinforced. The physician assumes the role of the expert, deciphers the symptoms of the patient, and prescribes an antidote to eliminate or control the symptoms. In keeping with the dominant ideology of capitalism and liberalism, the patient is seen as being responsible for her/his ailment and hence, compliance becomes a way for the patient to assume responsibility. This kind of processing of patients and the commodification of their symptoms within the economic arrangements underpinning the health care system result in a management of the health effects of violence that render the patient - in this case the woman who has been abused - as being responsible for her abuse. Post Traumatic Stress Syndrome, the Battered Women's Syndrome and psychiatric classifications become an avenue by which symptoms are managed and controlled. The labeling also serves another purpose - namely to negate the social dimensions of violence against women, and to reformulate them as an "individual problem of self-abuse" (Ahluwalia & MacLean, 1988:190).

Studies by Kurz & Stark (1988), Stark et al. (1979), Varcoe (1997) and Warshaw (1993), identify the specific ways in which women who are abused become labeled and their symptoms used to generate prescriptive interventions in the form of referrals to psychiatric services and antidepressants. In a study of the treatment of abused women in one hospital, Warshaw (1993) found that the very practices of the medical profession have a detrimental impact on the diagnosis of symptoms associated with gender-based violence. As she observes:

… using the standard medical shorthand, which is an important shaper of how physicians learn to organize their thinking, we see how the subject becomes a mere descriptor. What are foregrounded are the symptoms: swelling and pain on the mouth. The physician's note uses the passive voice and focuses on the physical trauma. Even the additional statement, 'hit by a fist,' is structured to give information relevant to the mechanism of the injury and what damage might have been done to the body. It removes the fist from the person attached to it. In doing so, the physician, although perhaps not consciously, makes a choice that obscures both the etiology and meaning of the woman's symptoms. (Warshaw, 1993:141)

Varcoe (1997) points to the ideology of scarcity as expressed in discourses of limited resources and inadequate funding for health care that are used to make sense of and rationalize the rapid processing and turnout of emergency patients. She also notes that patients are assessed on the basis of their appearance and class and that the treatment provided by nurses varies accordingly. In her study, the nurses' perceptions of violence hinged on signs of physical abuse manifested by the women they saw. Thus, their estimates regarding the prevalence of abuse in the women presenting at emergency were much lower than indicated by the statistical evidence.

In the case of battered women, it becomes evident that societal pressures and institutional discourses and practices combine to generate treatment that perpetuates violence against women, but in ways where the agency (will) of these women is harnessed toward their own self and intimate abuse. Hence, rather than acknowledge that the violence women are experiencing is a function of the patriarchal power of the family as embodied in the power of the male partner - a power which is supported and sanctioned by society as a whole - the women are prescribed antidepressants or diverted to psychiatrists or social workers in order to patch them up so that they can go back to their homes (Ahluwalia & MacLean, 1988; Stark et al., 1979). The outcome of such interventions is "misdiagnosis; repeated, and often inappropriate treatment of symptoms rather than the root problem; lack of empathy leading to greater trauma and poor collection of forensic evidence" (Kinnon & Hanvey, 1996).

Critical analyses of the failure of the medical system to properly address the widespread and systemic issues of violence against women have resulted in a range of interventions spanning from the introduction of screening protocols in hospitals to educational measures aimed at physicians and nurses, and the insertion of violence-related curricula in medical and dental schools (Berman & McLaren, 1997; Coeling & Harman, 1997; Furniss, 1993; Grunfeld et al., 1995; Hamilton, J., 1996; Henderson & Eriksen, 1994; Hotch et al., 1995).⁽⁹⁾

Summary

The health care system is an integral part of society, and as a social institution, it reproduces the larger social forces of sexism, racism and classism that underpin and shape the status of women within the wider society. Violence against women is pervasive and remains a painful reality despite the decades of activism from the women's movement, reforms in social policy, and educational initiatives. The elimination of violence rests on the eradication of social inequalities. The health care system is predicated on these inequalities as evidenced by the tiered structures that are operative within it, and the differential power and privilege accorded to individuals occupying the different levels of the hierarchy. Patients are accountable to nurses and physicians; nurses are accountable to physicians; and physicians may be accountable to hospital administrators. These categories are permeable to some extent but what they reflect is a presence and entrenchment of a hierarchy. Within this hierarchy, the woman who has experienced violence has virtually no power. If she is presenting in an emergency context, her power and agency are further reduced. As a victim of intimate violence, she embodies the brutality of patriarchal power within the home. Her power is further erased by the discourses and practice of western biomedicine which regard her as a constellation of symptoms to be categorized, managed and processed. Class, gender and race enter the already unequal encounter between the abused woman and the physician/health care worker. Depending on her class, she may be treated better or worse, and depending on her racial features, she may be treated in a worse manner, or have her concerns overlooked and her problems attributed to some innate cultural traits.

INSTITUTIONALIZED RACISM

As with sexism, the formal medical establishment and the health care it offers is not immune to racism. In fact, the traditional power and authority of physicians is maintained by ideological beliefs grounded in the perception of the superiority of western medicine, and the inferiority of other, indigenous forms of health care.

Overt racism in the medical system has been observed in the unequal practices of hiring whites over people of colour, the ghettoization of people of colour in certain jobs, and their lack of advancement and absence in decision-making positions. The reluctance to accredit medical practitioners trained in other parts of the world is another manifestation of the exclusive structure of power and privilege inherent in the medical system. This latter point is an obvious indicator of systemic racism given the Canadian government's concern and preoccupation with the 'brain drain' of qualified health personnel to the US.

In a study focusing on Black nurses in a Toronto hospital, Das Gupta (1996) observed that their work was more heavily scrutinized, the demands and expectations placed on them were greater than those placed on white nurses, and Black nurses were often sidelined for advancement. These findings corroborate an earlier study by Head (1986) of racial minority nurses in Toronto hospitals. Head found that racial minority nurses were significantly underrepresented in decision-making positions in hospitals, and further were not promoted at the same rate as white nurses, despite having the same or superior qualifications (cited in Henry et al., 1995).

In a series of focus groups with patients and physicians, Cave et al., found that physicians tended to stereotype patients according to their cultural groups. They also observed that patients acquiesced to the authority of the doctor and regarded western medicine as superior (1995). Beiser's (1998) overview of the literature indicates that minority status influences the kind of health care one receives. Blacks were more likely to be diagnosed with schizophrenia than whites, and "family doctors are less likely to refer non-English clientele to specialists than their English-speaking counterparts, and surgeons are less likely to perform procedures such as cardiac bypass surgery, or kidney replacement on minority, than on majority group patients" (1996:29). A recent American study found that Black patients were not only less likely to seek emotional assistance from professionals but were also more likely to be under-diagnosed for psychiatric disorders (Kosch et al., 1998). It is not clear whether this finding is equally applicable to physicians of colour.

In an interesting study on patient-physician pairing, Gray & Stoddard (1997) found that after controlling for socio-economic factors, minority patients tended to choose minority physicians. While there are methodological shortcomings to their analysis, the preference for physicians from the same racial or ethnic group is observable among Canadian immigrants and may be predicated on issues concerning language barriers, social networks, and cultural comfort.

Erasure, Trivialization & Silencing

Studies of immigrant women's access to, and encounters with, medical professionals consistently point to the erasure and trivialization of their health concerns. The MOSAIC (1996) consultation with immigrant women from various ethnocultural communities revealed that women felt they could not communicate with their physicians and further, that the physicians' focus on the physical aspects of their health negated the root causes of their illness and erased the totality of their being (see also Anderson, 1987). In other words, physicians did not employ a socio-ecological analysis that would situate the woman in the context of her experiences and lived reality. Given the stresses and impact of migration combined with the dislocation of traditional roles, the role overload identified by Choi (1997) and Meleis (1991), as well as the streaming of women into dangerous and unprotected jobs, it is surprising that physicians negate these vital aspects of immigrant women's health.

Anderson notes that the Indo-Canadian women in her study, "continually repeated that health professionals did not understand their concerns, so in other words, there was no point in trying to communicate with them" (1987:426). This lack of response serves to communicate to immigrant women of colour that their concerns are not worthwhile. Consequently, many immigrant women feel silenced. Abraham (1995) found that health professionals' insensitivity and apathy toward immigrant women stems from their racist stereotypes and perceptions about particular ethnic groups. Research conducted by MacLeod & Shin (1990), MacLeod et al., (1994), and Sidhu (1996) with immigrant women in Canada confirms this observation.

Sidhu's (1996) study of 22 immigrant women who had experienced abuse highlights the structural dependency of these women on their spouses. As sponsored immigrants, many of the women relied on the same physician as their abusive partners. The family physician is thus in a position of conflict serving the abuser and victim at the same time, and may be more likely to believe the abuser's account of the violence. As Sidhu argues,

This made it awkward for the women to discuss marital issues. Due to the physician-patient confidentiality, the physicians would not suggest a joint consultation between patients. It was up to the individual to approach the doctor. If the partners were unwilling to cooperate or expressed anger at the women for raising 'their' family problem in the public arena, the women risked more abuse from their partners. (1996:33)

Sexism combined with racist stereotypes contribute to immigrant women's vulnerability and erasure. The long-term health impact of dealing with these forms of oppression is exacerbated by the weight of "enduring racism in silence" (Jackson & Inglehart, 1995, cited in Cameron et al., 1996:201).

'The Undeserving Patient'

The prevalence of racist stereotypes about people of colour among health care professionals has been documented extensively by Varcoe (1997) in her participant-observation study of nurses in several emergency departments. Varcoe observed that nurses had definite notions of deserving versus non-deserving patients. Non-white, poor, and intoxicated or overdosed women were usually seen as non-deserving patients. Varcoe maintains that the health care system is organized around discourses of scarcity, deservedness, and violence. She further argues that violence is understood within two frameworks of meaning - that of pauperization and racialization. The two obviously intersect in situations where patients are both poor and of colour. However, in the case of women of colour, violence was more readily associated with their culture. This culturalization of violence or cultural racism (Razack, 1998) prevalent among many nurses is reflective of the dominant Canadian discourse on race and racism that pervades mainstream services (MacLeod & Shin, 1990). As Varcoe notes, nurses' perceptions of women of colour who had been abused was to attribute their abuse to their culture. This leads to a situation of heightened visibility and scrutiny on the one hand, and on the other hand, a dismissal of the woman's experience in terms of her cultural membership. As one nurse in her study stated:

Culturally, because I have had a lot to do with a [certain group of] people in the last [few] years, I would say overall, that as a group of nurses [at this hospital] people are more suspicious of abuse in a multicultural type of patient situation than they are in an actually Caucasian situation. (Varcoe, 1997:215)⁽¹⁰⁾

The immigrant women of colour interviewed by Anderson noted the prevalence of similar stereotypes which impacted on their ability to access appropriate health care. Anderson suggests that:

One could argue that non-white women's experiences are shaped by the history of imperialism and oppression, and are not only the result of their immigrant status. Instead, these experiences have to be understood in terms of their status as non-white immigrant women from a Third World nation. So, not only must non-white immigrant women contend with ideologies about women's roles, but they must also contend with stereotypes that are entrenched within the mainstream culture, which determine the ways they are perceived. (1987:433)

Summary

For the immigrant woman of colour who has experienced intimate violence, the encounter with the health care system is fraught with risks of being further revictimized. Not only may she be faced with language barriers, isolation, and fears about her legal status, but her whole personhood is reduced to racial stereotypes about the particular cultural group to which she belongs. Her positioning at the juncture of societal racism and sexism, institutional racism and sexism, and her own experiences of patriarchal violence in the home place her in a high risk situation. Her dependency on the State in terms of immigration status, on the medical system in terms of health services, and on her sponsoring spouse serve to drastically limit her choices and her agency. Yet, immigrant women of colour survive.

TOWARD EQUITY & RECOGNITION

In addressing the specific barriers that immigrant women face, the existing literature advances several recommendations which are noted below. Many studies argue for the implementation of culturally sensitive services (e.g., MacLeod et al., 1994; Majumdar & Roberts, 1995; Perilla et al., 1994; Sanchez et al., 1996; Schwager et al., 1991). Rhee (1977) argues for culturally appropriate services, and Williams & Becker (1994) indicate a need for culturally competent or culturally congruent services. Within these models, cultural issues tend to become foregrounded, and the influence of structural issues tend to be muted. However, as Moussa points out:

The phrase 'cultural sensitivity' is often used in Canada for relating in a positive manner to the cultural background of refugee and immigrant women. I would like to suggest that 'sensitivity' is a very passive, if not a patronizing term. One of the most important approaches for anyone working with refugee and immigrant women is first and foremost to respect differences in values and decision-making style. And secondly to recognize that refugee and immigrant women are not in a position of power in Canada because of pervasive racism, the class structure, gender inequality, and because of their uncertain legal status. An assumption behind 'cultural sensitivity' can also be that refugee and immigrant women have nothing to offer Canadian society let alone having ways they can solve their own issues. (1994:66)

In part, the appeal of the 'cultural sensitivity' approach is that it enables service providers and health care personnel to deal with the tangibles - the manifest attributes of the patient - and address these with cultural prescriptions. Structural issues such as racism, lack of employment, deskilling, marginalization and ghettoization, which contribute to vulnerability to violence are expressions of structural inequalities, and require political and social action. Health care, like other institutions in society, is predicated on a capitalist-commodity model despite the rhetoric of universalism and compassion. Thus, as patients are moved through the system, their illnesses are translated into units of time and concomitantly, dollars and cents. While the culturally-specific approach advocated by some studies is untenable in a milieu of immense racial and cultural diversity, it still functions as a remedy and to some small extent, actually facilitates service provision to marginalized groups (Agnew, 1998).⁽¹¹⁾ However, it is impossible for health care providers to know every culture in detail, and similarly impossible to apply culturally specific knowledge in ways that account for diasporic, relational, and generational manifestations of cultural formations. Nevertheless, as existing studies demonstrate, there is a need to take into consideration the various factors impacting on a person's life and find ways to address the ensuing dis-ease stemming from their social, structural and cultural location.

Finding Ways Out

Some of the strategies identified in the existing literature cohere around the following: creating social networks of support (Emmott, 1996); advocating critical analyses of structural issues and self-reflection (Brice-Baker, 1994; Hamilton, J., 1996; Legault, 1996; Lynam, 1999; Varcoe, 1997); empowering women (Varcoe, 1997; Yam, 1995); taking a historical approach to understand the social location of the women (Bohn, 1993), and employing a holistic approach (Sanchez et al., 1996). These strategies are not mutually exclusive but rather overlap in practice. When employed in concert, they work toward empowering the immigrant woman of colour, viewing her in context and as a person, and working with her to develop viable strategies. Underpinning all these strategies is the issue of respect and dignity - respecting different social locations, histories and realities without inferiorizing or trivializing their import.

Moving from Risk to Safety

Ramsden (1990, 1993), offers a model of 'cultural safety' which neatly encapsulates both the practical strategies that can be employed as well as a conceptual framework by which to understand, appreciate and address the power inequalities and imbalances that structure the medical encounter between indigenous peoples and the white medical professionals who serve them. While Ramsden's model is grounded in the Maori reality and relationship with the white settler community in New Zealand, her observations and findings echo the lived realities of Aboriginal people and people of colour in Canada. Hence, when she states that "we are not a perspective" (1990:2), she challenges the dominant normative model of multiculturalism which identifies other cultures as perspectives which the dominant culture as the central organizing principle - what Stuart Hall (1990) refers to as the 'white eye' - gazes out on.

In referring to cultural safety, Ramsden discusses 'cultural risk' and argues from the perspective of the Maori woman who is presenting to a white health professional. She defines cultural risk as "a process whereby people from one culture believe that they are demeaned, diminished and disempowered by the actions and delivery systems of people from another culture" (Wood & Schwass, 1993:2, cited in Ramsden, 1993:7). The Maori woman is thus at risk of being erased or having her concerns trivialized by a white, dominating establishment.

Although speaking in the context of nursing, Ramsden's recommendations on reducing cultural risk are appropriate to the kinds of changes that health care professionals in Canada can implement in order to ensure access and equitable treatment. Her recommendations pivot on and incorporate many of the strategies identified above, but underscore the recognition of the differential power relations between the dominant and subordinate groups. For instance, she notes that self-reflexivity and value interrogation are necessary steps but that in order to implement structural change, nurses (or other health care professionals) need to be made aware of the impact of poverty, historical and social processes, and to have this understanding inserted in the training of other health professionals so that in the long term, cultural risk is reduced. As Polaschek elaborates, the concept of cultural safety,

… makes clear the structural dimension of health care provision, that care is not simply provided for individuals but for members of groups whose care inevitably reflects the position of their groups as a whole within general society. It shows that such group interrelationships which influence health care provisions are unequal. It highlights the power dimension of ethnic relationships, from social disadvantage to explicit racism, which affect the provision of services such as health. It critiques the assumption of social consensus… (Polaschek, 1998:456)

The notion of power differentials is underscored in Ramsden's work as well as Polaschek's elaboration of it. Polaschek notes that 'culture' as used in this conceptual framework is not the same as the anthropological definition of culture which when popularized is susceptible to being static and reified. Rather, the framework is grounded in the wide diversity of Maori culture, reflecting the power relations that have subordinated that indigenous community.

Translating Cultural Safety into Reality

The eradication of racism and sexism within health care constitutes a necessary point of departure for implementing structural change and thereby reducing the power inequalities that contribute to the disadvantage of particular groups, and most especially, to the risks faced by immigrant women of colour. Implicit in this endeavour is the necessity of dismantling stereotypes and negative perceptions through such means as power sharing, and value-based self­interrogation (Hamilton, J., 1996; Lynam, 1992). Recognizing the differential and unequal impact of legislation and other policies on immigrant women of colour is also vital. Immigrant women of colour's dependency on the State in terms of immigration policies (Brice-Baker, 1994; Dosanjh et al., 1994), the medical system, social welfare agencies, and the increased scrutiny of these women must be acknowledged and apprehended. Using a socio-ecological approach that takes into account the structural, social and economic variables impacting on a woman's life is also a necessity.

Additional mechanisms that are identified in the literature that would make health care more equitable include the following:

1. Informing women about their rights, services that are available, and the particular procedures that are necessary to ameliorate their health condition (Cave et al., 1995). This can be achieved through outreach (Williams & Becker, 1994), partnerships with the communities, and the inclusion of community members in training and administration of services. It can also be achieved by relaying necessary health information on violence to diverse groups through the use of local, ethnic and mainstream media (MOSAIC, 1996).
2. Listening to immigrant women's voices is critical (Shroff, 1996/97; Varcoe, 1997) and can be undertaken by ensuring the representation of these voices in policy and program consultations, partnerships in projects, delivery of services, and inclusion of immigrant women of colour in decision-making bodies within the health care system. Majumdar & Roberts (1995) identify a successful model for the delivery of AIDS education that involved the training of women from different communities who then went back to their communities with the knowledge and information they had received.
3. Implementing support groups that are within geographic proximity to women's homes would help reduce isolation, which is a key risk factor, and also allow immigrant women of colour to develop social networks of support that are equally critical for their well­being (Dyck, 1992).
4. Implementing a coordinated health care approach that integrates diverse health professionals would not only help to reduce isolation but also reduce risks stemming from other factors such as language barriers, unfamiliarity with the bureaucracy, and a sense of helplessness (MOSAIC, 1996).
5. Increasing the availability of alternative models of health care and validating indigenous or cultural models of health care would also help in empowering immigrant women of colour.

For immigrant women of colour who have experienced violence, the most serious needs are interpretation, advocacy, and support. Advocacy and support for victims have been described as essential in the literature dealing with violence (Kurz & Stark, 1988). However, their importance and implications for the safety of immigrant women of colour are accentuated because of issues of legal status, dependency on the sponsor, as well as racism and sexism within the system. Kurz & Stark observed that in the hospital setting where one physician acted as an advocate for battered women, the treatment that the women received was not only more appropriate but actually facilitated their situation. The physician-advocate helped to transform 'problem patients' into 'patients with problems' (1988:263).

Summary

It is apparent that to meet the needs of racialized immigrant women who have experienced violence, health providers have to take into consideration the totality of a woman's location, as well as recognize the multiple forms of institutional, societal and individual levels of violence that are impacting on her. Such an approach involves embracing a socio-ecological perspective. It involves assessing the risks that render immigrant women of colour vulnerable to violence, and eliminating these risks in order to enhance their level of safety. To this end, a conceptual reframing is necessary so that, rather than centering the analysis on the needs of health care institutions, immigrant women's needs become the focal point of analysis and intervention. In­house advocates, social support networks and groups, and other practical measures are necessary in order to balance the current unequal power relations between immigrant women of colour and all health care providers.

CONCLUSION

This review of the literature outlines the major factors impacting on immigrant women of colour who have experienced violence in terms of their access to health care. Key factors that impact on immigrant women and that increase their risk to violence include: the dependency on their spouses as underscored by immigration legislation; isolation; lack of the dominant language skills and knowledge about the dominant cultural norms; ghettoization and exploitation in underpaid, hazardous and unprotected jobs; marginalization and alienation combined with the lack of social support networks; and the combination of sexism from within their communities and the dominant society, as well as the racism of the external society including health care professionals. Inferiorization, trivialization and erasure of the concerns and realities of immigrant women of colour are some of the ways in which immigrant women of colour are treated. The racism they encounter serves to categorize them in terms of their culture and often results in their social construction as 'undeserving' patients. Within a health care context where the discourses of scarcity, commodification and racialization operate, immigrant women of colour who have experienced violence are triply jeopardized - by their race, class and gender.

Existing studies identify a number of avenues whereby immigrant women and disadvantaged peoples can be better served by the health care system. Underpinning many of these recommendations is the recognition of the necessity to incorporate a socio-ecological model. The latter incorporates an examination of the structural location of the individual patient, a socio­historical analysis of the group and the stresses it has encountered, and an analysis of the social, economic and political reality of the group. The individual is seen within the context of larger and immediate social forces impacting on her lived reality. Ramsden's model of cultural risk incorporates these variables and offers a conceptual rethinking of the directions that health care workers can pursue. Within this model, health care providers are encouraged to critically reflect on and interrogate their beliefs, and to treat other groups and individuals in more respectful ways. More importantly, the model suggests ways in which to implement structural changes which can work to reduce the risk of disadvantaged groups both immediately and in the long term.

The literature also identifies practical measures that health care providers can implement to better serve the needs of immigrant women of colour who have experienced violence. These include avenues by which to reduce the isolation immigrant women experience, ways to empower them, and vehicles by which to reach out and inform diverse communities about the services that are available and about their rights to adequate and appropriate health care.

In conclusion, the barriers faced by immigrant women of colour in accessing the health care system are substantial. The system's response, as outlined in this review, is one of inferiorization, trivialization, and erasure - whakam or the emotional white-out that Ramsden described in the opening quote of this section. These responses are predicated on and in turn, reproduce the dominant discourses of racism and sexism. In order to redress the inequalities, the system requires structural change. However, the point of departure for such change has to be situated in a broader and more complex definition of violence. As Carraway argues,

Our societal definition of violence must include the direct results of poor medical care, economic inferiority, oppressive legislation, and cultural invisibility. By broadening our definition of violence, we combat the minimalization of our experiences as women of colour by the dominant culture. We must name the violence, or we will not be able to address it. (1991:1302)

While the above brief review of the literature provides a portrait of the kinds of issues that impact on immigrant women of colour and their access to health care, the following sections provide a more in-depth examination of the expression of these issues at the level of the daily lived reality of immigrant women of colour and the service providers who advocate for their needs.

^11. Agnew (1998) notes that advocating for 'culturally sensitive' services has been one of the few ways in which women of colour from immigrant communities have been able to ensure the provision of services to their communities.