INTRODUCTION
In order to access the experiences of immigrant women of colour
with the health care system in general - and more specifically,
women who had experienced abuse - we conducted:
(a) an environmental scan consisting of telephone interviews with
twenty-one organizations around the province; and (b) individual
interviews with six key informants and service providers working
with immigrant women. In addition, we conducted: (c) focus groups
with immigrant women who had experienced abuse, as well as with
bilingual and bicultural service providers; and (d) individual
interviews with immigrant women from diverse communities. Focus
groups and individual interviews were collected over the span
of a year during 1999. The following sections detail the findings
of the interviews and focus groups. As will be seen, many of
the emergent themes echo those identified in the literature review.
Methodology
Questions asked in the interviews and focus groups were developed in concert with frontline anti-violence workers and on the basis of issues identified in the literature review (see Appendices I, II & III). Questions were semi-structured and an informal interview style was used. Triangulation of the data was achieved through the use of different sources of information including the literature review, the environmental scan, key informant interviews, and focus groups with bilingual and bicultural service providers and immigrant women of colour survivors of violence, as well as through individual interviews with ten immigrant women of colour who had experienced violence. Ethics approval was obtained from Simon Fraser University prior to engaging in the collection of data.
Environmental Scan
The purpose of conducting an environmental scan was to obtain a general overview of how women who have experienced violence are treated by the health care system. Within this context, specific questions were then directed to obtaining information on how immigrant women of colour and Aboriginal women are treated by health care providers. Both these groups of women are racialized in particular ways and have low social status. The environmental scan consisted of responses obtained from organizations and key informants.
Organizations that participated in the environmental scan were identified through referral by other organizations and through random selection from a directory of women's organizations and transition houses. Health Canada's directory of transition houses was utilized for making the initial contacts. In addition, a database of women's organizations compiled by the FREDA Centre allowed for the selection of organizations located in rural areas. Researchers were provided with a background to the project, as well as a telephone interview script. They were asked to speak to the coordinators of the various agencies, and where this was not possible, to speak to a worker directly. In some cases, organizations did not respond. Those who did respond were asked for referrals to other organizations.
A snowball approach was used to contact key informants. Key informants were selected on the basis of referrals by anti-violence workers and advocates located in Vancouver. They were defined in terms of their expertise in this area and/or their familiarity with issues facing immigrant women of colour and the health care system. The key informants consisted of representatives from two immigrant settlement organizations, a hospital-based sexual assault program, a woman's centre, a transition house, and a health program with one of the regional health boards.(12)
In total, twenty-seven informants and service providers working in different organizations were contacted for the environmental scan. Most of the interviews were conducted by telephone; key informants were consulted in person. Twelve of the interviewees were from transition houses and shelters, three worked at rape crisis centres or at women's centres, four worked at immigrant settlement services organizations, four were in hospital-based services or clinics, two worked in social service organizations (i.e., neighbourhood houses), one worked in a program at the Ministry for Children and Families, and one was a regional health board multicultural worker.
Organizations consulted for the environmental scan are categorized
below in terms of their rural/urban location and the racial diversity
of the populations they mainly serve:
| Geographic Location | Number of Organizations | Racial Diversity | Number of Organizations |
| Urban-based | Mixed (includes all groups) | ||
| Rural | Aboriginal | ||
| Mix of urban & rural | White only | ||
| Total | Total |
Focus Groups
Two focus groups were conducted in order to obtain more direct information about immigrant women of colour and their experiences and encounters with the health care system. The first focus group consisted of five immigrant women of colour who had experienced violence. It was organized through a local immigrant settlement services organization, and included women who had participated in the English as a Second Language (ESL) program offered by the organization. Participants included women who had immigrated from Mexico, Latin America, India, China, and the Philippines.
The second focus group with bilingual and bicultural service providers was organized through the auspices of a Vancouver-based agency which specializes in providing counselling, accompaniment, interpretation and advocacy services to immigrant women and children who have experienced violence.(13) The eleven service providers who attended the focus group reflected the following backgrounds: Mainland Chinese, Filipino, Vietnamese, Korean, South Asian, East African, Polish, Latin American and Italian. Many of them had personal experiences of abuse and extensive collective knowledge about other women in their respective communities who had experienced or were still living with violence.
Individual Interviews
In order to supplement the focus group data, 10 individual interviews with immigrant women of colour were conducted obtained using a snowball approach whereby the women who were interviewed would refer the researcher to other women they knew. The interviews were conducted by an immigrant woman of colour researcher familiar with the issues.(14)
In total, twenty-six immigrant women of colour were consulted through the focus groups and individual interviews.
Data Analysis
Data obtained from the interviews, focus groups and consultations were collated and analyzed. A thematic analysis based on the responses obtained was completed. The responses were found to cohere around similar themes whether the data were derived from the scan, individual interviews, or focus groups.
ENVIRONMENTAL SCAN
The environmental scan integrates observations from interviews with service providers from twentyone organizations located around the province, and key informants from another six organizations located in the Vancouver Lower Mainland.(15)
The purpose of the scan was to develop a contextual background focusing on how women who have experienced violence are treated by the health care system in rural and urban settings. Within this context, the objective was also to construct a portrait on how racialized women are treated by physicians and nurses in walk-in clinics, private practices, and hospitals, as well as the particular barriers they confront in accessing adequate health care. As both Aboriginal women and immigrant women of colour are racialized, the emphasis was on obtaining information as to how both of these groups are treated.(16) The following analysis begins with a presentation of how women in general are treated by the health care system. Issues specific to Aboriginal and immigrant women of colour are discussed subsequently and separately in order to highlight their distinctiveness. Responses are grouped around themes emerging from the data.
Themes
(a) Factors Influencing Disclosure
When asked about the likelihood of women survivors of violence disclosing to their family doctors or emergency physicians, only three service providers responded affirmatively. One added that women would only disclose if they were asked the question directly, and another added that disclosure is only likely if the woman's injuries are severe and require medical attention. The remaining interviewees maintained that women are not likely to disclose abuse out of fear of not being believed, fear of being judged harshly, and the shame and stigma associated with being a victim of violence. Another stated that women tend to minimize the violence and assume responsibility for it, or will only disclose if the violence has been perpetrated by a stranger.
The interviewees overwhelmingly reported that disclosure depends on whether the woman has a trusting relationship with her physician. Disclosure can occur after years of abuse and depends on how comfortable the woman feels with her physician. Another interviewee added that doctors do not spend the time to sit and listen. One interviewee suggested that women who have been abused are more able to pick up non-verbal cues telling them that doctors are busy and nurses are judgmental. Disclosure is facilitated by the physician asking questions directly, and then pursuing the discussion. Many interviewees reported that while physicians may ask the questions, they do not discuss the matter further. Most women, as one interviewee added, are simply not heard, and most physicians are not trained to ask the pertinent questions or refer patients to other services. It was pointed out that the physician-patient interaction is structured on a power imbalance, where physicians have considerably more power than the patient. The latter has even less power when she is a woman and a woman who has experienced violence. Trust becomes critical if the woman is going to disclose the abuse.
Women who are isolated and transient are not able to develop relationships with their physicians. These women are more likely to access services through walk-in clinics. The clinics included in this scan reported that women do not disclose abuse. Another interviewee at a transition house stated that 25% of the women she had seen have disclosed their experience of abuse to their family physicians. She remarked that this was a significant improvement as compared to the past. One transition house worker noted that women are more afraid to disclose to their doctors for fear of having their children apprehended.
In rural areas, interviewees mentioned the issue of compromising confidentiality, lack of anonymity, and lack of medical services as impeding disclosure. One interviewee noted that in her small community, the emergency unit had four beds separated by curtains. It was difficult for women not to feel as if their privacy was compromised particularly as they were likely to know the physicians and nurses in attendance, as well as the other patients. Moreover, just coming into the hospital with injuries was a tell-tale sign of abuse, and hence many of them either minimized the abuse or pretended that the injuries were 'accidents.' Further, it was noted that in rural areas which face a chronic shortage of physicians, the woman and her abusive partner are often treated by the same physician. This contributed to the woman's lack of security about confidentiality.
(i) Physician Response
Most of the interviewees reported that physicians (general practitioners and emergency staff) did not respond appropriately to women who had experienced violence. Nine interviewees reported that emergency physicians did not ask women about the abuse directly, and were more interested in attending to her physical needs. Further, like general practitioners, emergency physicians were also more interested in processing their patients as quickly as possible, and ignored the links between emotional and physical abuse. As one interviewee noted, women get 'written off' by doctors as suffering from depression, panic disorder or post-traumatic stress. Interviewees noted that women are prescribed drugs such as antidepressants to help them cope with the abuse. Physicians, it was felt, were reluctant to get involved in cases concerning violence.
Interviewees highlighted stereotypes about women that are current among many physicians. Women are told to 'just leave' or are lectured about why they remain in the abusive relationship. One interviewee mentioned that a woman she had seen was "made to feel stupid for tolerating the abuse." Another reported that the physician told a woman that "she must like the abuse since she had tolerated it for so long." Yet another physician reportedly told her patient that her husband was "too cute to be abusive." Six of the interviewees had observed doctors behaving in a rude and condescending manner toward women survivors of violence, and five stated that the physicians had used a woman's past medical history of substance abuse or mental health to blame her for the abuse and dismiss her disclosure. Four of the interviewees mentioned that physicians are not aware of the resources within the community and did not refer women to other services. As one interviewee stated, it is difficult to get 'objective care' and that physicians' responses are influenced by whatever 'baggage' women have in terms of their medical histories and behaviour.
Generally, female physicians were viewed as more supportive and empathetic. One transition house reported that it receives most of its referrals from a female physician working in the area. However, another interviewee noted that while female physicians may be more sympathetic, they often do not respond adequately. In this context, it was also noted that women tended not to disclose abuse to male physicians, and as one interviewee pointed out, male physicians tended to align with the abuser. Another interviewee noted that abusive men had in the past influenced the perceptions and treatment of their spouses through their interactions with the mental health service provider.
(ii) Nurses' Response
Half of the interviewees stated that nurses are generally more supportive, caring, and sensitive to abused women than doctors in the emergency departments. Nurses, it was noted, tended to spend more time with the women, debriefing them and documenting their stories. In only two cases, were nursing staff reported to be rude, disrespectful or ignorant of issues surrounding violence. One interviewee who is a hospital social worker observed that nurses' behaviour ranges on a continuum from sensitive, supportive and respectful, to demeaning, verbally abusive, dismissive and punitive. Another mentioned that nurses often don't have the time to debrief women who have been abused, and consequently shift the responsibility to other services.
Public health nurses were praised for their outreach efforts, their holistic perspective, and knowledge of services in the community. One transition house worker reported that most of their referrals come from public health nurses, lactation consultants, prenatal consultants, and ambulance workers.
(iii) Protocols
Protocols concerning the screening and treatment of victims of violence were found to be operative in a number of sites that were included in the scan. However, interviewees noted that while protocols in hospitals in Vancouver worked favorably, in other sites, they were implemented inconsistently and not enforced. The training was not mandatory and procedures were not followed consistently. Nonetheless, in those hospitals where protocols had not been implemented, inconsistency in service delivery was more marked and exacerbated by the high turnover of staff.
(iv) Other Health Care Providers
Other health care providers that were identified as being supportive to women who had experienced abuse included physiotherapists, dentists and dental hygienists, chiropractors, and alternative health care personnel. Physiotherapists were specifically mentioned as offering a more holistic view of health care and being able to ask questions that would elicit disclosure.
Mental health workers were perceived to have a lower understanding of woman abuse. It was noted that these workers approach women from a medical model where the emphasis is on pathology. The woman is therefore seen as 'crazy' when in fact the issue is the crazy context in which she lives. Any history of childhood abuse contributes to this pathologization and increases the chances of her experience of abuse being dismissed or trivialized.
(b) Documentation
Interviewees were asked if the issue of documentation was a concern for women who had experienced abuse. The question was based on the findings in the literature which indicated that documentation was a concern for immigrant women because of their legal status. The aim was to assess whether documentation was a concern for all women accessing health care.
Interviewees indicated that most women did not realize the importance of documentation, particularly if they were going to press charges or seek custody of the children. Twelve of the interviewees observed that the process of documentation was intimidating for women. Women were afraid that confidentiality would be compromised, and feared the repercussions that might arise. Interviewees also noted that women were afraid of the loss of respect or the shame they would experience if the documented information was made public. Interviewees noted that health care providers need to explain the importance of documentation. Without adequate documentation that serves to corroborate her story, the onus is on the woman to prove a history of abuse. One interviewee observed that keeping records can also help women reduce their own feelings of denial and make them aware of the ways in which their experiences are being minimized by others. However, interviewees were also quick to point out that documentation can also work against women especially if it leads to the involvement of child protection agencies. As one interviewee stated, documentation reflects the clash between a woman's right to privacy and the system's desire to record details. In too many instances, women have been revictimized by the system which uses their records against them.
Some interviewees mentioned that doctors do not document the case adequately for fear they will later be subpoenaed by the courts. Another interviewee noted that guidelines as to the kinds of information that should be documented are lacking.
(c) Urban/Rural Areas
Interviewees noted that services in rural areas tend to be limited. Further, women are at risk because of the isolation, lack of adequate services, difficulties of obtaining transportation to services, and the tight-knit nature of the community. It was observed that smaller communities tend to censor abuse and silence women. One interviewee articulated the perception that rural areas receive substandard practitioners. Another indicated that the shortage of physicians had resulted in an unofficial 'blackballing' of patients who wanted to switch doctors, and patients were being charged for transferring records. Moreover, because of the shortage of physicians, women had to rely on the same doctors as their abusive spouses. The lack of alternative health centres and counselling services were also noted.(17)
One interviewee from an urban northern town reported that it was a "very masculine region where gender specific role playing" occurs creating an environment that fosters abuse and where abuse is normalized. She added that the social structure is very patriarchal and dominated by fundamentalist religious attitudes. The population is male-dominated and transient and relies exclusively on a single industry. Whenever there is an economic downturn, women are at a greater risk of abuse. Yet, this area has been marked by a chronic shortage of health care professionals.
While urban areas enjoy numerous services and can afford a measure of anonymity to women, they are also riddled with problems. As one interviewee aptly pointed out, in urban areas the bureaucracies tend to be larger and more complex, making it difficult for women to negotiate their way through the systems. As well, the bureaucratic structures fragment services, sometimes forcing women to go through a revolving door to access the appropriate service.
(d) Factors Impacting on Aboriginal & Immigrant Women
As racialized women, Aboriginal and immigrant women of colour not only face similar issues as other women but the particular ways in which these issues are refracted through the prism of cultural difference and racism amplify their effects. Both Aboriginal women and women of colour occupy subordinate positions in the hierarchical structures of society, albeit at different levels. Further, their rights, access to services, and social status are mediated by the definitions imposed by the Canadian state, i.e., as status/non-status Indians/Metis, or as immigrant/refugee/migrant or undocumented women (Thobani, 1998). Racism, sexism and classism are also common experiences that influence and shape the lives of Aboriginal women and women of colour. Experiences of historical colonization and neo-colonization are also common denominators for both groups of women though their manifestation and degree of impact vary.
(i) Sexist Stereotypes & Cultural Racism
In response to questions specifically concerning Aboriginal and immigrant women of colour, interviewees noted that when Aboriginal and immigrant women present to emergency or disclose to their physicians, they are often met with attitudes that suggest to them that violence is culturally based and hence, is an innate part of their cultural heritage. Some interviewees noted that physicians believe that women from these groups should deal with their problems within their own communities. Another noted that some nurses believe that these women only want attention and are not in real medical need.
Interviewees observed that physicians were reluctant to explore the issue in any depth because of their ignorance about particular cultures. Another interviewee pointed out that there were a lot of stereotypes about Aboriginal and immigrant people circulating among health professionals. As a result, Aboriginal and immigrant women are less likely to be believed. One interviewee mentioned that racist attitudes were more prevalent among older medical staff.
Another interviewee stated that racism textures the everyday reality
and interactions of medical professionals with Aboriginal women
and immigrant women of colour. She gave an example of a situation
which involved an Aboriginal woman who was presenting. The woman
was ignored by the nurse even though two other white women had
come in after her but were served before her. The nurse, when
confronted, was oblivious to the preferential treatment she had
shown.
(ii) Aboriginal Women
Interviewees were very aware of the systemic discrimination faced by Aboriginal women. Many cited that health care providers were dismissive of Aboriginal women's experiences of violence because they perceived these experiences to be linked to alcohol and drug abuse. Thus, the Aboriginal woman is treated unsympathetically and treated as an 'undeserving victim.' Physicians assume that violence is a part of their lifestyle. One interviewee noted that she had observed that when Aboriginal women present, the attitude of the health care providers is one of "oh, here she comes again." Another added that Aboriginal women are given Tylenol 3 and immediately questioned whether they are on drugs. Comments such as "we're not seeing you," and "you probably don't have a health care card," are often used to dismiss women. Aboriginal women's experiences are erased. The intersections between historical violence and intimate forms of violence are neither explored nor integrated in the treatment of Aboriginal women.
Interviewees also noted that Aboriginal women have few places to turn to. In one community, an interviewee mentioned that relations between the Aboriginal community and the white community were strained. The lack of Aboriginal doctors exacerbates the situation of Aboriginal women. On the one hand, they are forced to leave their communities to access health care services, but on the other hand, they are met with racist attitudes and erasure from the nonAboriginal communities. Trust levels between the Aboriginal communities and white service providers are extremely low. Aboriginal women are more likely to utilize walk-in clinics than have a single family physician. One interviewee noted that Aboriginal women report receiving the "look of recognition" from physicians. That look reinforces and communicates to them their demeaned status and worthlessness in the eyes of physicians. Attitudes of inferiorization combined with differential and discriminatory institutional practices ensure the perpetuation of institutionalized forms of racism.
Several factors exacerbate the situation of Aboriginal women. Aboriginal women are wary of written documentation. Not only are they under constant surveillance by the various systems, but within the health care system, documentation also works against them. Historically, documentation has been used to categorize and deny them their rights. Low levels of literacy combined with this historical experience contributes to their suspicions about documentation. In many cases, documentation has led to the apprehension of their children.(18)
(iii) Immigrant Women of Colour
In the case of immigrant women of colour, service providers noted that language barriers compound disclosure. Where language is not an issue, immigrant women of colour are more likely to disclose abuse to their physicians after a period of time has elapsed and they have developed comfort with the physician. However, disclosure also depends on the severity of the abuse, the geographic (rural/urban) area in which the woman resides, and on whether health care professionals ask about it directly. In rural areas, the lack of confidentiality and anonymity circumscribe disclosure. Many interviewees also mentioned the issue of public shame as deterring immigrant women of colour from disclosing. Another discussed the tight-knit nature of some of the communities of colour and indicated that women were not allowed to access services in situations involving violence for fear it would stigmatize the whole community. When women accessed services, they were harassed by members of their community. Women were made to feel ashamed and responsible for breaking up the marriage. Disclosure was also impeded by women's fear that their abusive spouses would obtain full custody of the children.
Several interviewees mentioned the particular vulnerabilities of 'mail order brides' who were involved in interracial marriages.(19) They highlighted the isolation of these women and the power imbalance of the interracial marriage indicating that the white spouse would ensure that the woman's concerns were trivialized and her experiences of violence disbelieved. Many immigrant women could not drive and were doubly isolated in rural areas. Interviewees indicated that immigrant women of colour tended to be prescribed medications, usually antidepressants, for their symptoms of violence.
Language and cultural barriers were mentioned frequently by interviewees. These were identified as contributing to miscommunication and misdiagnosis. Some interviewees underlined the necessity for cultural interpreters to accompany and advocate on behalf of women. Another interviewee noted that too often the men in the community accompany their wives to the doctor and translate on their behalf. Often, children are put in the position of interpreting for their mothers. This creates a power imbalance within the family with children being the cultural brokers, mediating between the different and unequal cultural worlds.
Interviewees also noted the impact of immigration status and women's lack of knowledge regarding their rights. Women are afraid of jeopardizing their immigration status or having themselves or their husbands deported should they disclose the abuse. One hospital-based social worker indicated that the hospital required a demand for disclosure of abuse by sponsors. Documentation was perceived negatively by immigrant women of colour as they often saw it in conjunction with issues concerning their legal status. As is the case with other women, the purpose or implications of documentation are not explained to immigrant women.
(iv) Culture, Race & Gender of Physician
Interviewees were asked whether having a physician from the same cultural or racial background would make any difference in ameliorating the situation of immigrant women of colour who had experienced violence. Interviewees pointed out that while having a physician from the same cultural background would enhance communication and eliminate language barriers, the likelihood of the physician being supportive and facilitating disclosure depended on her/his beliefs about violence, and the kind of relationship that s/he had established with the woman. One worker stated that the women in the community she dealt with would not feel comfortable disclosing to a male physician from the same community for fear that he would make the knowledge public. It was pointed out that women who had disclosed to male physicians from their own community had been told that "this is a family matter." Another interviewee mentioned that the women in the ethno-racial group that she was familiar with, visited a female physician from their community. Female physicians from the same community were reported to be more supportive of women who had experienced violence.
(e) Communication of Information
Interviewees were asked how best to communicate health-related information about violence to immigrant women. Their recommendations included the following:
In addition to the above, interviewees were asked to make recommendations regarding the health care system and its services for immigrant women of colour. These recommendations are integrated with those emerging from the focus group and interview data and presented at the end of this report.
CONSULTATIONS WITH KEY INFORMANTS
Many of the issues raised by key informants echoed those identified by interviewees in the environmental scan. However, in addition to these, key informants also discussed the following issues as impacting on immigrant women of colour who have experienced violence, and their encounters with the health care system.
Themes
(a) Police-Hospital Reporting
One of the key issues identified by key informants working in the hospital setting dealt with the requirements of reporting the incident of violence to the police. Key informants indicated that this compromised women's confidentiality, and further endangered them to retaliation by their abusive spouses. The informants also indicated that documentation and reporting to police invoked fear among immigrant women of colour who were concerned about how this might jeopardize their immigration status and sponsorship agreement.
(b) Lack of Information
Several key informants who work in the area of multicultural health and immigrant settlement services indicated that while multilingual information (brochures, fact sheets, etc.) are available in abundance, they are not reaching immigrant women of colour. As one informant stated, these women "are not plugged in" and unaware of the preventive health care system. They further noted that existing outreach and distribution measures do not result in the provision of information about health care, the effects of violence, or even rudimentary information on how to find a physician. Such material exists but again, its strategic dissemination is absent. Proactive strategies by which to disseminate information are lacking. This is especially relevant when considering that most immigrant women are dependents of their spouses, and hence, in an abusive situation, their contact and exposure is limited. Language barriers enhance the isolation, thus making it difficult for women to know where to turn to for help.
(c) Poverty & Financial Issues
Several key informants stated that immigrant women of colour, like other women fleeing violent relationships, have no money to buy prescriptions, obtain transportation or pay for medicare. This is particularly true for women who have left abusive relationships. While BC Benefits Hardship Assistance provides some money, this is deducted from subsequent cheques, and further, BC Benefits recuperates the cost from the abusive partner. This contributes to the already fearful situation of women. Uncertainty about their immigration status combined with the constant threat of deportation contributes to immigrant women being economically unable to cover the costs associated with treatment, or even obtain medical assistance. As one key informant underlined, the costs of medicare insurance are covered by the sponsor.
(d) Physician's Authority
Key informants noted that immigrant women of colour tend to regard physicians as authority figures. They reported that women's complaints are not treated seriously by physicians. Complaints are minimized. Mental health issues are not dealt with or are undiagnosed, and physicians do not make the effort to link the mental health effects of violence to women's somatic complaints. Moreover, physicians fail to make the necessary referrals and do not seem to be aware of community-based services that could help the women. Women reported having difficulty in convincing their physicians of the illnesses they were experiencing. They also reported that physicians do not spend enough time going over their complaints and explaining treatment. Thus, illnesses such as low-grade depression and anxiety disorders are not given enough time. Further, key informants observed that spouses often act as interpreters for women, thereby compromising confidentiality and potentially misinterpreting requests or information provided by the physician. Women are also unaware of the health care bureaucracy and how it works. The lack of a medical interpreter was identified as a major issue by one of the key informants. Another noted that women's homeopathic and cultural remedies are not considered legitimate by physicians.
(e) Lack of Multi-Racial Representation
Key informants reported a lack of trained staff to deal with the needs of immigrant women of colour in the health care system. One informant pointed out that equity in employment practices is still lagging and hence, there is a chronic lack of adequate representation of immigrant women of colour at various levels of the health care system. Several key informants noted the prevalence of stereotypes about different cultural groups within the system. This was especially true of hospitals.
(f) Broadening the Definition of Violence
Several of the key informants working with immigrant women who have experienced violence indicated the need for broadening the definition of violence to include systemic racism and discrimination. Informants also outlined the need for sensitive health care, education about women's rights in relation to immigration and welfare benefits, and the need for advocacy within the system for immigrant women of colour who have experienced violence.
FOCUS GROUP WITH SERVICE PROVIDERS
A focus group conducted with eleven bicultural and bilingual service providers through the auspices of a local, specialized agency providing services and support to immigrant women from diverse cultural backgrounds yielded the following information. Many of these responses echo those obtained from the environmental scan and consultations with key informants. Direct quotes from the focus group participants are italicized.
Themes
(a) Help-Seeking Patterns
Service providers were asked to identify the help-seeking patterns of immigrant women of colour who have experienced violence. Most indicated that women seek assistance from other family members, friends, their faith community leaders, community outreach workers, and ESL teachers. Service providers indicated that women rarely approach doctors for assistance. In extreme situations of abuse where the injuries are severe, women will seek medical assistance but will minimize the injuries and attribute them to 'accidents.'
(b) Barriers
Barriers identified by these service providers included the following:
(i) Lack of Knowledge Regarding the Health Effects of Violence
Service providers added that women do not seek to disclose to physicians because they do not necessarily understand their symptoms as arising from the violent context in which they live. One service provider drew the parallel between financial abuse and the partner's control of finances. The woman did not necessarily realize that his control was tantamount to a form of abuse. She had normalized the behaviour.
On the other hand, service providers noted that physicians themselves are unaware of the links between mental health and physical abuse, and do not spend the time to decipher women's concerns in the context of the violence they are experiencing. Thus, it is apparent that the lack of knowledge about the health effects of violence among both immigrant women and the physicians they turn to, reinforce each other, resulting in a no-win situation for immigrant women who are experiencing these health effects and trying to deal with them.
(ii) Legal Status
Issues concerning immigration status were a common thread in the focus group discussion. Service providers indicated that for women who were sponsored dependents, and even women who sponsored their husbands, disclosing violence was problematic because of the legal consequences. Service providers also mentioned the case of undocumented women who could not obtain medical assistance except from free clinics. In terms of sponsorship regulations, one service provider recounted the case of a woman who had sponsored her husband:
But the problem is that the sponsorship obligation is for 10 years. She's tied to the man because he would threaten her and say, 'Well, I'm going to go and get social assistance so you'll be in trouble. You're going to have to pay for my apartment, my food, my clothing.'
Hence, even though the legislation has been changed in order to deal with issues of domestic violence, the reality is that for this woman, BC Benefits will pursue her for restitution of the costs incurred from providing social assistance to her spouse.
Fear of deportation is a constant reality for many immigrant and refugee women. Women are unaware of their rights. As these two examples illustrate, health care professionals are not always sensitive to the issue of legal status or women's rights.
It is very important in a situation where a woman ends up in a hospital for the hospital staff or the personnel to assure the immigrant women, because a lot of time the women are feeling very scared that 'If I do talk about the abuse then maybe eventually I might be deported back to my country.' Because I find that even though the transition staff are so sensitive to this issue, when it comes to sponsorship issues, even they don't talk about it.
Women are unaware of the differences between landed immigrants, permanent status, and convention refugees. They do not know what rights and privileges are associated with each status and live in constant fear that they might reveal something that will lead to their deportation.
Access to medical services is also mediated by legal status. Women who are undocumented 'aliens' or visitors do not have the same access. One service provider noted that:
I had a client who was a visitor and she has two children. Of course she did not qualify for any medical services. She was just getting some herbal remedies for colds or she was praying that the kids would not get sick. But finally, they had some issues that required a dentist. So we found out there was a guy who wanted to donate his services. But other than that, there's nothing.
Women who are undocumented or do not have legal status have to seek out health care services through free clinics. However, knowledge about where these clinics are located is often inaccessible except through a community worker or advocate.
(iii) Fear of Documentation
Fear of deportation and uncertainty about their rights also contribute to the reluctance to disclose abuse. Additionally, women are fearful that information about their abuse will be made public or become common knowledge in the community. However, the lack of documentation also works against women who want to press charges or seek custody of their children. As one service provider noted:
I find that when it comes to a point where the woman is planning to leave and when I say, 'Okay, can we get some medical records because that can help your case,' then usually the women turn around and say to me, 'But I never told my doctor.' Or, on the contrary, at times I have heard from the women that, 'I told my doctor … I don't want this to go into the record.'
(iv) Cultural Racism
Service providers indicate that stereotypical notions about different ethno-racial and cultural groups are prevalent in the health care system, particularly in hospitals. These influence the ways in which women are perceived and subsequently treated. As this service provider indicated:
You are judged in the sense that the minute a South Asian woman walks into the emergency department, she's already judged. Okay, maybe this is what it is, maybe she has an arranged marriage, she's not going to talk about the abuse. Maybe even if she talks about it, she's not going to seek any services. Even if she goes to the transition house, she's going to go back. If the police are called in, the police will take the statement halfheartedly, thinking, 'anyway, she's not going to go through the whole process so what's the use of doing all this work?'
Another service provider mentioned:
… the principal problem is stereotyping. Like categorizing people. Let's say southern Europeans are emotional people therefore you tend to downplay what the woman or the patient is saying because you assume that because they are emotional, their verbal expressions, their body language is so much more expressive than North Americans. So the doctor tends to say, 'well okay, perhaps I should cut it in half.' Well the general perception that we have as immigrants is that North Americans think that their culture and their mode of culture is superior to any other, therefore they have to educate us and make us meet their standards. I think it's very serious if you look at the whole context and the implications that brings up. And for immigrants, it's a very serious situation because we are never looked at as equals, we are never looked at as being people who can actively contribute to this country. And when it comes to the health care system, we actually run into a set of problems.
These implications were pointed out by a particular service provider in relation to the issue of female genital mutilation (FGM). She mentioned that women who have had FGM are treated differently and negatively by the health care providers.
Another service provider indicated that health care professionals perceived certain cultural groups as having cultures of violence. As she put it: the attitude that the mainstream society has about women of colour - they seem to think domestic violence is part of our culture somehow.
(v) The 'Preferred Patient'
One of the implications of the differential treatment stemming from cultural racism is the construction of the 'preferred patient'. The literature has demonstrated that preferred patients or 'deserving patients' (Varcoe, 1997) are those who are white, middle class, and who are not presenting for substance abuse. In the situation of immigrant women, the preferred or deserving patient is the woman who will leave the abusive relationship. The difference here is that within the ranking of deservedness, a woman of colour may qualify for deserving treatment, if she exhibits active agency and decides to leave the relationship with the help of the staff. In other words, making the staff feel that they are contributing to something 'valuable' as in rescuing the woman elevates her status to that of a preferred patient.(20) This standard seems to be applied to immigrant women even though their dependencies on their partners are complicated and underscored by legislation, as well as financial, economic and social dependency. Nevertheless, as one service provider indicated:
I find that if a social worker or the doctor gets the feeling that the woman is ambivalent, that the woman is not sure about separation, they don't even want to talk about it. Only the woman who will say that 'I want to separate' is the woman they'll refer, not acknowledging that even if the woman is not separating at this time, how important it is for her to connect with a support service for her future.
The language of benevolence underpinning the social construction of the deserving or preferred patient is an inherent aspect of the Canadian discourse of racism.
(vi) Financial Issues
Costs incurred from accessing health care services were also cited as deterrents by some of the service providers. This was particularly mentioned in the case of obtaining ambulance services. As this service provider stated:
I hear that from so many of my clients where they end up with the ambulance bill and at times, these women have to go on income assistance and they don't even have a dollar to spare and here they have to pay $44 for the ambulance bills. And then you speak to the financial aid worker if they will cover the cost, that's again a struggle. Some workers will take care of it, some workers will say 'sorry, it's from the past. We don't want to cover it.'
This observation corroborates the perspective of the key informants who also mentioned financial costs in terms of prescriptions, health care insurance, and transportation as deterrents.
(vii) Language Barriers - Lack of Female Cultural Interpreters
Language barriers were cited as some of the key factors impeding women from seeking health services for effects resulting from violence. Cultural interpreters are not readily available, and women are unaware of these services. As a result, many women seek health care from physicians in their communities who share the same cultural frame of reference and are fluent in the language.
The power and control dynamics of the abusive relationship are amplified in the immigrant woman's situation where she is completely dependent on her abusive spouse to select a physician for her, drive her to the doctor, interpret for her, and get her the prescribed medication. Women's ability to seek assistance independently - their autonomy - is compromised by language barriers as well as lack of knowledge about the conceptual frameworks and norms of the dominant society. In the case of medical services, having an abusive partner interpret for the woman can result in a violation of her rights. One service provider gave the following example:
[One client] was living with him and he didn't get her a medical card so she was going through all these problems and then because of his negligence, she was diagnosed with a [reproductive] problem … and then he was translating for her as well. … He had children in his country [of origin] and he told the doctor that this woman doesn't need children, and because her [organs] were already damaged, they took out her ovaries. Now she cries everyday, and he was her interpreter and it was his doctor that he took her to.
This service provider added that there are not enough women interpreters available and that women who have been abused or who have reproductive health issues are reluctant to communicate these concerns through male interpreters. Another service provider added that men often accompany their wives to the physicians' offices and consequently, the women cannot confide in their physicians. It was suggested that physicians be discouraged from having the spouses present when they are conducting their examinations with women, and that instead nurses or other health care workers be present.
(viii) Conceptual Frameworks of Meaning
While language is one obvious barrier, another more subtle and pervasive barrier emerges in the differences in conceptual frameworks of meaning that are employed by health care providers and the immigrant women whom they treat. As service providers in this focus group noted, the meanings of certain words carry different connotations to the immigrant women they serve. Thus, terms such as confidentiality and counselling have different meanings and physicians do not provide adequate explanations. As one service provider mentioned, when women are asked to go to a support group or a counselling session:
They get so discouraged by that. 'The only help they could offer me is support groups and counselling.' I think some time needs to be spent going through and explaining what is the role of a support group. It doesn't mean that you just sit with a bunch of women and whine about your husband. But that's the common perspective a woman has about a support group. And counselling. Sometimes counselling brings a very negative connotation. That needs to be explained to them.
Service providers also indicated the need for physicians to be accountable to the code of confidentiality and to explain the meaning of confidentiality to the women they see.
(ix) Pathologizing Abuse
Several service providers mentioned that the medical professionals' response to immigrant women who are abused is to prescribe them antidepressants. Another strategy, particularly if they are unable to understand the woman because of a language barrier, is to admit her into a psychiatric facility. One service provider mentioned that she is often at a psychiatric unit where she is asked to interpret for the patients. She observed that many of the patients there, both male and female, were there not because of any mental issues but because nobody could understand them. It was assumed that there was something wrong with them. The service provider mentioned that the mental institution's reluctance to obtain the services of an interpreter was based on economic costs. She indicated that having patients remain within an institution results in additional funds for the institution.
(x) Dismissive Responses - Minimizing the Violence
Service providers noted that most physicians tend to be dismissive of immigrant women's health care concerns. The brevity of time and the rapid processing of patients were cited as factors influencing the lack of sensitivity. In addition, women's concerns were dismissed because they were women and hence the implicit stereotype of women as 'complainers' underpinned the physicians' attitudes. As this service provider recounted:
… sometimes doctors tend to either dismiss it or to say, 'Oh, keep busy. This will pass.' And they don't really see that the woman is trying to say something. She doesn't want to disclose the whole situation but is trying to give some clues. In the community, they just go to the family doctor. They try to find family doctors who are from the community and they try to sort of unload their situation with the family doctor who doesn't have the time to listen to the whole story, of course.
Another service provider recounted a situation involving a woman who was injured, but whose husband told the police that she had mental health problems. As she stated:
And I asked her, 'did you ever end up calling the police?' She said, 'yeah, I did call the police but my husband told the police that I have a mental health problem. So the police didn't pay attention. But, the police did take me to the hospital because I was badly bruised and I was hurt.' And she says at the hospital again, 'the doctor did not spend time with me to ask me what was the issue, like how did I get hurt?'
This service provider could not understand how two systems - the police and the health care system - ignored this woman's plight and basically appeared to believe the abusive husband despite the abuse being manifested in the form of visible injuries.
The dismissal of women's concerns was also mentioned in the context of physicians' reluctance to spend time with them and efforts to process them as quickly as possible.
(xi) Passing the Buck - Shifting the Responsibility
As indicated in the literature review, physicians and other health care providers who come into contact with immigrant women also shift the responsibility once their work of addressing the physical injuries is completed. Statements such as 'we're going to close the file' are used a lot. One service provider stated:
They don't want to walk the extra step, even though they do acknowledge that immigrant women have very different needs than the women who are born and brought up in Canada. They do say it, but when it comes to actually putting that in practice, it's not being practiced.
Another added:
I think it's the attitude of passing the buck onto other professionals instead of that collaborative effort where they call you and we work together. It's okay, 'We're done with her. Now it's your problem.' And if something goes wrong, we've done our part.
The immigrant woman has already been constructed in this discourse as a "problem patient" rather than a "patient with a problem" (Kurz & Stark, 1988:263). Add to this the fact that when community workers are contacted, it is often at the last minute when the woman is about to be discharged. For workers who are have heavy case loads, it means dropping everything in order to ensure that the woman has some kind of support before she is returned home.
(xii) Lack of Awareness of Other Services
Service providers noted that in those instances where physicians were responsive to women's experience of abuse, they would recommend that women seek out services. However, the situation for immigrant women is compounded by the lack of awareness about services, a lack that is echoed by physicians themselves. One service provider stated:
[Physicians] wouldn't mention the resources and we know, working with immigrant women, how difficult it is for them to take the first step on their own. Like if only the physician would put in an effort to call an agency like ours or another agency and say that, 'there is this woman. Can you please connect with this woman?' or 'Can you come and meet with this woman in my office?' I think that we could get a lot of women to come out, but that doesn't happen. Even in hospitals, I find that there are hospitals where there are social workers who are aware of resources - I get a lot of referrals - but the hospitals where the social workers are not aware of our services, I don't hear from them completely. It's not that women are not going to these hospitals, it's just that they are not aware of the resources. So to educate not only the physician but also the other staff or the other people that work along in the same field about the resources is necessary.
Another service provider mentioned that when referrals are made,
they are communicated inappropriately. She referred to a case
where the physician's office had called her and given her the
telephone number of the woman to be contacted. When she called
the woman, the woman was agitated and angry because her abusive
spouse was in the home at the time. The woman did not feel free
to talk, and was scared that her spouse would find out and retaliate
against her. In this case, as in others that were mentioned,
physicians do not seem to be aware that their actions can endanger
a woman's life.
(xiii) Family Physicians Who Share the Same Cultural Background
Language was identified as a significant barrier impeding women from seeking assistance from health care personnel. When asked if women sought assistance from physicians who shared the same cultural/linguistic background, service providers affirmed that they did. However, they immediately raised concerns about the potential breaches of confidentiality and privacy as deterrents. These concerns were qualified when comments were made about female physicians from the same cultural background. In contrast to male physicians, female physicians were spoken of very favourably, and the same fears of breaching confidentiality were not raised in their case.
The issue of confidentiality has to be understood in the context of the family physician who serves not only the immigrant woman's immediate family but also her extended family. In many cases, physicians who come from the same cultural community are well known, and they share the same high social status as their white counterparts. So one family physician may have as his clients the immigrant woman, her spouse, children, parents-in-law, sisters and brothers-in-law, their children, and so forth. This pattern is very much based on the networking and sharing of information and resources that occur in the immediate context after migration. In such a context, the issue of confidentiality not only emerges with respect to the physician but also his/her staff who may be members of the same cultural community. The issue of changing physicians is hampered by considerations such as the fact that often the male head of the family has the care card in his possession, and within the context of the power and control dynamics of an abusive relationship, will monitor who his spouse sees and in the case of a physician, not only drive her there but insist on being in the examination room.(21)
(xiv) Fear of Breach of Confidentiality
In speaking to the issue of male physicians from the same community, one service provider noted:
… quite often clients say that I would not tell anything to my physician who speaks the same language, who is from the same community. It carries some kind of feeling of embarrassment.
Another added:
[Women] always say to me that, 'I used to go to my doctor but I never opened up to my doctor because I thought he would tell everything to my husband or to my mother-in-law or to anyone in the in-law family.'
(xv) Reluctance of Physicians to Get Involved
Not wanting to get involved and fear of jeopardizing their own reputations within the community were cited as factors to explain the lack of response from physicians who shared the same cultural background. As one service provider stated:
… the doctors who speak the same language seem to be less sympathetic and less understanding as compared to English-speaking doctors. I always find it such a struggle to get any information from [name of linguistic group]-speaking doctors because they don't want to be part of it, because they want to keep their image with the extended family, or with the husband rather than with the woman.
The economic consequences of getting involved in issues concerning violence was raised by one service provider who noted that providing medical care is a business. As she put it:
… we have to take into consideration that the medical field is not just to help people, it's a business. And so for a lot of [mentions nationality] doctors, we sort of compare what they have to lose if they start getting involved in domestic violence issues. First of all, they lose business from the community which is their main bread and butter. Some people will say, 'Oh, here he is, breaking families apart.' Number two, there are people in the community who will say, 'It's a family matter. Why is he calling other workers, talking about this woman and this issue of domestic violence.' And we have to take that into consideration. It's a business and so he doesn't want to lose business and therefore, if you start touching issues like family violence, it ruins your rapport with the community and therefore you lose business.
Not only are women forced to seek health care services from physicians from their own communities because of language barriers, but when they do so, their needs are compromised by the physician's concern about maintaining his reputation in the community. Another service provider added that physicians in her community simply did not want to recognize the reality of violence. They could not accept that violence against women was prevalent in their community.
Female physicians from the same cultural communities as the immigrant women themselves were perceived to be more sympathetic, less judgmental, and more aware of services in the community. As one service provider noted:
I find that in the [name of community] some of the female doctors, they're very pro-active and they're doing such an excellent job. And when the women go to them, they talk about the abuse, they give out the agency's name and phone numbers and they encourage the women. [One doctor] calls me personally and says to me that 'this woman needs your help. Can you get in touch with her,' or she'll facilitate the meeting, our first meeting. And I think if more doctors can do that, it will really help the women.
However, while these female physicians are more helpful, they are also vulnerable to harassment from within the community. Patriarchal forces that are strengthened by retreatism into communities as a result of the racist milieu, assert and express themselves in ways that are detrimental to female physicians. Thus, the same reasons for which some male physicians maintain a safe distance from taking a position against violence in their practices, make female physicians more vulnerable. This situation very much echoes the kinds of dynamics that occur in small towns and enclaves with respect to physicians who take an active stance on domestic violence and abortion rights. In these situations, physicians are targeted for taking a stand and supporting women's choices.
(xvi) Protocols in Hospitals
Service providers were overwhelmingly in support of protocols for screening domestic violence. They mentioned that when doing accompaniments with immigrant women who had been abused, hospitals with protocols in place provided better service and health professionals were more empathetic with women. However, they also noted that sending women home with pamphlets was not appropriate given that their spouses would see the information. One service provider reported that:
I have heard from some of my clients that they do do follow-up calls like a month later. Like some women, they haven't made up their minds as to whether they want to leave or not. And so they go home and then about a month or two later, she does call some of them under the guise that she's trying to see about … because this woman came to the hospital about a feminine matter so the husband doesn't know. But then the client would know who she is and she just checks to see if the woman is okay.
(xvii) Public Health Nurses
As with the findings of the environmental scan, the service providers in this focus group were very supportive of the role of the public or community health nurse. They noted that the nurses were critical in ensuring that mothers were not isolated after the birth of their child. They suggested that that public health nurse could be mandated to conduct periodic visits to immigrant households, particularly those of recent immigrants. This would help break down the sense of isolation that immigrant women experience and also enable those who are being abused to make links with women outside the home and through them, links with other services.
(c) Suggestions
The service providers made several concrete suggestions, some of which are integrated in the recommendations presented at the end of the report. However, they emphasized the need for a coordinated approach to health care for immigrant women who have experienced violence. Further, they noted the need to conduct outreach activities that provide information and facilitate networks with the different racial and cultural communities in the area. They especially emphasized the need for physicians to become educated about the signs of violence, and to become aware of services that are extant in the communities they serve. They underlined the necessity of physicians to take the time to communicate with the immigrant women who consult them, ask them directly about the violence, explain the various options available in terms of treatment, and refer them to the appropriate services. They urged that physicians not ask husbands to interpret for the women, or to have the husbands present at the time of the examination.
FOCUS GROUP AND INTERVIEWS WITH IMMIGRANT WOMEN OF COLOUR SURVIVORS
A focus group with immigrant women of colour who had experienced violence was organized through the auspices of a local immigrant settlement services organization. The women who participated in the focus group came from a variety of backgrounds which included Mexico, Latin America, India, China, and the Philippines. All of these women had been students in the ESL program and had a basic level of fluency in English. However, attendance at the focus group was problematic for some of the reasons identified in the literature that are inherent to the situation of immigrant women. Transportation was a problem for some women. Other women had to return to their places of work so the focus group had to be terminated after a duration of two hours. Although women had a basic understanding of English, the need for interpretation was apparent. Questions that were asked in the focus group had to be communicated in simple English and were vetted by an immigrant settlement worker prior to the focus group (see Appendix III for a sample of the questions). As well, some of the women were visibly fearful of the ways in which the information might be used, and while we attempted to assuage their fears, it undoubtedly influenced their response. All of them had experienced violence.
In order to supplement the information obtained from the focus group, ten individual interviews with immigrant women of colour were conducted by a research assistant.(22) The majority of these interviews were with South Asian women, and two with East Asian women. The interviews were informal and lasted for approximately one hour. A snowballing method was used to locate women who were interested in being interviewed.
The following sections present an integrated thematic analysis of the data obtained from the focus group and individual interviews. Many of the themes identified below echo those articulated in the previous sections of this report and resonate with the findings of the literature review.
Length of Time in Canada
Within the focus group, participants had lived in Canada for a period ranging from 3.5 to 13 years. Most of the women were older - in their 30s and 40s. Women who were individually interviewed exhibited an age range that spanned from the early 20s to the late 50s. Four of the women were in their 20s and had lived most of their lives in Canada. The average length of residence in Canada was 14.9 years, and the range spanned from 5 to 24 years.
Themes
(a) Barriers
(i) Finding a Physician
When asked how the women (both focus group participants and interviewees) selected their physicians, the majority indicated that either their husbands or families had chosen the physician. Only one woman reported that she had found a physician by consulting a list that was available from the immigration office. Her selection was based on the name of the physician that reflected the same nationality/culture. In a majority of the cases, the physician treated the entire family and in some cases, the extended family. Other participants emphasized their lack of knowledge about the health care system. They noted that upon arrival, immigrants are faced with taking care of the basics of life and thus choosing a doctor is a matter of expediency rather than careful scrutiny.
(ii) Disclosure Issues - Shame and Confidentiality
Although most of the physicians were chosen by family members and/or husbands, the majority of the participants in the focus group and interviews did not emphasize the nationality or cultural background of their physician as contributing to their ability to disclose. Rather, this was seen as immaterial and much depended on the kind of trust they had established. Most women had not disclosed to their family physicians or the staff they encountered at emergency departments. However, the issue of public shame and humiliation within the community was noted by several of the interviewees as impeding disclosure. As this interviewee stated:
For me, I was so afraid and embarrassed I didn't go to anyone I knew. How could I? I was this strong ambitious woman. How did I let this happen to me? I knew my family would tell me to try and work it out, that is what my sister and cousins had done. So I did not tell anyone until I was strong enough to leave my husband…
(iii) Legal Status
Legal status was mentioned by both focus group participants and interviewees. Focus group participants indicated that legal status determined how much information was provided to immigrants and refugees. Convention refugees were given more information in contrast to landed immigrants who had to depend on their sponsors or relatives for assistance in negotiating the various normative and bureaucratic structures of Canadian society.
As in the focus group with service providers, interviewees also mentioned the lack of information they have about their rights and how this impedes their leaving abusive relationships. One woman noted that:
I didn't even realize I was in an abusive relationship until it was really bad. I didn't see any alternatives for myself. I guess if I knew I could get financial help or my immigration would not be taken away maybe I would have left before it became really bad. Now it is too late for me. Maybe if women knew it can happen to anyone.
(iv) Economic Constraints
Economic constraints also impeded women from leaving abusive relationships. The fear of not being able to have custody of the children because they were unemployed as well as the lack of knowledge about systems that might offer assistance were cited as two of the most common barriers. Added to this, women could not afford to seek medical attention as it often resulted in them taking unpaid time off work. As this woman stated:
Yes, it might have helped [to have a doctor or nurse who spoke the same language]. But the money was more important, and who would have watched the children if I had to work? A Punjabi-speaking doctor could not change that for me.
Economic constraints also influence access to transportation, and ability to pay for medication.
(v) Naming the Abuse - Vague Symptoms
For many of the women who were interviewed, the abuse began as emotional harassment and then escalated to physical violence. However, women stated they did not recognize the early warnings as signs of abuse. The health effects of violence that they experienced stemmed from the emotional abuse but in seeking health care for these symptoms, the physicians they encountered also did not recognize them as signs of abuse. Thus, the inability of the women to identify these symptoms as signs of emotional abuse was reinforced by the physician's ignorance of the health effects of violence. As one woman stated:
I had a very pessimistic view of life and often contemplated suicide. Because of the stress, I turned to smoking as a conditioning solution although I knew it was ineffective. Under stress, I often suffered from fatigue. I over ate but sometime ate to a point where I had to puke. I was also prone to colds and headaches, tension in my back and neck muscles. My immune system was weakened from the emotional tension and stress, and over the last two years I have developed allergies on my face, usually involving dry red patches or rashes.
Another woman stated:
I did not have any physical injuries as far as bruises and broken bones. This is always how I defined abuse until it happened to me. I didn't even realize what was happening. I am an educated woman with a career but that didn't matter.
The manifestation of emotional abuse in 'vague' symptoms and somatic complaints was also echoed by focus group participants. As one participant expressed it:
I think it would be easier that way for them to realize what is going on with that person because sometimes, like for me, I was having so many things, I really thought I was going to die. I didn't know what was going on with me. So I think for the doctor, it would be easier to detect what was happening to me if she knew my situation.
(b) Encounters with the Health Care System
Women's encounters with the health care system varied as a function of the level of care they accessed and the conditions under which they sought care. Thus, some women obtained assistance from staff at walk-in clinics, while others sought care from their family physicians. Where injuries were severe as a result of physical violence, women turned to emergency departments. Again, the response varied. Nurses and specialists were cited as being more helpful and supportive. Public health nurses were frequently cited as being the most supportive in helping women to break the isolation. In contrast, family physicians were often identified as not providing the necessary level of care and as 'watching the clock.'
(i) Watching the Clock
For many immigrant women of colour, language barriers already impede the flow and pace of communication between physician and patient. Add to this the complexities involved in disclosing violence, and women often leave feeling frustrated that their concerns haven't been heard nor has there been an attempt to explain the possible causes of their symptoms. As this focus group participant reported:
When I go to the doctor, I don't expect the doctor to give me an hour because I know it cannot be. But at least to listen. Not my whole life story but to at least have enough time for me to say, 'Okay, this I what I'm feeling,' and maybe for them to ask, 'Do you think this could be related to something else, with a problem that you might have?' Or something like that. But lately, when I go to the doctor, she just asks, 'What are you feeling?' and then she starts writing and that's it. So I don't have time to express myself, that this is my difficulty or my consequence of whatever it was that I'm feeling. I think it would help just to have a little more time.
The reliance on doctors who share the same cultural background (because of language barriers) often makes it impossible for immigrant women to change physicians or find ones that will actually listen to them. One woman in the focus group reported that she now makes up a list of all her concerns so that she has this in hand when she goes to her appointment.
(ii) Not Asking about Violence
Inadequate time and lack of listening often results in physicians not asking about violence. When physicians do not ask about violence, women do not reveal the abuse they are experiencing. As these women reported:
I went to see my doctor because I started getting nosebleeds and fainting spells. He never asked what was wrong. He did some tests but never really said you are anorexic. I didn't find out until I got pregnant. That's when he said, 'well you should eat more.'
Another mentioned that:
… language is very important. But it only matters if the doctor or nurse is going to listen to their patient. If they are too busy to listen or do something, it doesn't matter what language you speak. I see that all the time in my job.
From the interview and focus group data, it was apparent that in those hospitals which had screening protocols in place, women were more apt to be asked about violence. However, much depended on how the asking was done. In some cases, individual interviewees reported highly negative experiences with emergency departments where questions about violence were asked in a perfunctory manner, or in some cases asked when the abuser was in the immediate vicinity thereby impeding women from disclosing the violence. One interviewee recounted a particularly traumatic case of physical violence which resulted in her presenting at the emergency room. She stated that while she received medical care, she was never once asked about the violence nor provided with any compassion or support. Another mentioned presenting at an emergency department on a regular basis and again, not being asked about the violence. As she put it:
I went to the emergency room. But never for the real reason. Once my husband got angry with me because his cousins were visiting and I was in our room studying. He pushed me and I fell back and banged my head against the wall and fainted. He carried me downstairs and told everyone I had fainted and then banged my head. We repeated the same story at the hospital. So I was treated like any other patient. I was going to the hospital on a regular basis but no one ever asked any detailed questions about why I kept fainting or banging into things. … My only complaint is that no one stopped to say, 'why have you been here almost every month for a year and a half? That can't be normal?' But I try and not to be angry anymore. What is the use?
(iii) Children as Interpreters
Women in the focus group noted how children are used as interpreters. They were very opposed to this and argued for health care providers to obtain the services of professional cultural interpreters. As this woman stated:
… to take a child and to put him in a position like that, it's like putting my child in my situation and instead of helping my kids, I am also hurting them.
(iv) Conceptual Frameworks of Meaning
As with the service provider focus group, women indicated that terms that are taken for granted have different meanings for them. Hence, referring women for counselling indicates to them that they are mentally unstable. The discordance in conceptual frameworks of meaning also arises in women's preference for and use of alternative therapies, and in particular, indigenous practices. These are often viewed by allopathic practitioners as harmful or irrelevant.
(c) Suggestions
Women in the focus group and individual interviews articulated the following suggestions for improving the distribution of information about violence to immigrant women of colour, as well as recommendations regarding the training and conduct of physicians:
12. Key informant interviews were conducted in person by Harjit Kaur.
13. The focus group with bilingual and bicultural service providers, as well as with immigrant women of colour who had experienced violence, were organized by Benita Bunjun.
14. Individual interviews were conducted by Suki Grewal as part of her course work under the supervision of Dr. Parin Dossa.
15. Interviews with representatives of organizations located in different parts of the province were conducted by telephone. Kelly D'Aoust coordinated the environmental scan and conducted the majority of the interviews. She was assisted by Tracy Conley and Adriane Billyard. This analysis is based on Kelly D'Aoust's thematic breakdown of the interview data.
16. Although there are significant differences between Aboriginal women and immigrant women of colour, the scan was designed to include both groups because of their racialization in Canadian society, as well as their low social status.
17. These concerns have been noted in a study of violence in two rural communities in British Columbia. See Jiwani et al. (1998).
18. See for instance, Duffy & Momirov (1997), and Koshan (1997) for more background on Aboriginal women, violence and the law.
19. For more information on "mail order brides," see Chin (1994), Narayan (1995), and the report of the Philippine Women Centre & the Global Alliance Against Traffic in Women Canada (1999).
20. Elsewhere, I have made the argument that the only time women of colour are deemed to be acceptable by dominant, normative standards is when they show signs of assimilation or when the dominant society can perceive itself to be in a benevolent situation, as in rescuing Third World women from their oppressive conditions (Jiwani, 1992).
21. It is the sponsor's responsibility to pay for the medical care of his dependents.
22.
These interviews were conducted by Suki Grewal.