This report began with two poignant quotes by Christine Rasche (1988) and Irihapeti Ramsden (1993), respectively. These two quotes eloquently summarize the situation of racialized immigrant women who have experienced violence and their encounters with the health care system. They describe on the one hand, the physical experience of violence that knows no cultural or racial boundaries; and on the other hand, the response of health care providers that results in an 'emotional white-out' for abused women whose histories, needs and lived experiences are erased, inferiorized and trivialized.

Violence against women is grounded in the unequal and subordinate status of women. Thus, violence is about the abuse of power in a context of inequality. The formal medical system is stratified along the lines of power and privilege. Different groups have more power and privilege relative to other groups. The woman who has experienced violence encounters this system at different points. However, in contrast to the physician, nurse or even the ambulance driver, she has relatively little power. Further, the system is raced, classed and gendered in that the dominant power resides with white, heterosexual males who belong to the upper- or middle­class income bracket. The racialized woman, whether she is an immigrant woman of colour or an Aboriginal woman, has considerably less power and privilege in such an encounter.

As the environmental scan suggests, immigrant women of colour share with their white sisters, some of the same barriers that the latter experience when accessing health care. These barriers are predicated on systemic and institutionalized sexism within the health care system. Women who have experienced violence and who present to emergency staff and/or family physicians are often responded to with disbelief, minimization of their experiences, and medicalization of the abuse. Their concerns are often trivialized or erased, and they are subjected to blame. They are in fact constructed as 'problem patients' as indicated in the literature, and revictimized by the very system they turn to for assistance.

Aboriginal and immigrant women of colour have to deal with multiple and intersecting forms of violence. The gender-based violence they experience in their communities intersects with and is compounded by the everyday and institutionalized racism and sexism they encounter within the health care system. Institutionalized racism expresses itself in the streaming of women into dangerous occupations which are downwardly mobile. It is also manifested in the diversion of women away from language and employment programs that would alleviate their situation. Everyday racism underscores women's subordinate status by constantly inferiorizing them, erasing their contributions, and minimalizing the violence they encounter. Cultural racism within the various bureaucratic systems underscores their inferiorization and 'otherness,' and amplifies the risk they face when turning to these institutions for support and assistance.

In many cases, physicians' lack of knowledge about the health effects of violence combined with their orientation toward the efficient processing of patients contributes to the inadequacy and inappropriateness of their response and treatment of women who have experienced violence. Further, some physicians are reluctant to engage in any discussion about violence, or to refer women to other services in the community. This may reflect a lack of training that would equip physicians to recognize the health effects of violence and ask the right questions. However, in many of the situations identified by service providers and immigrant women of colour, physicians do not invest in the time required to develop a trusting relationship with their patients. Rather, they are constantly 'watching the clock,' thereby contributing to the lack of ease and the discomfort of immigrant women of colour, as with other women who seek their services.

Clearly, if physicians do not spend the time with patients, are not cognizant of the health effects of violence, and are not aware of community services that can help women, women who are experiencing violence will not be in a position to disclose that abuse. Similarly, if the physician is treating both the woman and her abusive partner, and/or her entire family, she may not feel comfortable in disclosing the violence for fear of a breach of confidentiality and retaliation from the spouse. This situation is particularly relevant for immigrant women of colour and women in rural areas. In the former case, racism, lack of dominant language skills and lack of knowledge regarding their legal rights, contributes to their vulnerability in seeking services and fears about having their concerns documented.

The review of the literature as well as the data from interviews and focus groups demonstrate that stereotypes about women and specific ehtno-racial groups structure the common-sense understandings of violence among health care providers. This results in attitudes toward racialized women that hold them and their cultural communities responsible for the violence. Cultural racism defines this discourse and underpins many physicians' reluctance to discuss violence with racialized women, and to attribute the violence to 'innate' cultural traits. Thus, rather than perceiving the risk factors that make immigrant women vulnerable to violence, physicians tend to localize the abuse and attribute it to the immediate cultural context in which the woman lives. This reinforces the stereotype that some cultures are more violent than others. It also deflects attention away from the structural forces and inequalities that contribute to immigrant women of colour's vulnerabilities to violence. Most immediately, it deflects attention away from the physicians' shortcomings and failure to provide adequate care.

Language barriers combined with structural dependency on the sponsoring spouse forces many immigrant women of colour to seek medical care from physicians selected by their abusive partners. These physicians are often reluctant to identify the abuse and to provide referrals and assistance. Further, many of these physicians rely on the abusive partner or children to interpret for the women, thus compromising women's ability to disclose the abuse. In other cases, potential breaches of confidentiality contribute to the silencing of women. The silencing is reinforced by patriarchal forces within the community which threaten to stigmatize or exclude the women should they disclose. The situation parallels the experiences of women who have been abused in rural communities and demonstrates the salience of structural forces in rendering some women more vulnerable than others. Again, as the literature demonstrates, the strength of patriarchal forces within communities of colour is not an innate or essentialist element of these communities, but rather is rendered more potent by the dislocation and displacement of these communities through migration, economic exploitation and their exclusion from participation and integration into the dominant society. Racism and sexism thus work hand-in-hand in silencing the voices of immigrant women of colour.

Women of colour do want to tell their stories of abuse. This study shows that where screening mechanisms and protocols were in place, women at least had the opportunity to disclose. However, the ways in which they are asked questions about violence is equally important. Further, having information that helps them to define the abuse is even more important.

Fears of involving the police inform issues around documentation for immigrant women of colour. As with women who have experienced abuse, the import and strategic use of documentation is rarely explained by health care service providers. Racism not only feeds popular stereotypes about communities of colour as being more violent, but it also informs social policy and police practices so that these communities are under constant surveillance and men within these communities are criminalized. For communities to be labeled as violent leads to a situation where on the one hand, the women are dismissed as the violence they experience is normalized or culturalized, and the men on the other hand, are subjected to intense scrutiny and more likely to be subjected to punitive measures. For women in racialized communities, being aware of the differential and racially inscribed relations of power often means being silent about the violence. Not only are they threatened with deportation by their abusive partners, but the State also threatens to deport both themselves and their partners. These dynamics also make communities of colour more cautious about disclosures of violence, and contribute to the stigmatization and exclusion of women who 'tell.'

The reluctance to get involved on the part of many male physicians who share the same cultural frame of reference as the immigrant women of colour they serve, is again rooted in a similar dynamic, albeit one grounded in the economic success and the social status ascribed to health care professionals. On the one hand, there is the need to maintain a credible reputation and social status among clientele. On the other hand, taking a stance by actively advocating and supporting immigrant women of colour who have experienced violence can result in being stigmatized in the community and losing clientele. For female physicians, the risks are greater as they are also targeted by patriarchal forces within the community and harassed for taking a stand against the violence. As with every society, women who challenge the normative order are subjected to punitive measures. Similarly, those who advocate for unpopular causes are subject to backlash and violence, as is evident in the cases of physicians who have continued to provide abortion services. In this case, however, the potency of backlash is experienced to a greater extent given the small size of the community, its minority status, its geographic concentration, and the turning inward that has occurred as a result of the racism of the wider society.

Without a socio-ecological analysis that takes all of these variables into account, it is easy for health care professionals to continue to revictimize immigrant women of colour who seek their services. A socio-ecological model would not only help to contextualize women's lives, but would locate these experiences within a wider conceptual framework which recognizes their high­risk status as emanating from their structural location at the juncture of multiple and intersecting forces of domination. These forces of domination translate into the kinds of violence to which immigrant women of colour are subjected. These include social, economic and intimate forms of violence.

Reducing the risk to and enhancing the safety of immigrant women of colour entails a recognition of the societal, systemic and individual forms of violence they encounter. It involves a dismantling of cultural stereotypes, sexist stereotypes, as well as racist and sexist attitudes and behaviours that inform and structure social institutions. It also entails an awareness of the dynamics of abuse within intimate relationships, social institutions and societal attitudes and norms. It necessitates a dismantling of the hierarchies within the medical system which favour some patients over others on the basis of their race, class, and gender, and where the 'preferred patient' is identified as one who is willing to be rescued by the system despite endangering her life and legal status.

Within the formal health care system, 'culturally sensitive' approaches can easily succumb to a piecemeal approach to social change. In part, this is a result of the very nature of the system, predicated as it is on a western biomedical model which defines illness in discrete terms and categories and relies on prescriptive antidotes that can help eradicate the illness or at least manage the symptoms. The conceptual framework that organizes such an approach favours tangible solutions. Cultural prescriptions in the form of services and treatments which are organized, concrete and discrete have an affinity to the medical model. In contrast, solutions that argue for structural change involve mobilization, changing attitudes, practices and conceptual frameworks. They involve advocacy and are predicated on a social justice model of substantive equality (as opposed to formal equality). The difficulty of translating this approach within the dominant framework of western biomedicine is apparent in the continued inadequacy of the medical professions' response to violence against women. Rather than dealing with the systemic roots of gender-based violence, as grounded in the inequality and subordination of women, the system tends to focus on the physical signs of violence and treat them as if they are isolated from the larger social context.

For the immigrant woman of colour, the system's focus on physical manifestations of violence feed into and reinforce her own notions of what constitutes abuse. Racism, sexism and classism combined with the lack of dominant language skills, unfamiliarity with the conceptual frameworks of meaning and the bureaucratic nature of the medical system, work in concert to create barriers impeding her access to services. This situation amplifies the risk that women face - risks that are institutionally and societally grounded. In such a situation, it is not surprising that women fail to disclose abuse to medical practitioners, nor is it surprising that women first disclose to their friends and family. The few social networks of support available to immigrant women of colour need to be reinforced, and one of the avenues by which this can be done is to create spaces for women to network with each other. It is only in such safe spaces that information about abuse can be rendered meaningful enabling women to be able to use it in ways that are most appropriate for them. A more critical avenue through which to redress the unequal position of immigrant women is to support advocates who can work with them to navigate the complex and often fragmented bureaucracy of health care services. Additionally, the work of the public nurse and the community outreach worker need to be recognized because of their instrumental role in helping to reduce the isolation, and hence the vulnerability, of immigrant women of colour.

However, without structural changes, social support networks and outreach by public nurses can only function as band-aid solutions addressing the most immediate needs. Band-aid solutions are temporary in nature. Dismantling inequalities within the health care system requires a more serious and committed approach. It requires recognition of alternative ways of healing, and recognition of the resources, skills and expertise that immigrant women of colour have to offer. The harnessing of these skills and expertise would not only address the issue of the 'brain drain' but would also facilitate the introduction and integration of different approaches to health care. Further, it would address the current ghettoization of people of colour in the lower echelons of the health care system and redress the power imbalances within the system. However, these changes necessitate a rethinking of the current model of the provision of health care services where access to the system is mediated by the 'care card,' and services are commodified in terms of dollars and cents. For immigrant women of colour who often have neither the money nor the unpaid time it takes to access services, the current system exacts social and economic costs which they can ill afford.

In conclusion, structural change remains the only viable solution if we are to meet the needs of immigrant women of colour and truly achieve the expectations of a health care system that is universal, humanitarian and compassionate. Until then, we will continue to have a system that perpetuates inequalities.

RECOMMENDATIONS

RECOMMENDATIONS TO PHYSICIANS, REGIONAL HEALTH BOARDS, PROFESSIONAL BODIES AND VARIOUS LEVELS OF GOVERNMENT

1. That, as per its mandate to promote "the highest quality of health care delivery to the people of British Columbia," the British Columbia Medical Association create a committee that focuses on gender-based violence, and encourage physicians to become aware of the health effects of violence.
2. That such a committee focus on the impact of multiple and interlocking forms of oppression and how these interact with intimate forms of violence.
3. That the British Columbia Medical Association Committee issue guidelines concerning the care and treatment of women who are abused, and encourage the employment of an integrated socio-ecological model in physician practice.
4. That the British Columbia Medical Association compile and disseminate a list of physicians who are conversant in different languages, who come from different cultural backgrounds and who are knowledgeable about the health impacts of violence. The list should be made available to immigrant settlement societies, posted at the airport, and distributed to community centres and other physicians.
5. That all professional bodies and medical schools be mandated to undertake and implement education and awareness regarding the impact of systemic racism, sexism and classism. Hence, educational initiatives and provision of services should take into consideration the multiple and intersecting forms of violence that render particular populations at risk.
6. That regional health boards commit resources toward the employment of public health nurses and community health care workers to conduct community outreach. Outreach should not be limited to the period immediately after the birth of the child but should include outreach to new immigrants and to women who are isolated.
7. That the government and the various professional bodies involved with the provision of health care, support and encourage research on the effects of intimate violence and the interlocking effects of multiple forms of violence.
8. That community outreach workers and public health nurses be drawn from the communities they are to serve and be provided with the tools by which to deal with situations of intimate violence.
9. That regional health boards ensure the provision of specialized interpreters who can be called upon to interpret for immigrant women who have experienced violence. Information about credible interpretation services should also be made available to all practicing physicians and clinics. Interpreters should also be trained in dealing with violence and in recognizing the dynamics of violence that are operative in intimate relationships.
10. That governments and regional health boards work together to create opportunities of networking which would reduce the risk of isolation that immigrant women and women of colour face.
11. That settlement services and advocacy organizations be provided with additional funding in order to support their work with and advocacy on behalf of immigrant women of colour.
12. That physicians refrain from using children or husbands as interpreters when examining a woman at any time, no matter how convenient this may seem at the time.
13. That ongoing education be provided to physicians and other health care workers about the links between mental health and violence, as well as ways in which to detect and screen for violence, and further, to understand the root causes of gender-based violence. Physicians need to be aware of violence as a health issue, and to be attuned to the symptomatic manifestations of violence.
14. That the BC Medical Association take a lead role in encouraging physicians to acquire knowledge about the health impacts of migration, racism, sexism and other forms of oppression.
15. That documentation about violence should be at the discretion of the patient rather than being imposed by the physician or other health care workers.
16. That reporting violence to the police be done at the discretion of women who are abused and in consultation with health care service providers.
17. That measures be taken to support female physicians from diverse communities to practice within these communities and to encourage them to serve the women in their communities.
18. That alternative systems of healing be recognized and supported.
19. That medical coverage for the utilization of alternative systems be implemented and that costs be covered to a greater degree than at present.
20. That screening mechanisms and protocols for violence be implemented in private practices, walk-in clinics and hospitals throughout the province. However, the development of these protocols should involve members of the communities that are impacted as well as health care professionals at these various sites.
21. That physicians and other health care professionals be made aware of, and encouraged to utilize existing community-based support services that deal with women in abusive relationships. More particularly, they need to be aware of where women from racial minority backgrounds can access these services. This information should be available in their offices so that patients can perceive it and access it in unobtrusive ways.
22. That physicians and nurses be encouraged to make referrals to other community services directly, and where possible facilitate the first meeting between the patient and community service provider.
23. That family physicians be discouraged from serving an entire extended family at any time as this makes confidentiality problematic, and it also hinders women from disclosing abuse especially if they are being served by the same physician as their abusive partner and/or family.
24. That male physicians be required to examine the woman in the presence of a female nurse. Physicians should be strongly discouraged from examining women in the presence of their partners.
25. That physicians and nurses be required to explain to patients what they mean by maintaining confidentiality and the conditions under which confidentiality will not be maintained, for example in criminal justice proceedings.
26. That physicians take the time to explain and listen to their patients in a respectful way that also maintains the dignity of the patient, and that they be made aware of the differing conceptual frameworks of meaning that are being used by their patients.
27. That a more coordinated approach be taken in the delivery of health care services to women who have experienced violence, and particularly to women who are at risk because of the multiple forms of violence directed against them. This includes women who are poor, homeless, in transition, and women who do not speak the dominant language.
28. That all health care service providers be made aware of the various categories of immigration legislation which govern the lives of immigrant women, and to use this information to assuage the concerns of immigrant women who seek assistance from them.
29. That health care professionals be made to realize the often dangerous conditions in which all women who are experiencing violence live, and the escalation of that danger upon leaving the relationship. This information should be understood in the context of providing referrals, and hence referrals should be made in the most sensitive and appropriate manner.
30. That health care services be provided in an equitable manner regardless of the woman's decision to remain in or leave the abusive relationship.
31. That stereotypes about racialized groups as being violent communities be eradicated. Educational initiatives that deal with this issue should be encouraged and implemented at all levels of the health care system.
32. That the provision of adequate and appropriate health care not depend on the presentation of a 'care card.' Women's access to a 'care card' can be limited by the abusive partner.

1. That health related information about violence be made available in different languages and distributed at religious and cultural centres, as well as at schools, libraries, walk-in clinics, specialized grocery stores serving different communities, neighbourhood houses, community centres and other frequented sites.
2. That information about violence and its health effects be communicated and distributed to multicultural societies and immigrant settlement agencies, as well as to advocacy groups who are involved with immigrant women and women of colour.
3. That settlement services and advocacy organizations be provided funding in order to support their work with immigrant women of colour.
4. That information be distributed through the mainstream and ethnic media, and through cultural programming that is broadcast during the day.
5. That the federal and provincial governments produce posters, cards, and other media incorporating information about violence and its health effects, and that such information be distributed in women-only spaces, and made publicly visible and accessible in private spaces such as bathrooms. This information should be available in a multilingual format.
6. That education initiatives be implemented through outreach, and through family­oriented events.
7. That the current 1-800 number used for disseminating information about violence also include information about the health-related effects of violence. Health Canada's National Clearinghouse on Family Violence can be encouraged to take the lead in this area.
8. That a multilingual telephone line be set up which can be accessed by immigrant women and women of colour to obtain information about health services and knowledge relating to migration, the impact of racism, sexism and other forms of violence.
9. That immigrant women of colour from diverse communities be trained to deliver information about the health effects of intimate and systemic forms of violence in their communities.
10. That community advocates be recognized and supported for their work in empowering immigrant women and communicating information about health care.