Refugee Women culture health refugees immigrants
Updated 5/2006
Introduction
Although they tend to suffer the most serious consequences of war and immigration, women and children remain an often hidden population among refugees in general (UNHCR, 1998). Approximately 80% of the refugees immigrating to the United States and other countries of second asylum are women or children.
Women are a highly vulnerable population because of both physical realities and traditional cultural roles and perspectives. Many have left most, if not all of their family and support systems behind. Some have lost husbands and children to war, famine, or illness. A large percentage of women refugees have spent time in refugee camps where conditions are crowded and frequently unsanitary. Many have been the victims of violence themselves. All have left everything familiar behind.
As if the tragedy and fear that forced these women to leave their homes were not burden enough, many find themselves in a country that is completely foreign, with unknown customs, language, values, and protocols. They are immediately faced with the major role changes, which further increases their vulnerability.
Studies show that refugee women are affected differently than men by the events of their pasts, and have special concerns stemming from these events and responses (Kang, Kahler, and Tesar, 1998). Regardless of the specifics that drove refugee women to flee their homes, they typically come to countries of second asylum refuge (such as the United States) with all-encompassing human needs, including physiological, psychological, sociological, and spiritual.
Physiological Issues
Access to Health Care
Refugees are required to have a full physical examination within the first year of their residency in the United States. However, this may be the only form of health care provided to many during this time period. Language barriers, limited transportation, refugee agency knowledge deficits regarding health needs, and the refugee's limited knowledge of health care sources all inhibit the refugee womanís access to primary and specialty health care. In addition, refugee women may not know about the financial assistance offered through various agencies.
Personal and cultural issues may also cause a woman to hesitate seeking health care. Many refugee women come from very private backgrounds and may fear allowing someone outside their culture to examine or treat them. Others have always relied on traditional methods of treating illness, and may distrust western medicine techniques (Downs, Bernstein, and Marchese, 1997).
Diet and Nutrition
Malnourishment is common to refugees in general, but is especially common to women; and particularly so in war conditions or refugee camps in counties of first asylum. This occurs in some cases because in many cultures, the food goes primarily to the male family members who work to support the family. The women must then survive on what is left over. In addition, through menstruation, women lose more nutrients (particularly iron) than men do. Breastfeeding may also be a factor in unmet nutritional needs. Coupled with these factors is the general lack of well-balanced diets in some famine and war-stricken regions, and the food shortages present in refugee camps. All this results in women living for varying lengths of time with less than optimal nutritional intake (or absorption) of calories and nutrients. Inadequate intake is less a problem in countries of second asylum such as the U.S., Japan, France, and so on. However, poor nutrition leading to obesity may become a problem.
Dehydration is also frequently seen in refugee women, particularly upon arrival to their country of first asylum. Water in refugee camps may be rare, and clean water even more difficult to obtain. Some women suffer from diarrhea and quickly become dehydrated. Although dehydration does not occur as frequently once the women resettle in host countries of second asylum, the preexisting results of it may need to be addressed by health care providers.
Shelter
A factor that may greatly increase or decrease the refugee womanís vulnerability is her source of shelter. In many countries of first asylum, refugee women live in crowded refugee camps where she may be exposed to abuse or illness. Some women may live in brothels or sweatshops to survive. Although there may be different options for the refugee woman in countries of second asylum, shelter that is safe, dry, warm, and affordable may still be difficult to find.
Childbirth Issues and Birth Control
Refugee women tend to have greater parity, delayed prenatal care, and lower hematocrits than their host country counterparts (Kang et al.,1998). Refugee women are also more likely to have complications during labor and delivery and to deliver low birth weight babies. Financial implications of having children may also increase the physical and emotional strains on refugee women.
Each culture has its own views of childbirth, and these need to be assessed in terms of the culture and on an individual level. In general, exploration should be made of a woman's desire to prevent or space births - regardless of the woman's faith background. The challenges and difficulties of refugee life may override religious proscriptions.
Rape and Sexual Abuse
Refugee women are extremely vulnerable to sexual abuse and rape. Women of many cultures tend to be dependent upon men for the essentials of daily survival, food, shelter, etc. In many cultures, women are viewed as property and are expected to submit to men. This, coupled with the fact that men are generally physically stronger than women, opens the door to sexual and physical abuse outside and inside marriage. In most third world countries, abuse is not even reported due to the social status of women.
Refugee women bring this background to their countries of asylum. Because of their vulnerability, rape and sexual abuse are extremely common among female refugees and immigrants. Though few are forthcoming with such history, horrifying reports of cruelty and rape have been reported by the few who will speak out. Note also that dealing with psychological and physical trauma may take many years or may never occur (see discussions of mental health, posttraumatic stress disorder, and related issues in the mental health section of this site.
Four major sources of rape and sexual abuse have been identified. Most commonly, soldiers are reported to torture and rape prisoners of war and residents of the villages they invade. Many young Tibetan and ethnic Albanians report being told that their lives were being spared only because they were to be used to "service" the soldiers. Secondly, women report being sexually abused by their spouses and family members. In India, it is reported that it is not uncommon for in-laws to participate in wife abuse and "bride burning" continues to be practiced. Coupled with this, is the fact that the United States is one of the few countries where women are given the right to refuse to have intercourse with their husbands. Traditional gender roles in many cultures allow men to criticize and chastise their wives, along with having full control of the sexual aspects of the relationship. The third source is the men of the refugee womanís native country, performing random acts of rape and abuse, which tend to increase under war conditions. In addition, men in the refugee camps frequently find ways to trap and abuse weakened women. Finally, men in countries of second asylum may take advantage of unsuspecting and frightened immigrant women and by deceptive means lure them into situations they are unprepared to handle.
It is critical that when working with refugee women, a history of rape and abuse is considered possible, yet at the same time value women's privacy and sense of chastity. It is also important to understand that witnessing or even having knowledge of violence toward others increases an individual's sense of vulnerability. One also must be sensitive to the women's attitude towards men, including male health care providers. Trust and caring must be developed over time with refugee women. Also, current precautions against further abuse may need to be taken.
Female Genital Cutting
Until just a few years ago, few in the West were aware of the practice of female genital cutting (FGC) or female genital mutilation (FGM). FGC has also been called female circumcision (FC), but this promotes a comparison to male circumcision, which in many cases is misleading (as male circumcision does not cause discomfort other than the procedure, nor is it related to control over the circumcised person). Today, it is known that more than 114 million women in the world have undergone some form of FGC.
Genital cutting involves the removal or in some cases ritual scarring of genital tissue. There are four types of FGC classified by WHO:
| Prevalence
Rates and Types of FC/FGM by Country* |
||
| Prevalence |
Country |
Type(s)
Most Commonly Practiced |
| 50% |
Benin |
Type
II |
| 70% |
Burkina
Faso |
Type
II |
| 20% |
Cameroon
|
Types
I and II |
| 43% |
Central
African Republic |
Types
I and II |
| 60% |
Chad |
Type
II [Type III only in eastern parts of the country bordering Sudan] |
| 5% |
Democratic
Republic of Congo (formerly Zaire) |
Type
II |
| 43% |
Cote
d'Ivoire (Ivory Coast) |
Type
II |
| 98% |
Djibouti |
Types
II and III |
| 97% |
Egypt |
Types
II (72%), I (17%), and III (9%) |
| 95% |
Eritrea |
Types
I (64%), III (34%), and II (4%) |
| 90% |
Ethiopia |
Type
I and II [Type III is practiced only in regions bordering Sudan and Somalia] |
| 80% |
Gambia |
Type
II [Type I practice only in some parts] |
| 30% |
Ghana |
Type
II |
| 50% |
Guinea |
Type
II |
| 50% |
Guinea
Bissau |
Type
I and II |
| 50% |
Kenya |
Types
I and II [Type III practice in eastern regions bordering Somalia] |
| 60% |
Liberia |
Type
II |
| 94% |
Mali |
Types
I (52%) and II (47%) [Type III practiced in the southern part of the country (1%)] |
| 25% |
Mauritania |
Types
I and II |
| 20% |
Niger |
Type
II |
| 60% |
Nigeria |
Type
I and II [II is predominant in the South and Type III practiced only in the North] |
| 20% |
Senegal |
Type
II |
| 90% |
Sierra
Leone |
Type
II |
| 98% |
Somalia |
Type
III |
| 89% |
Sudan-North | Type III (82%), I (15%), and II (3%) |
| 18% |
Tanzania | Types II and III |
| 50% |
Togo | Types II |
| 5% |
Uganda | Types I and II |
| Sources: Carr D.
Female Genital Cutting: Findings from Demographic and Health
Surveys. Macro International Inc., Sept. 1997. * From the book, Caring for Women With Circumcision, by Nahid Toubia, MD. Used with permission from Rainbo Publications. |
||
To the above we might parts of the Middle East, including northern Saudi Arabia, southern Jordan, and Iraq; there is "circumstantial evidence to suggest it is present in Syria, western Iran, and among the Bedouin population of Israel" (Wikipedia, 2006). The average age of girls who undergo FGC is about three years of age, although ages range from seven days to fourteen years. The age varies based on the type of cutting to be done and the customs of the area in which the procedure is to be performed.
A major concern about FGC, beyond the pain and deleterious long-term effects it causes, are the circumstances in which it is done. Frequently, conditions are unsanitary, and the procedure is done by a "midwife" using a non-sterile sharp instrument such as a razor blade, scissors, kitchen knife, or pieces of glass. These instruments may be used on several girls in succession and are rarely cleaned beyond wiping. This greatly increases the risk and incidence of infection, and in some cases results in the transmission of HIV. Primary fatalities result from shock, hemorrhage, and septicemia.
Other long-term complications may occur as well. Dyspareunia, aversion to sex, genital malformation, delayed menarche, and chronic pelvic complications are common results. Menstruation, which may last 10 days or longer, causes pain and often is malodorous. A woman who has been tightly infibulated urinates drop by drop and may need 15 minutes to void. This results in urinary retention and causes recurrent urinary tract infection.
One of the justifications used for FGC is tradition. It is said that the procedure helps to ensure family honor, cleanliness, virginity, and fidelity of the wife. It is also believed by some that it serves as protection against spells. A girl who is uncut may be considered "unclean" and therefore, unmarriageable.
Religious beliefs are also used as a reason for practicing FGC. However, a large group of women who have undergone the procedure are Muslim, and the Koran says nothing to support the procedure, nor is there any written history or literature that indicates the practice was part of the customs in the time of Mohammed. Therefore, FGC cannot be called a true religious tradition of the Muslim people, although it is associated with some of the tribal religions of southern Africa. The practice is performed largely because of myths about the female genitalia. Some groups believe that the clitoris is "dirty" and makes a woman "unclean". Others believe that it will grow like a penis if it is not excised and this will make intercourse between man and woman impossible. The myth also exists that the clitoris is evil and has the power to make men impotent and to kill children at birth.
In the United States, a federal law was passed in 1996 that makes performing the procedure on a girl under 18 years of age a felony, punishable by fines or up to five years in prison. FGC is illegal in most western countries as well as some African and other countries. While FGC is seldom performed in the West, there is reason to believe that girls will have the procedure done by being sent from Western countries to countries where the procedure is legal.
In the West, FGC is usually discovered accidentally during a routine exam. Health care providers should remember that women who have experienced FGC have smaller vaginal openings, and are likely to experience pain during pelvic examinations. FGC also has serious repercussions for vaginal deliveries because the perineal area lacks the elasticity to stretch during delivery. FGC doubles the risk of maternal mortality in childbirth, as well as increasing risk for infant mortality and morbidity (e.g., head trauma during passage through the introitus).
If the region is well healed without excessive scar tissue or cysts, no special prenatal care is required. However, it is important to address emotional needs associated with the physical status. If the woman was previously infibulated, and de-infibulated during the birthing process, it is legal in the United States to re-infibulate her. However, efforts should be made to counsel the woman on the related health risks. The large majority (90%) of women choose to not repeat the procedure after hearing only brief medical concerns. It is vital to show the woman that her feelings, fears and values are respected.
Any woman who has undergone this procedure and been exposed to Western values will be likely to have questions and concerns about physical problems or sexual ramifications. It is important that these be validated and dealt with in a spirit of compassion and privacy.
Disease
Many refugee women come from countries where diseases uncommon to the United States are endemic. While in their homes or in refugee camps, where infection spreads rapidly, refugee women may have contracted diseases such as malaria, intestinal parasites, filariasis, schistosomiasis, and other disorders (please see the section on health for risks specific to various areas of the world).
Along with these, are diseases more commonly seen in the United States, such as hepatitis, tuberculosis, and sexually transmitted diseases (STDs). STDs occurring in refugee women include those common in Western countries (gonorrhea, syphilis, chlamydia, HIV) and those less common in the West (trachoma, lymphogranuloma venereum, granuloma inguinale). Women are especially at risk for STDs because of the sexual violence that may have occurred, choices made by some (e.g., sex for food), ritual practices such as the "cleansing" of African widows by having sex with a relative of the deceased husband, and because women contract STDs at a greater rate than men because of differences in female and male anatomy (LaFraniere, 2005).
When working in the health care setting with refugee women, one must pay careful attention to the womanís responses to accurately assess her level of comfort and/or understanding. In some cultures, smiling and nodding is the only appropriate response when speaking to someone in a respected position. Women may also fear that if they have a particular illness (HIV, syphilis), deportation may occur - which is not the case. Even they voicing questions or admitting to not understanding something may be perceived as possibly offensive to health care providers.
It is important for health care providers to help refugee women understand local health practices and standards. Teaching on medications is also critical. Many people stop taking medicine once they begin to feel better, and this is especially so among refugees. Some refugee women save the left over medicine for a time when she or someone in her family needs it again. Because of this, specific instructions must be given and follow-up provided for optimal results.
Psychological Issues (Please see the mental health section of this web site)
Post Traumatic Stress Disorder
Mental health problems are present in every group of people and among refugees, especially women, are significantly over-represented. This is due to the traumatic events experienced by refugees, and women in particular. Some women may have had pre-existing conditions which were triggered or worsened by the stress of what happened to them. Other women experience new onset conditions as a result of the stress of the homeland situation, trauma, flight, or relocation. Depression and anxiety disorders are seen in approximately 58% and 24% of refugee women, respectively (Kang et al, 1998). The most common diagnosis among refugee women, however, is post-traumatic stress disorder (PTSD). In one study of Yugoslavian refugee women, 65% developed PTSD (Kang et al, 1998). In refugee women who have experienced physical or sexual torture, even more develop the disorder. In addition to traumatic occurrences, many women develop high levels of anxiety upon being separated from their families, which increases the chances of developing or exacerbating PTSD.
Relocation Stress
Some studies have shown that the period of the greatest psychological strain for refugee women is the first year after their arrival in the United States. The role changes a refugee woman undergoes and the lack of understanding she may have of the system contribute to this. However, there is no time in a refugee's life when there is no risk of stress.
Refugee women come from many different backgrounds and may find themselves in a setting completely unlike that which they are used to. For example, one woman may have lived all her life in a small rural village and upon coming to the United States, may find herself in a large, metropolitan area. This would be a major stressor even to a woman who spoke the language and was used to the customs of the United States. For the refugee woman it can be overwhelming. Major psychosocial issues in resettlement are:
Sociological Issues
Role Strain
Role strain occurs when oneís normal pattern of behavior developed in response to the demands and expectations of others changes abruptly, resulting in feelings of stress. This frequently occurs when women from one part of the world come to another part of the world - where foreign ways are seldom valued by the larger society. In addition to the changes in the womanís role, the stresses on the familyís roles and structure may lead to role strain in each of its members. Role strain is common among refugee women as they try to adjust to life in their host countries, while attempting to maintain the traditions and cultures of their homelands (as concurrently, their children embrace the new culture). Pressure is frequently put upon the woman to create a haven or to recreate the "old home," which when coupled with societyís expectations of the woman to become somewhat Americanized, may lead to significant stress and role strain.
Role Changes
The role of women in many countries worldwide is subservient. Upon arrival to the United States, they gain much freedom. It may be difficult and uncomfortable for the woman to reconcile this new freedom to her traditional views on the role of the woman. It usually is even more difficult for the men to reconcile these changes.
In addition, married women may find a job before their husbands, which adds the new stressors of work to their load. Also the refugee woman may have mixed feelings about her new role as the person financially supporting the family. The husband may feel guilt that he is not the one supporting the family and may resent his wifeís contribution to the family, creating conflict and additional stress for the woman.
Early Marriage
In some cultures, it is not uncommon for girls to get married at early ages. When these women come to the United States as refugees, they may be only 14-17 years old. The difference of age in married women here, may cause the woman to feel further isolated in the larger society and she may have a more difficult time making friends, since she may feel she does not "belong" with the girls her own age or with the older married women. Due to their young age, these women generally have fewer personal resources to deal with the strain of being a wife in this culture, as well as to stress created by relocation in general. These women need much support and a sense that they are accepted.
Children
Refugee children generally are the first in their families to adjust to the major changes of relocation and resettlement. They usually learn the language far more quickly and completely than their parents and become adept at the living in the new system. However, this may raise some issues within the family and creates new concerns for the refugee mothers.
Respect is considered important in most traditional families. However, usually the average level of respect shown to parents by their children is lower in the United States than in the womanís place of origin. The woman may not know how to maintain family structure as children act in a way that would have been considered inappropriate and disrespectful in the old land, but is "normal" in her new location. This also can create a great deal of stress as the woman feels she is losing control of her family and losing her influence and the influence of her culture and traditions in her children.
Discipline becomes an issue as parents try to deal with respect and simple disobedience problems. However, this, in itself, may become a problem. In many cultures knocks on the head, slaps, and hits with sticks are viewed as acceptable methods of punishment. In the United States, this can lead to accusations and convictions of child abuse. The refugee mothers and fathers need to be educated about the laws in their new home regarding child abuse and its definition.
Children may be hurt by environmental hazards in a new place as well. Mothers may not know the hazards present in their own home. Traffic, electrical outlets, gas outlets, and cleaning supplies are just a few sources of danger that may be new to the women. In addition, the weather in the new residence may be significantly warmer or cooler than in the nation of origin, requiring teaching about clothing, air conditioning, and gas heater safety.
Finally, education may be a major issue in refugee families. Many cultures do not give any importance to the education of girls, beyond household skills. This mentality may either cause refugee women to avoid education and to discourage the education of their daughters or it may encourage them to take advantage of the new opportunities open to them. In turn, this may lead to conflict between the refugee woman and her husband. Most refugee women try to ensure that their children obtain a higher level of education than they themselves achieved.
Family Separation
Many refugee women have lived in close proximity to their extended family for their entire life, and it is thus difficult to live in different country and without access to family support. The separation may be stressful to the woman and may make it difficult for her to build confidence in herself in a new setting.
Ownership Issues
Many refugees come from regions where women have no or unequal property or inheritance rights. This may become an issue immediately for widowed, divorced, or single women, or may arise at a later time in families. This is another issue that may lead to conflict between the refugee women and their husbands.
Spiritual Issues
Perceived Hopelessness
As a result of the traumatic and tragic experiences of their pasts, combined with the struggle refugee women face as they try to resettle in another country, many develop a sense of hopelessness, coupled with a sense of powerlessness. Women may feel that they have no control over their situation and that they are riding on the waves of a force they have no control over. Refugee women need to be empowered through teaching and encouragement. Offering even small choices to the women will help to build their sense of autonomy and will help them have a sense of control.
Religion (Also see section in this web site on religious and spiritual influences on health)
Religion is a key part of life for many refugee women. It is a source of strength and encouragement, as well as offering meaning to life. In many cultures, religious practice spills over into all aspects of life. It is important to learn about each womanís specific beliefs and to treat them with respect.
Conclusion
Refugee women should be treated with special sensitivity and respect. Health care providers must watch carefully and take note of things that make the woman more or less uncomfortable. If possible, initial care should be provided by another woman, as many cultures view this as most appropriate.
Refugee women have concerns and needs that vary from person to person and encompass every aspect of life. They carry the heavy weight of a violent, frightening, and often tragic past, as well as the pressure of facing an unknown future. Yet they press on, daily fighting against the odds to survive. As fellow residents in the nations, states, cities, neighborhoods in which these women live, we must do all we can to ease the transition of resettlement. Like the old pioneers helped one another build their lives with barn raisings and other support, we too should reach out and help these refugee women rebuild their lives. "I was a stranger . . ."
The key to assisting refugees is education and knowledge. The more we learn about refugee women, their concerns, their pasts, and their present situations, the better we can identify needs and serve in some way to help meet them. Before long, these women will have the ability to become contributing members of the community. According to UNHCR, women are great peace builders and may act to pass on information to others, thus, facilitating change in the behaviors of their family and friends, and later contributing positively to the community as well (UNHCR, 1998).
Authors: Jennifer Foster, Destiny Micklin, Brenda Newell, and Charles Kemp
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