Back in 1998, I was requested by two obstetricians who ran a well-woman clinic for Somali women at Middlesex Hospital in London, to conduct preliminary research on why Somali women in Britain may fail to access medical facilities available to them, and on their attitudes to the custom of female circumcision. The clinic was well attended often for the purpose of circumcision reversals especially in advance of childbirth, or because of medical complications arising as a result of their circumcisions. These obstetricians were obviously concerned that more women could be accessing the facilities they provided, and perhaps that some women, whose complications could be particularly severe and life-threatening, could be accessing treatment earlier on in the course of their medical conditions. The purpose of the report was to apply for funding for fuller research into these matters.
I interviewed a number of Somali women who visited the well-woman clinic, and also in Bethnal Green, and staff at Tawakal Somali Women’s Group – an organization in East London devoted to the well-being of Somalis in London, and the promotion of Somali culture. Where necessary, I had the services of an interpreter.
To my knowledge, nothing was done with the report which I produced, and therefore I am publishing it here in case it is of interest and informative value to researchers. I believe most of the findings of this report to still be relevant today.
Language and Information
The main factors cited for failing to take advantage of medical services relate to language and information. Somali women who are not literate in English, or who have not acquired a facility with the English language, cannot read leaflets or access information in English. For reasons of language, and their position as refugees, they may simply be unaware of what is available to them, since they do not know their way around an unfamiliar system, and are used to a very different system in Somalia: a system in which medical care is not readily available to everyone. In addition, it is customary for Somali women to remain at home, so many women may not go to public places where information is available.
Inadequate interpretational facilities
Inadequate interpretational facilities were also cited as a major factor in explaining why women may either be reluctant to consult medical personnel, or may receive inaccurate information, which may result in their failure to follow up a consultation or course of treatment.
One implication of poor interpretational facilities is lack of confidentiality. Somalis are encouraged to take relatives along to medical consultations as interpreters, but this frustrates any wish for confidentiality, the prior information of the patient, and the patient’s prerogative to choose what to disclose or not to disclose to relatives. The same is applicable in the case of community members who may act as interpreters, as Somali women may not wish to run the risk of information on their medical condition spilling out into the community.
Another implication of the lack of professional interpreters is that since relatives or friends may not be experienced in medical interpretation and translation, information may be incorrectly transmitted. Husbands, I was told, frequently hold on more tenaciously than their wives to the way things were in Somalia, and it is therefore not an uncommon occurrence for them to withhold information from their wives, or to convey incorrect information. An example given was of a pregnant woman who already had many children. Her doctor suggested that she may wish to consider measures to prevent future pregnancies. Her husband who accompanied her to the consultation simply told her that the doctor said that she needed to lose weight. When she consulted the same doctor with a different interpreter during her subsequent pregnancy because of related complications, she discovered what the doctor had actually suggested at her previous visit. This case was cited to me as a general, rather than isolated, example of the way in which husbands may be involved in the misinformation, or lack of utilisation of medical facilities, of their wives. It was explained to me that husbands frequently wish to continue the Somali way of having a child each year, despite the British context making it too difficult to have a large number of children.
Shame attached to certain medical conditions is a factor preventing some women from seeking medical attention. According to aspects of Somali thought (and this is not just confined to Somalis), the patient may be believed to be culpable of the illness she bears, such as in the case of AIDS or other sexually transmitted diseases, and this attitude may extend to other conditions, such as genital infections and vaginal thrush. In such cases, women would be reluctant to consult medical personnel.
Some women feel that they are considered shameful and looked down upon by doctors because of their status as refugees, which may make them reluctant to consult them. It is possible that, in Somali thought, dishonourable status may be attached to the condition of not being rooted in the land where one is living, as is the case in neighbouring Ethiopia.
Fear of vaccinations and mind-altering drugs
In some cases, a fear of certain types of medical treatment may be an inhibiting factor in seeking out medical help. Since vaccinations are known to have been a significant cause in the spread of various illnesses, from AIDS to Hepatitis, some Somalis may therefore be fearful of consulting doctors because of their fear of vaccinations.
I was informed that, in addition, in Somalia, drugs prescribed by doctors to treat depression were inappropriate, and caused permanent damage to sufferers’ mental health, destroying their personalities. Depression is a major problem among Somalis in Britain, especially because of loss suffered and terrible scenes witnessed in the Somali war. Some have seen family members murdered before their eyes. However, rather than seek medical treatment for depression, there are some Somali women and men who waste their lives chewing chat (a drug similar to marijuana) or drinking excessive quantities of alcohol in an attempt to numb themselves from the after-effects of trauma.
Lack of confidence in the British medical services
A Somali woman who had been in Britain since the 1960s expressed a lack of confidence in the medical services in Britain, of which she claimed to have witnessed the decline over the years. She felt there were too many mistakes and oversights, and too little pride in medical practice in Britain, and contrasted this to medical practice in Germany where she maintained that standards were higher because of eagerness to obtain the best possible results from their work. Her opinion was informed by her own experience, particularly in the case of her son who had suffered from epilepsy following an accident. She told me that with conventional medical treatment, his condition deteriorated, but improved once she discontinued his medical treatment and cared for him at home in her own way.
Preventative health care
It was suggested to me that consultation of medical practitioners for the purpose of preventative health care was not a concept which existed in Somalia, and it may therefore not occur to people to consult medical services until they actually become ill.
The concept of acting to prevent the onset of illness does exist in ideas of healthy diet, and so forth. But in Somalia, preventative health care was not linked to conventional medical facilities.
In Somalia, Islamic leaders would often be consulted in the mosques for healing by hearing the Qur’an read by religious Sheikhs and through other religious methods. Other forms of traditional healing using herbs and amulets are attributed to rural and uneducated Somalis, rather than town or city people, but no-one interviewed knew of any of these traditional practices continuing in Britain. I was told that many Somali refugees in Britain are in fact from rural areas. However, these practices would not conflict with any wish to access orthodox medical facilities. Of course everyone wants health, I was told, and will access all health facilities available to them, as long as they have confidence in them.
The attitude to female circumcision varies among women according to their age and generation.
Somali women of the generation whereby they have grown-up children may be attached to the custom. One woman of this generation expressed disinterest, although concern with related medical complications. Another woman with grown-up children was very strongly opposed to the custom, encouraging other women to undergo reversals. However, it is an ancient custom, I was told, and cannot change overnight.
Women of the younger generation – in their 20s, 30s, and younger, would not be willing to have their daughters circumcised. This, I was told, is a general reflection of attitudes of young Somali women in the United Kingdom, and an attitude which is increasing among young women within Somalia. One young woman expressed the opinion that female circumcision is “unnecessary”, and two others described the conditions under which they underwent the procedure, and the experience, as “terrible”.
Two women stressed that female circumcision is not in accordance with Islam, and is therefore not a necessary aspect of their culture, or one which has to endure. Some women were also concerned to point out, perhaps in objection to being characterised in relation to this practice, that female circumcision is not something that is specific to Somalis, but that it also exists among many other nationalities, and was even practised in Europe not so long ago. However, it appears that female circumcision still occurs among Somalis in Europe, and parents may take their daughters to Saudi Arabia where it is performed under anaesthetic.
Concern, however, was expressed with the way in which their circumcision customs have been publicised and emphasised in the British media, providing the British public with a very unbalanced and negative portrayal of their culture. They wished for positive aspects of their culture to be conveyed to balance the picture, and for a more sensitive treatment of the subject of circumcision, perhaps confined to women inside their community.
The implications of this report extend to various other language groups in the UK.
Today a translation service provided by the NHS known as “Language Line” means that during medical consultations, translation can be supplied over the telephone. This must solve the problems regarding patients’ confidentiality, and the accurate and complete transmission of vital information to the patient, which interviewees outlined in 1998.
Arising from the interviews was an obvious need for programmes – or perhaps DVDs or websites – in the languages of various ethnic minorities which would enable women to understand the need for medical intervention and treatment in the case of medical conditions to which they may attach a sense of shame, as described. Such programmes, DVDs or websites should also provide explanations of the need for medical intervention in the area of preventative healthcare, and also proper explanation of vaccinations, and drugs prescribed for depression, to enable a patient to understand the ways in which such treatments might be beneficial.
What also arises from this report is a need for outreach services providing information to members of Somali and other communities who tend not to go to public places where such information would be available, and a need for appropriate support for refugees from war-torn countries who may be severely traumatized by what they may have witnessed and experienced. Somali community organizations, cultural centres and women’s associations throughout London fulfil some of these needs.