Responses by health care providers in Ireland to the experiences of women refugees who have survived gender- and ethnic-based torture

Women’s Studies International Forum 27 (2004) 351 – 367 www.elsevier.com/locate/wsif

Responses by health care providers in Ireland to the experiences of women refugees who have survived gender- and ethnic-based torture Inbal Sansani

Synopsis Women refugees who have survived gender-based torture comprise one of Ireland’s most vulnerable segments of the refugee population. There is widespread agreement regarding the particularities of women refugees’ experiences, including interrelated issues like lack of language training and childcare options. The increasing number of women in Ireland’s refugee community accentuates the disparity between their particular needs and the various services available to them. I propose a holistic and humanitarian approach to the rehabilitation of torture survivors. I will contend that rape as a form of torture is invariably a gendered and ethnicised phenomenon. Because the social constructions of gender and ethnicity manifest themselves in the physical body, women’s bodies are targets of violence. Women who have survived gender-based torture share unique survival and healing needs. I will argue that it is necessary to develop specific policies and programs, as well as an integrated service delivery model, to address the situation of this marginalized group to ensure women’s opportunity to create a healthy life for themselves and their families. I will posit community-based approaches to torture rehabilitation that have been successful in Canada and Nigeria to advocate for the implementation of appropriate services to these women survivors in Ireland. D 2004 Published by Elsevier Ltd.

Introduction Examining the provision of health services in Ireland to women asylum seekers and refugees who have suffered gender-based victimisation is a complex endeavour (Begley et al., 1999). It has been argued that women refugees are at the same time vulnerable and indomitable (Hans, 1997: p. 3). Described as dthe most affected refugee groupT when uprooted by conflict, dwomen, whether raped, secluded, unable to E-mail address: [email protected] (I. Sansani). 0277-5395/$ - see front matter D 2004 Published by Elsevier Ltd. doi:10.1016/j.wsif.2004.10.005

feed their children, or abducted, are victims of war and suffer physically, psychologically, and spirituallyT (Hans, 1997: p. 3). Although women may carry into exile the trauma of gender- and ethnic-based violation and/or of helplessness to protect their families, women are also perceived as dthe backbone of the refugee communityT (Hans, 1997: p. 3). International research reveals that 30–60% of all refugees settled in Europe have experienced torture and other forms of serious violence. A Dublin general practitioner (GP) found that 44% of his patients have survived torture (Begley et al., 1999: p. 95). Because

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of survivors’ initial reluctance to share their experiences of torture with strangers, these figures likely reflect a minimal estimate. The apprehension of divulging one’s trauma is particularly salient with regard to women who have survived rape and other forms of gender-based violence (ICCL, 2000: p. 23). This article explores the responses by service providers to the experiences of women refugees who have survived gender- and ethnic-based torture in the context of the health care and other welfare services in the Republic of Ireland. The article seeks to assess the discrepancies in the services needed and those provided based on a largely theoretical analysis supplemented by primary data. I begin with a discussion of the methodology which framed this research, and then problematise existing definitions of torture and dsexualT torture as a foundation for a discussion of the occurrence of gender- and ethnicbased torture. I construct two arguments to demonstrate that torture is invariably a gendered and ethnicised phenomenon. First, I argue that the infliction of torture relies fundamentally on the corporeality of the body. Second, I contend that this body is perpetually a gendered and ethnicised body because the social constructions of gender and ethnicity are inextricably linked to one another and jointly manifested in the physical body. Rape is gendered and ethnicised because it derives meaning from particular social contexts. It is also dmultifunctionalT because its consequences are dictated by the social and cultural aspects of a victim’s reality. I conclude that because women’s bodies become targets of violence on the basis of gender and ethnicity, an understanding of the interrelationship between these two elements of identity is integral to a comprehension of the complexity of women’s status in episodes of both war and relative peace. This dstatusT—the particular issues that arise in the post-migratory phase—includes the health care and other services available to women survivors of torture in the countries to which they have migrated (e.g., Stokes, 2003). Until 2001, there had been no national centre for torture survivors in Ireland.1 The Eastern Health Board2 (EHB) refugee service has not specifically targeted survivors of torture. Although aimed to target general situations of dtraumaT, it may not be equipped or qualified to deal with the specific

experiences of refugees who have suffered such victimisation. In addition, the prevailing Western biomedical model, as opposed to a holistic or social one, may not be an appropriate approach to assisting trauma survivors of any ethnic group, let alone refugees from various countries who have survived torture and other forms of violence (Huff & Kline, 1999). Knowledge of the past and present political climates in the dhomeT countries of Ireland’s refugee population led me to conclude that there are torture survivors within it whose health care and other needs may not be adequately addressed by the country’s existing services.

Some methodological considerations dHealthT is a culturally relative concept that conceals a wide range of assumptions. Liss (1998: pp. 15–16) offers two approaches to understanding the concept of health. The first is an analytical perspective, in which health is defined in terms of disease: da person is in good health if he or she has no diseaseT. The second, holistic perspective of health begins from the opposite position; dthe function and activity of the entire person is conclusive for the judgement of a person’s healthT (emphasis added). Health is therefore a dimensional concept, meaning that dthere are different degrees of health: a person may be either more or less healthyT (Liss, 1998: pp. 15–16). In assessing the extent and nature of service provision in any field, the most apparent choice of perspectives is that between the providers and users of the services. I focused on service providers based on the belief that emphasising providers’ roles is more constructive than interviewing service recipients in this instance. This decision was based in part on the lack of service provision assessment in this area in the Irish context. I focused my research on service providers who address different refugee needs in order to attain a comprehensive view of the services available to this population.3 I endeavoured to gauge the extent of health care and other services available to survivors of torture in Ireland and, without approaching the clients directly, assess the needs of this population in order to evaluate the discrepancy between that which exists and doptimalT services.

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dService providersT, for the purpose of my study, included representatives from various governmentfunded and independent programmes and organisations that provide for the needs of refugees in various ways (e.g., education, housing and integration). Saltman, Figueras, and Sakellarides (1998: p. 351) argue that dactors can transform themselves and participate in the transformation of the field in which they interact if new information modifies their perceptions of thingsT. General practitioners and other service providers are such actors, dsimultaneously defined by the relations that they maintain with. . . other actors and by the symbolic and material resources that they controlT. Because any service delivery system dis a product of the actions [and] meanings of the people within itT (Annandale, 1994: p. 337), seeking out the actors responsible for various types of service provision is a direct route to the assessment of these actors’ performance within their particular field. My inclination to interview service providers was compounded by a choice not to access directly the duserT group. First, voyeuristic potential may exist in enterprises that endeavour to elicit information from a dminorityT population. Second, I thought it intrusive to approach a refugee with the expectation that she will share her dstoryT with me. In the context of my research objectives, pursuing personal accounts of torture in order to gauge the extent of health care needs in the refugee population was inappropriate and unwarranted. Certain cultural traditions prescribe that women who have been victims of rape and other forms of gender- and ethnic-based violence have been ddishonouredT. Women’s experiences of gender- and ethnic-based torture are therefore an inevitable source of shame. Most survivors are generally reluctant to discuss such experiences, and would probably not choose to do so with a perfect stranger. Furthermore, if dretellingT a trauma is also drelivingT that trauma, asking a woman refugee to share her experiences—the consequences of which I may not be qualified to deal with—is irresponsible and unprofessional. Knudsen (1995: pp. 29–30) raises an important ethical question concerning the research design appropriate for studying persons in vulnerable situations. He cautions that, as researchers, we should understand our roles as dgatekeepers to landscapes of emotionsT. In particular, he warns that dour roles may become complicated if a person is attempting to deal with unprocessed traumaT.

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I concluded that my dprofessional and personal abilitiesT were inadequate to deal with such information, and that I was not dprepared and willing to accept the ethical responsibility to function therapeutically— if necessaryT.

Feminist research foundations In order to combat dany exclusive definitions of who is feminist or what is feminist about a research projectT, Byrne and Lentin (2000: p. 4) define feminist research by articulating what it includes: Feminist research methodologies stress gender as a basic theoretical concept, a deconstruction of the power relationship between researcher and researched, a political commitment to the emancipation of women, and models of research and practice which privilege participation, representation, interpretation and reflectivity. In this framework, feminist knowledge is accountable and dacknowledges and reveals the labour processes of its own productionT (Stanley & Wise, 1993: pp. 188–201). The primary sources of this article are qualitative, with interviews comprising the greatest source of information.4 I employed a semi- or unstructured interviewing technique (Reinharz, 1992: p. 18). The character of this project, and the spectrum of interviewees I accessed, necessitated this approach. Reinharz posits that dinterview research typically includes. . . opportunities for clarification and discussionT and that dopen-ended interview research explores people’s views of reality and allows the researcher to generate theoryT (Reinharz, 1992: p. 18). This method therefore allowed me to respond purposefully to the intervieweesT disclosures. d[T]he actual pattern of questioning in intensive interviews is built up bnaturallyQ from the progression of responsesT (Berkowitz, 1996: p. 59). My initial search for interviewees was broad, including all the Dublin-based organizations that dealt with issues involving asylum seekers, refugees and immigration at large, the provision of health care services in Ireland (e.g., EHB), as well as ethnically

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and nationally oriented organizations (e.g., the Vietnamese–Irish Association). By contacting both organizations aimed at providing services to the refugee population and organizations based on the ethnic, cultural, national or religious affiliation of particular segments of the refugee community, I sought not only to assess the services available to refugees in Ireland from Irishbased organizations, but also the services offered by certain groups to their own communities and the extent to which such a gamut of groups gauge that the needs of a certain segment of the refugee population are met. I welcomed the opportunity to interview a spectrum of people in order to attain the most comprehensive perspective on the existing needs and the services available to Ireland’s refugee population. It is important to note that slightly more than half of the people I interviewed were Irish, and the rest were members of the refugee community. As the interviewee pool was comprised of approximately half women and half men, I note both gender and ethnic affiliation when I cite interviewees’ responses.

Refugee women in Ireland The increasing number of women in Ireland’s refugee community accentuates the disparity between their particular needs and the various services available to them. Notwithstanding the general spectrum of opinions among interviewees, there was widespread agreement regarding the particularities of women refugees’ experiences. Lack of language training and childcare were mentioned as paramount concerns, as were difficulties in accessing health care services, issues of social isolation and inappropriate accommodation. As the following examples demonstrate, these issues are often interrelated. An Irish woman representative of the West Tallaght Resource Centre explains that childcare is a central issue in refugee women’s lives (Interview, 16 June). In Women and the Refugee Experience: Towards a Statement of Best Practice, the Women’s Committee of the Irish Council for Civil Liberties (ICCL) concurs that dlack of childcare facilities present a major obstacle to women who wish to avail of education and training opportunities, as many refugee women do

not have recourse to assistance from an extended familyT (ICCL, 2000: p. 30). The majority of refugee women who contributed to the ICCL guidelines didentified the lack of culturally sensitive translation facilities as the paramount health issueT (ICCL, 2000: p. 27) (emphasis added). The guidelines indicate that drefugee women, including those who speak English, may have difficulties in understanding the way that services are structured and accessed in IrelandT (ICCL, 2000: p. 27). The ICCL suggests that health education for providers emphasising different practices may help combat this problem. In addition, it argues that because drefugee women are often the primary providers of healthcare to family members, it is essential that they have access to health care informationT (ICCL, 2000: p. 28). Several of the issues highlighted by the ICCL are considered among the standard health needs of refugee women.

Theorizing gender- and ethnic-based torture Torture is a complex phenomenon that yields multifaceted effects across the spectrum of trauma and its consequences. Gender- and ethnic-based torture, involving nuanced actions to specific targets, generates particular and identifiable effects in its victims. Understanding the intricacies of this specialized, compound version of torture is necessary to the provision of effective and focused care to the survivors. The limited definitions of torture that have been proffered in legal and medical frameworks, such as the United Nations and World Medical Association (WMA) that inform the vast majority of torture literature, do not appropriately account for, or represent, the features or quality of gender- and ethnic-based torture. The prevalence of these definitions, however, despite such insufficiencies, defies a popular understanding of this phenomenon and thwarts efforts to provide suitable services to the survivors. The spectrum of perpetrators and the wide range of physical and psychological abuse complicate the formulation of a comprehensive definition of torture. The WMA definition (1975) governs professional

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standards and ethics for physicians and political states: Deliberate, systematic or wanton infliction of physical or mental suffering by one or more persons acting alone or on the orders of any authority, to force another person to yield information, to make a confession, or for any other reason. The practical applicability of the WMA definition is undermined by its ambiguity. For example, the vague interpretation of context and intent is questionable. Essentially, torture is defined as any sort of infliction of any kind of pain by any party for any reason—a definition that fails to reflect the complexity of the act. Torture is not an accident; it is a purposeful violation of the autonomy of a human being. Furthermore, it is not employed for danyT reason, but for the specific purpose of destroying the intrinsic dignity of the victim. Although this definition may be valid for healthcare personnel in that it allows for a broad range of experiences, it does not, among other deficiencies, appropriately represent the specificities of torture and thereby delegitimises its complexity. The World Health Organisation’s European regional office (1986) (cited in van Willigen, 1992: p. 277) definition of organised violence follows: The interhuman infliction of significant, avoidable pain and suffering by an organised system of ideas and attitudes. It comprises any violent action that is unacceptable by general human standards, and relates to the victim’s feelings. Organised violence includes, inter alia, dtorture, cruel, inhuman or degrading treatment or punishmentT (van Willigen, 1992: p. 277). The WHO working group that formulated the above definition describes organised violence as an dimportant health hazardT (van Willigen, 1992: p. 277), and, like the WMA definition in its de facto breadth, may be favourable in its allowance for a wide range of interpretation in a clinical setting. The phrase dgeneral human standardsT, however, does not include culturally relative considerations because it suggests that some dgeneralT standard exists. Yet any interpretation of violence at large or the effects of torture relies on subjective definitions of these standards. The phrase drelates to the victim’s feelingsT counters to an extent the use of dgeneralT in

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that it relinquishes to the victim the power to define the act. It is important to focus on the specificities of the practice of torture, such as the premises for choosing targets and the choice of method employed, in order to comprehend its consequences and, in turn, the most fitting manner through which to care for its survivors. The dreal purposes [of torture] are to humiliate, weaken, and destroy the personalityT (Jaranson & Popkin, 1998: pp. 17–18). Methods of torture are generally classified as either physical or psychological, although the two categories are perceived to be largely interrelated. In fact, it is rare that one occurs without the other, and it can therefore be argued that any distinction between them is artificial. Suedfeld (1990: p. 9) includes dsexual torture, including rape and the hurting or mutilation of sexual organsT in a category of torture techniques that encompasses dphysical maltreatments [that] have a more salient component of mental anguishT. This classification suggests that dsexualT torture is particularly effective at the psychological level. Lira and Weinstein (1986) and Lunde and Ortmann (1992) define sexual torture in principally parallel categories including violence against the dsexual organsT, dphysical sexual assaultT (e.g., rape) and dmental sexual assaultT (e.g., threats and humiliation). Both definitions, while accounting for the relationship between physical and psychological methods of torture, fail to consider the effects of the victim’s cultural background on her understanding of dsexualT torture. Although Lunde and Ortmann (1992: p. 312) concede that dthe perception of what is or is not sexual torture depends on the cultural background, education and social status of the survivor and may varyT among women of different ethnic backgrounds, this awareness is not expressly reflected in their definition. For them, the central element of the trauma of dsexualT torture is that dthe victim is subjected to involuntary sexual acts which, precisely because they are involuntary, are very painfulT (emphasis in original). Describing torture as painful precisely or simply because it is dinvoluntaryT is an incomplete and inadequate explanation that operates in isolation of cultural considerations. Plainly, all acts of torture are involuntary. One’s culture dictates her experiences of dsexualT torture—the manifestation of its pain—as well as her experiences as a survivor thereof.

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The destruction of a victim’s gender identity is the explicit purpose of dsexualT torture. Allodi and Stiasny (1990: p. 144) define dsexualT torture as dan instance of sexual oppression since the victims are attacked specifically through their gender identityT. For example, Agger and Jensen (1993: p. 687) posit that while heterosexual rape has a dominant position in the dsexualT torture of women, homosexual rape is the dominating element in the dsexualT torture of men. If dsexualT torture is an attack through one’s gender identity, it is wholly misleading to characterise it as dsexualT. Filice, Vincent, Adams, and Bajramovic (1994) argue that the subjective meaning of rape depends upon the historical and cultural conditions that surround it. Torture is imbued with meaning and power only when it is culturally contextualised. The intimacy of an act that involves one’s sexuality delegitimises her personal identity both in her perception and in that of her community. The source of pain is then found in cultural codes of behaviour. The victim experiences identity destruction compounded by the shame of perceived compliance. Agger (1994: pp. 8–22) argues that in the recovery process, dthe problem of complicity and the feelings of shame are prominent features of the trauma of torture victims, especially if they have been sexually abusedT. The effectiveness of dsexualT torture is based on its ability to manipulate and destroy traditional gender roles across the gamut of femininities and masculinities. Therefore, it is misleading for Allodi and Stiasny (1990: p. 144) to argue that din terms of psychological and behavioral reactionsT, dthe sex of the torture victim is the main independent variable affecting the occurrence of the trauma, [and] its nature, severity, and outcomeT (emphasis added). Trauma stems from social constructions of meaning, such as gender and ethnicity, which is precisely the reason this particular method of torture is dgenderedT rather than dsexualT. Torture is manifested as a gendered and ethnicised phenomenon, in part, because of the social inscriptions of gender and ethnicity on women’s bodies and the role of rape in times of conflict. Agger (1989: p. 309) argues that sociocultural concepts are more evident in the dsexualT torture of women than in the dsexualT torture of men. The nuanced practice of torture yields distinct consequences for women and men.

Connell (1995: p. 71) argues that dgender is a social practice that constantly refers to bodies and what bodies doT; gender also references what is done to bodies. Scarry (1985: pp. 27–28) argues that the torture victim understands the power relations of the torture interaction through the physical pain manifested in her body. Turner (1996: p. 185) similarly argues that dwe labour on, in and with bodiesT; the body’s role is of dan instrument or intermediaryT for punishment. Regardless of the methodology of torture, the body is always at issue because it is inseparable from the power relations that invade it. According to Foucault (1977: p. 16), dpower relations have an immediate hold upon [the body]; they invest it, mark it, train it, torture it, force it to carry out tasks, to perform ceremonies, to emit signsT. In times of conflict, ethnicity references the bodies in question. Constructions of gender and ethnicity are employed simultaneously; dethnic affiliation determines who will be victimised, while gender determines the kind of violence that will be perpetratedT (Cacic-Kumpes, 1995: p. 12). Lentin (1999) argues that gender and ethnicity gain saliency in wartime; drape in a war context is the means by which differentials of power and identity are definedT (Rejali, 1998: p. 30). Because rape engenders and ethnicises, it is a dynamic discourse of identification and negotiation. Gender and ethnic identities are relative constructs imbued with power or the lack thereof. According to Kimmel and Messner (1989: p. 8), dPower dynamics are an essential element in both the definition and the enactments of genderT; and, according to Cohn (1993: p. 228), gender is da central organizing discourse of cultureT. A parallel argument may be made for the role of ethnicity; power is also an integral aspect of the signification and perpetuation of ethnic constructions: Barth (1996: p. 79) contends that dethnic groups only persist as significant units if they imply marked difference in behaviourT. The association between gender and ethnic discourses is highlighted in conflict situations. As the nation’s biological and cultural reproducers, women are vulnerable to forced impregnation, for example, and because they are dconstructed as the symbolic bearers of the collectivity’s identity,T they dembody the line which signifies [its] boundariesT (YuvalDavis, 1997: pp. 45–46).

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If no clear relationship exists between groups in times of relative peace, escalation into ethnic conflict immediately thrusts women’s roles into the foreground as the markers of ethnic boundaries and reproducers of ethnic difference. Rejali (1998: p. 30) contends that dwhen an unmarked system collapses, as in Bosnia–Herzegovina, women’s bodies become a battlefield where men communicate their rage to other men—because women’s bodies had been the implicit political battlefield all alongT. A highly effective transgression across the enemy group’s boundaries is achieved through the rape of its women. Rape in conflict reaffirms the conception of women’s bodies as the figurative and literal boundaries of an ethnic group. Therefore, rape is the ultimate manifestation of the enemy’s trespass. The rape of the women in a community can therefore be regarded as the symbolic rape of the body of the community (Seifert, 1994: p. 64), or, as Lentin (1999: p. 3.12) argues, dwartime rape. . . must be ultimately seen also as the rape of the nationT (emphasis in original). An insufficient understanding of torture as a gendered and ethnicised phenomenon is part of the reason that service providers’ responses to torture survivors’ needs have been inadequate. The medical profession’s reference to gender-based crimes as dsexualT torture is significant in terms of the power of the medical establishment over women’s bodies. The purportedly objective clinical reference of dsexualT masks the complexity of this phenomenon and perpetuates the medicalisation of trauma (e.g., Davis, 1988). Because dsexT is a biological term, whereas dgenderT refers to the socially constructed meanings attached to being female or male, dsexualT torture appears to present a tangible, controllable and dscientificT field of inquiry when compared to dynamic and subjective social constructions. As demonstrated above, however, this label renders a complete understanding of gender-based torture impossible. The following illustrations of the responses by some male service providers demonstrates not only the gender and ethnicity nexus in relation to genderand ethnic-based torture, but also highlights the scant understanding of the complexities of gender- and ethnic-based torture both theoretically and experientially in the Irish context. For example, a male

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Western European doctor living in Ireland who has treated torture survivors in Dublin claims that in surviving rape, dthe woman is stronger than the man. . . in accepting what happened to her. . . women say they switch off their mindsT (Interview, 11 May). In response to my question about the importance of women’s honour in certain societies and the effect this may have on the manifestation and nature of their trauma, he conceded that although this issue is important, rape is ultimately more humiliating for men because of its demasculinising effect. This conclusion is enigmatic for several reasons. First, this comment highlights a popular conception of rape as dacceptableT behaviour; indeed, the prevalence of rape has led to its normalisation. Its preponderance, however, does not diminish its effects for the individual woman who has been violated.5 Second, this comparison creates a hierarchy rather than typology among various types of gendered crimes against particular subgroups of a population. Third, this comment is naRve in concluding that a victim’s defense mechanisms during the infliction of torture necessarily decrease its consequences. An Irish male lawyer who works with asylum seekers and refugees in Ireland claims that rape is dno worse for women or menT because the basic issue is ddefilementT. He advised me not to dassume that what is needed for men is different than what is needed for women [because] the effects of sexual torture are the same for men and women, except when a child is producedT (Interview, 16 May). However, the distinctions in the rape of women involve more than djustT impregnation. According to a male doctor from Africa who practices medicine in Dublin, dwomen have been forced to leave [their home countries] simply because of the sexual violence they have sufferedT (Interview, 17 May). He explains that dif a woman has been traumatised or depreciated, she has no valueT. Therefore, dmost of the women will not complain, they will keep it a secret. They will be the losers if they speak; they will lose their value in the communityT. Fear of being stigmatised or ostracised perpetuates the silence that often masks gender-based crimes. An Irish woman representative at the Vincentian Refugee Centre shares the story of a newly arrived woman from Africa who was raped in prison every night for two weeks. The woman does not label the

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crime as drapeT; she refers to her repeated violation as dsexT. The representative explains that the woman arrived at the Centre in order to inquire about housing. The fact that she had not yet completed an application for asylum raised the issue of her trauma. The woman had not accessed the available psychological services (i.e., EHB) and refused the representative’s suggestion to so do. According to the representative, the woman explains, dI lived through it, I’m a survivor, that’s itT (Interview, 11 May). The lack of willingness among some survivors of gender-based violence to broach their experiences, particularly with strangers, highlights the complexities in dealing with these issues. Indeed, this representative claims that although the woman’s trauma may have exacerbated her need for refuge, she would not have mentioned the violence in her asylum application. According to the male doctor from Africa, dit is not easy [for women] to have their trauma acknowledged. . . Another problem with sexual abuse is that it’s not easy to talk about these sorts of thingsT (Interview, 16 May). Women’s silence is hence perpetuated at home and abroad.

Service provision and rehabilitation in Ireland Recognising gender- and ethnic-based torture as an intensely destructive phenomenon compels a critical examination of rehabilitation and survival. There are many issues involved in the rehabilitation of torture survivors and, ultimately, their ability to reconstruct their lives. This section examines different approaches to the rehabilitation of women torture survivors in general, particularly of those who have suffered gender-based victimisation, and advocates ethnically and culturally sensitive and appropriate care within a holistic approach to service provision. I suggest that the implementation of specialised services for torture survivors may better serve IrelandTs refugee community than the existing, generalized services available to the majority population in Ireland, as provided by the EHB. A study of the relationship between racism and the statutory sector as it relates to the experiences of refugees and Travellers (an indigenous nomadic Irish ethnic group) in Tallaght (a suburb of Dublin) found a lack of specific support toward refugees across the statutory sector (McVeigh & Binchy, 1998: pp. 28–30,

42–43, 50–53). Based on interviews with a female representative of the EHB and a male service provider at the Parnell West Refugee Centre in Dublin, I concluded there exists an insistence that the refugee population in Ireland is not treated differently to anyone else; these interviewees maintained that the statutory sector does not discriminate against Travellers and refugees. McVeigh and Binchy (1998: p. 28) problematise this lack of dpositive or anti-discriminatory intervention,T claiming that treating refugees and Travellers like anybody else is often an excuse for not having a specific programme to address the particular disadvantage experienced by certain groups. More importantly, they argue that it is often necessary to treat marginalized groups differently—to develop specific policies and programs—in order to address their social exclusion and ensure that they have the same access to services as everybody else. The failure to fully recognise and respond to the specific needs of refugees ddistorts institutional policy across a wide number of agencies. . . and combines as a particular form of institutionalised racismT (McVeigh & Binchy, 1998: 51). The Irish woman psychologist at the EHB explains that torture survivors are individuals exhibiting dnormal responses to abnormal experiencesT (Interview, 10 May). This simplistic phrase was popular among professionals in the trauma rehabilitation field. Although I am cautious in employing the term dnormalT, I believe that this message is fundamentally valid. A campaign for, or the provision of, specialised services, however, does not suggest that refugeesT reactions to torture are dabnormalT. Indeed, it has been argued that the dpsychotherapy of torture survivors is surprisingly traditionalT (Elsass, 1997: pp. 6–7). Indeed, it is often simply described as dthe need to tell and live through the traumatic event, but without the provocation which otherwise may characterise crisis interventionT (Elsass, 1997: pp. 6–7). Furthermore, such psychotherapy must be attentive to the dwider context that continues to traumatise the survivorT (Elsass, 1997: pp. 6–7). Cunningham and Silove (1993: pp. 751–54) explain that there are two general categories of rehabilitation services for refugees in countries of resettlement. The first includes dservices addressing the broad range of welfare and medical needs faced by refugeesT. The second encompasses dservices which

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specifically focus on the psychological needs of people who have been torturedT. Because the relationship between the two categories is reciprocal, dthe capacity for specialised services to focus on the specific needs of torture survivors in countries of resettlement depends on the strength and coherence of the wider service(s)T. An integrated network of services that addresses primary needs such as housing and language training is increasingly effective because it allows the torture rehabilitation services to focus on the specific needs of survivors. Well-coordinated general services are likely to assist refugees in establishing a semblance to their lives that will in turn enable them, as survivors, to approach and benefit from trauma rehabilitation more effectively. In his research on health service provision for refugees in Ireland, Tomkin (1999: p. 2) claims the official approach of the EHB toward refugees has been one of dintegrationT and dnormalisationT. He argues that this approach implies that refugees are expected to adapt to the same services as the domestic population. As a result, traumatic migratory experiences are often unaccounted for in the drush to approach refugees like other Irish clientsT. Tomkin also argues, however, that isolating refugees as special cases requiring urgent psychological attention is also problematic, and hence service providers are hesitant to isolate and stigmatise refugees with dsocially loadedT terminology. Kathleen Allden, who has been engaged in teaching and clinical work with torture survivors on an international level and directs a programme for torture survivors in the United States, articulates a similar critique of the health care delivery system in Ireland (Personal Communication, 19 May). Allden argues that former advocacy of torture survivorsT needs in Ireland has been repeatedly countered by a dnationalised health programme that insisted that the conventional health care system could meet the needs of everyone, including this high risk groupT, despite the lack of direction as to how torture survivors’ needs would be met where dthere are obvious cultural and linguistic considerations beyond the [generalised] services that [refugees] needT. In Ireland, interviewees uniformly highlighted the lack of integration among services that target refugees’ needs. The Irish male Dublin Corporation lawyer who works with refugees contends simply

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that dservice delivery does not start with an attitude of cooperationT (Interview, 16 May). The reciprocal relationship emphasised by Cunningham and Silove is nonexistent in Ireland. This lack of integration has led to both considerable duplication and glaring gaps in the services available to refugees. A greater coherence among services would allow refugees to tackle immediate needs upon arrival and subsequently address more specific needs. For example, an Irish woman counsellor at the Dublin Rape Crisis Centre (DRCC) explains that prospective clients may not possess the drudimentary levels of safety and stability in their inner and outer worldsT that the Centre requires for initiating a service relationship (Interview, 12 June). She elaborates that a sense of security may not necessarily involve dthe house or the [legal] statusT and that in order to constructively confront gender-based trauma, a survivor must not be dcurrently in crisis around other thingsT. Although the counsellor acknowledges that refugees suffer multiple, serious, and interconnected traumas, and that, therefore, neat distinctions among the particular aspects of one’s trauma may be difficult to achieve and promote, she maintains that if a woman has established a relatively safe daily context, she may succeed in confronting her rehabilitation with regard to rape more directly, even if it remains bound up with other crises. The DRCC’s position is problematic because it appears to abdicate the Centre’s responsibility for care of the whole individual. It is contradictory to address a woman’s gender-based trauma in relation to the various crises in her life but to refuse to work with her until she has resolved these other crises.

Stigma, culture, and health Because of their experience[s], people have learned to hide their feelings. The best way to lose freedom in a dictatorship is to express your feelings. Male Refugee from Central Africa (Interview, 17 May). Discussion of the relationship among stigma, culture and health varied among the interviewees. Tomkin (1999: p. 37) argues that the dissue of social stigma is one of the main reasons why refugees are not accessing official support servicesT. The Irish

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woman representative from the West Tallaght Resource Centre claims that refugees are generally dismissive of counselling services because dit’s not an accepted part of their practiceT (Interview, 16 June). Among the interviewees, however, two refugees—one woman and one man—from different African countries said that it is acceptable to seek services in their respective home countries, when one’s actions are dabove a certain limit of behaviour, when it becomes noticeable in the neighbourhood, [and when] other people start complainingT (Interview, 17 May). Refugees may be reluctant to avail of psychological services for various reasons. It may be surmised that psychological services are not a part of dtheirT culture. This attitude is problematic, however, because it not only homogenises drefugeesT, but also dismisses their emotional and mental health needs. The Irish male lawyer with Dublin Corporation claims such reasoning is dan excuse not to deal with the issueT and to limit one’s responsibilities when confronted with inappropriate resources (Interview, 16 May). It may also be suggested that refugees are apprehensive about accessing services because they do not want to draw unnecessary attention to themselves and appear as a burden to Irish society. I propose, however, that the main reason refugees are not accessing the existing services is because these services are inappropriate and insufficient for their particular needs. The tension between stigma and culture may be resolved by creating a safe and accessible space for refugee survivors of torture. An Irish male psychologist in private practice in Dublin maintains that because da context of safety and trustT does not necessarily exist for refugees, djust talking is not enough. . . you need a special setting to bring people through [their trauma]T (Interview, 14 June). For example, the availability of a centre that has earned credibility in the refugee community could be an important source of support for the community at large. Only 2% of refugees have accessed the EHB psychological services, despite the prevalence of trauma among Ireland’s refugee population (Interview, 10 May). An Irish male representative from the Refugee Information Service describes service provision for asylum seekers in Ireland as rudimentary (Interview, 4 May). Indeed, at the time this research was conducted, the dgeneral government psychology

serviceT sponsored by the EHB was the only form of service delivery available to torture survivors in Ireland (Interview, 27 March). The EHB psychologist explains that this service provides for everyone in the community and that dthe service for refugees is part of the overall planT (Interview, 10 May). The EHB position is that dit fragments refugees to have a bspecial serviceQ. . . [because] they don’t want to be diagnosed but to be understoodT. This contention is problematic. First, an appropriate service would not ddiagnoseT survivors of torture based on a Western model of dpost-traumatic stress disorderT, for example, but, rather, seek to determine the elements that comprise their trauma in a specific culturally sensitive and holistic context. Second, dunderstandingT survivors of torture and their experiences necessitates a deeper, nuanced and holistic approach to rehabilitation beyond the doverall planT generally available to EHB clients. According to a spokesperson for Spiritan Asylum Services Initiative (SPIRASI), the fact that the EHB services are dnot geared explicitly toward trauma survivorsT is precisely the problem, because dit’s just a clinical psychology serviceT (Interview, 27 March). The EHB approach to psychological services is based on the dprevention modelT (Interview, 10 May). This model seeks to provide an immediate source of support for the client. According to the EHB psychologist, this model prescribes dholdingT exercises in order to ground and reassure refugees upon their arrival in Ireland. Although prevention exercises may be merited as a preliminary stage to long-term therapy, this model is not a substitute for extensive, continuous rehabilitation (e.g., Filice et al., 1994). Most of the interviewees agreed that specialised services for survivors of torture are necessary.6 Indeed, several interviewees mentioned as problematic the lack of support services available beyond the EHB structure. The male doctor from Western Europe who currently provides health care to torture survivors on an ad hoc basis claims that not only are there not enough services in Ireland, but that the existing services do not properly help refugees. Indeed, he claims that dyou don’t see a torture victim for five minutes and say bITm sorry but you have to goQ. . . You have to spend time with these peopleT (Interview, 11 May). On account of refugees’ vulnerability, it is imperative to allow time for relationships of trust to

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develop, and to ensure that continuity of service provision is available. In Good Practice Guide on the Integration of Refugees in the European Union, a survey of 21 health care facilities throughout Europe, the European Council on Refugees and Exiles (ECRE) examines the EHB Medical Unit/Refugee Application Centre in Dublin (ECRE, 1999: p. 12). According to the ECRE summary, two positive aspects of the service are dhealth check and preventionT and dtimely recognition and treatment of health problems arising from after effects of torture and forced migrationT. Both of these conclusions were expressly contested by most of the interviewees. A male refugee doctor from Africa who lives in Dublin and worked extensively with torture survivors claims that refugees have one chance to seek trauma-related services beyond the standardised medical tests provided by the EHB service. Beyond this single opportunity, which arises during a general, introductory visit to a GP or medical officer, access to the EHB services is effectively severed. The initial contact between newly arrived refugees and Irish providers is restricted in two important ways. First, refugees are unlikely to mention any aspect of their trauma to a foreign health care provider for lack of a common language and their suspicion of the services’ governmental orientation. For example, one negative aspect of the EHB Medical Unit is that it is din the same building as the Refugee Application Centre. . . [which] may engender fear and confusion in the usersT (ECRE, 1999: p. 12). This issue was raised by a majority of the interviewees. Distrust often prevents refugees from accessing health care and support from their new environment. The male refugee doctor from Africa claims that dunless [refugees] have confirmation from someone they trust, they will not engage with the service because they don’t know where the information will goT (Interview, 17 May). Similarly, a refugee representative from SPIRASI contends that many people feel the EHB facilities are dtoo open and that there is no securityT (Interview, 16 May). Because of refugeesT experiences of persecution and migration, it is imperative to create an independent, accessible space that would welcome torture survivors who seek rehabilitative assistance.

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The male refugee doctor from Africa suggests that the setting plays a role in the way a centre is perceived and in refugeesT attendance (Interview, 17 May). Indeed, dif you have a centre that supports people in general, and [you] put a psychologist there, it’s better than a psychologist in a mental hospitalT. The current location of the EHB psychological services is St. Brendan’s Hospital, a mental health institution. The context of a dsupport centreT that includes dan office for victims of traumaT is less threatening and stigmatising. The independent male doctor from Western Europe reiterates this claim by stating, dwhat ITd like to see is a building, away from government buildings, away from surgeries, away from equipmentT. Specifically in the Irish context, Hughes (1997: pp. 25–27) advocates an independent centre to treat torture survivors: dSurvivors of torture must have the security of independent, impartial, unbiased and trained health and welfare professionals and advocatesT. Indeed, a woman refugee from Africa criticises the Irish government’s concept of a done-stop shopT that includes both the EHB’s Medical Unit as well as the Department of Justice’s refugee application centre. She explains that refugees do not access the EHB service because dit’s in the same room as the justice departmentT, further suggesting that dyou need to have an independent sort of placeT because dthings that are important are not bone-stopQT (Interview, 15 June). The SPIRASI representative claims that dthe EHB is not the most ideal [place] to work with torture survivorsT because dpeople are afraid of interviewsT (Interview, 16 May). The interview structure returns refugees dto the idea of torture, to that position, when another person is deciding their fate. This is the government structure, like an interrogation. You want to guard yourselfT. Cunningham and Silove (1993: p. 758) similarly argue that dwhen services are funded primarily by the government, there is a legitimate concern that the service may be used to foster, directly or indirectly, the government’s policiesT. It is difficult to imagine government-sponsored services that would be completely divorced from its general policies toward refugees. Second, most service providers lack the training and skill to recognise the after effects of torture among refugees. In fact, ECRE lists dlack of staff expertise in the regular health system especially as for mental

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health needsT as one of two main critiques of the EHB service. The male doctor from Africa claims that dat the medical unit, if you don’t say anything about trauma or psychological life, then you have nothing to complain about and the contact endsT (Interview, 17 May). This structural weakness may also be attributed to the fact that, at the EHB, dthe main focus of the activities is the detection of hepatitis B and tuberculosisT (ECRE, 1999: 12). According to one of the interviewees, d[providers] are always thinking about tuberculosis as opposed to traumaT (Interview, 27 March). The interviewees who criticised the lack of awareness among refugees of the EHB services and the limited access to these services also offered suggestions for improvement in service delivery. The male doctor from Africa proposes to doffer more possibility for people to meet those who can help them. . . [and give] more information in the first days [of arrival]T (Interview, 17 May). He suggests that increased information, including dwhy it will benefit [them], and how it will be doneT may serve to maintain the initial connection between the refugee and the medical services. Therefore, the initial contact may have a greater likelihood of becoming a continuous relationship, and refugees will acquire a greater awareness of the rehabilitation possibilities available to them, should they choose to pursue such care. The importance of exposing refugees to available services is that when a torture survivor feels ready, she will have the information necessary to seek help. The Irish health service delivery system is also undermined by a general disbelief of refugees’ stories by the government and public at large. The male African doctor who has worked with refugees in Dublin and abroad claims that dthe first problem is the acknowledgement of what they have gone through in their countriesT (Interview, 17 May). Furthermore, a male refugee from Central Africa explains that during asylum claim interviews, immigration officials dtell you that you were not tortured, that there is no torture in your countryT (Interview, 15 June). Not only does such disbelief dadversely impact on [refugeesT] ability to healT, according to the Irish male lawyer with Dublin Corporation, it also discourages torture survivors from seeking help (Interview, 16 May). Consistent with the lawyer’s advocacy of integrated services is the suggestion that the government and

service providers jointly dtackle the tension between the need for patient-centred treatment and . . . a system that reinforces the damage by refusing to believe people’s storiesT. In other words, dif [health services are] patient-based you have to have a reason to believe the person . . . [so] how do you explain that one place believes you and the other [i.e., the Department of Justice] doesn’t?T Refugees’ vulnerability upon arrival is exacerbated by a system that disregards their personal recollections in order to deny their claims for asylum. A refugee who has been through a reception of disbelief at the hands of the justice department is unlikely to share her story with a health care provider.

Rehabilitation within a holistic concept of health The opportunity and ability to heal, recover and rehabilitate is distinctly defined in the context of torture survival. The purpose of rehabilitation is to assist torture survivors to live productively with their trauma. Although torture cannot be reversed, the course of rehabilitation is opposite to that of torture. An Irish woman physiotherapist working in the torture rehabilitation field concedes that torture rehabilitation does not necessarily involve a dcureT, but that survivors may benefit by rationalising and thereby integrating their experience into their daily lives in order to be able to cope with it better, if not completely (Personal Communication, 21 June). Similarly, the DRCC counsellor contends that it is possible to heal from gender-based violence, although dhealingT may simply mean allowing the trauma to occupy a different role or place in the survivor’s life. She describes healing as a continuous journey by explaining that those who heal dcan see what they have gained by having worked on these issues . . . and [so doing] brings them to a place of closer personal connectionT (Interview, 12 June). Cunningham and Silove (1993: p. 756) suggest a flexible approach that allows the therapist to focus on both dthe intrapsychic residue of the torture experience, as well as [on] strategies that will aid survivors to develop a sense of agency in dealing with their new and often alien environmentT. Van Willigen (1992: pp. 294–295) argues that because organised violence threatens all aspects of

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health, dit is of great importance to adopt a multidisciplinary approach to [its] consequencesT. A multidisciplinary method to rehabilitation includes approaching the survivor client as a whole human being as opposed to a compilation of different pieces, which, if dbrokenT, can only be fixed by a group of specialists. Because the effects of torture are ultimately psychological, and because, for women, what is at stake is also the fact that they carry the collective burden of honour and shame (Yuval-Davis, 1997), it is inaccurate and ineffective to differentiate among the spectrum of crises the survivor may experience as a result of torture. In order for the survivor to heal completely, it is necessary to confront her rehabilitation holistically. The male doctor from Africa regards the lack of a holistic approach—dtaking in all aspects of lifeT—in the Irish medical system as one of the main obstacles to refugees’ health care provision. His personal and professional experience with refugees leads him to conclude that refugees assume their problems will not be understood among dwhite people, white medicineT. He suggests that an integrated approach—danalysing a problem from different perspectivesT—may not be possible in IrelandTs dsystem of specialistsT. On account that da physical or mental problem can have [its] source in the social or spiritual . . . a person can have a few problems at one time and . . . see four or five specialists, but itTs still the same problemT (Interview, 17 May). For example, Churchill Ohaeto Ibeneche, the executive director of the Consulting Centre for Constitutional Rights and Justice, a rehabilitation centre in Nigeria, believes that survivors’ willingness to access services is not influenced by whether or not their culture discourages such help, but rather is attributed to their level of comfort and acquaintance with the mode of treatment available. He explains that, in Nigeria, dcurbing the problems associated with the need for special service[s] . . . has to do with integrating the treatment models of the [West with] the traditional African models of treatment and healingT (Personal Communication, 3 June). In terms of gender-sensitive care for women, Pearson, Pagaduan-Lopez, and Cunningham (1998: p. 15) present a holistic approach that reflects both variegated health care needs as well as specific sociocultural issues. In an interethnic Women Care-

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givers and Survivors of Torture Workshop the authors conducted in the Philippines, the participants deemed dfamily support—acceptance, emotional care, trust and understandingT as important elements for survivorsT rehabilitation. The counsellor at the DRCC claims that some refugee women clients have not shared their stories with anyone prior to seeking therapy. She suggests that the ddifferent gradations of the shame attached with sexual violenceT prevent most women from sharing their trauma with others. In addition to family support, the option to choose a provider—therapist, gynaecologist, obstetrician, etc.—of the same gender as the client is a fundamental issue in the rehabilitation process (Interview, 12 June). The lack of women interviewers and interpreters to conduct asylum interviews in Ireland is extremely problematic. According to the ICCL Women’s Committee (2000: p. 19), female interviewers and interpreters should be provided for refugee women during the process of claiming asylum. However, the ICCL (2000: p. 19) notes that dmerely being female does not ensure an awareness of gender issues and appropriate training is essentialT. It is imperative to offer women the opportunity to share their story in a manner that will not compound their shame and thereby perpetuate their silence. Pearson et al. (1998: p. 15) suggest that domestic violence services are also an important element of a holistic approach to women torture survivors’ rehabilitation. The refugee family is incredibly vulnerable upon its arrival and resettlement in a foreign country. Inevitable circumstances of high stress and uncertainty may lead to friction among family members and heavily impact the spousal relationship. The EHB psychologist shares a story of counselling a distressed couple after they learned that the wife, who had been raped in their home country, was pregnant. The couple does not know whether the husband or the rapist is the father of the unborn baby. Although there is no mention of spousal abuse in this scenario, it serves as an example of the issues confronted by the refugee community that serve to compound the stress of daily life. Language training and childcare facilities are integral aspects of a holistic support system for women (Pearson et al., 1998: p. 16). These are important issues for all refugee women, and are necessary for the

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success of any women’s rehabilitation programme. Moussa (1994: p. 3) argues that dchildcare is an essential component of any service to immigrant/ refugee mothers [because they] will not, and cannot, attend group sessions if such care is not providedT. This conclusion has been reiterated in the Zena Project survey Barriers and Needs of Bosnian Refugee Women with Regard to Education, Employment and Social Inclusion (1999: p. 20). According to the survey, women refugees most at risk of being socially isolated are women who are married, have young dependants and a low level of previous education, and who are unemployed. The most direct method of creating services that are appropriate for refugees is to work cooperatively with the different refugee groups in Ireland. Many of the interviewees expressed concern that there is a discrepancy between what a refugee may be feeling and what the provider may think she feels or knows. Appropriate services are based on dthe question of where theyTre at as opposed to where we think they should be . . . There are perceived needs and real needsT (Interview, 11 May). Cunningham claims that torture and trauma service delivery is not only about providing clinical work, but that it also involves dencouraging the development of social support groups. . . [and] a strong consultation process with affected ethnic communities [regarding] their input into the model of service delivery that works for themT (Personal Communication, 25 April). The participation of refugees in the construction of any service delivery model will also prevent culturally sensitive training from becoming da convenient category of religious, linguistic and nonverbal cuesT (Tomkin, 1999: p. 53). Guidelines provided by the Women’s Committee of the Irish Council for Civil Liberties (ICCL, 2000: p. 28) maintain that drefugee women and others in the refugee community should be consulted at all stages of the planning, design and delivery of health servicesT. The Committee also encourages Irish service providers to dengage actively in an ongoing consultative process with women from refugee communities to ensure that the . . . services [respond] adequately to the evolving needs of refugee women and their familiesT. The importance of acknowledging refugees’ experiences of torture extends to the acceptance that

women and men in the refugee community have either suffered different experiences or respond in distinct ways to similar episodes of violence. Acknowledging the diversity of experiences in the community will not qualify them, but rather will expand the perception of service needs. Developing a support centre on the basis of a singular (male) standard will exacerbate the exclusion of refugee women, and may fail to account for childcare and domestic violence services, for example. Constructive rehabilitation services may honour the differences among Ireland’s refugees by allowing the spectrum of voices to be reflected in their creation. Close cooperation between Irish providers and refugees may assist in bridging the social and cultural gap between Irish nationals and the different refugee communities in Ireland, as well as among the different refugee groups. The effectiveness of rehabilitation programmes is directly related to integration. According to the African male refugee SPIRASI representative, dif services are not provided that will help heal the lot that has suffered torture, integration will take a lot longerT (Interview, 16 May). Indeed, the male refugee doctor from Africa claims that dpsychological problems are problems for integrationT because trauma effects one’s relationship with other members of the community (Interview, 17 May).

Conclusion This article explores the extent of service provision available to women refugees who have survived gender- and ethnic-based torture in the context of the health care and other services available to them in the welfare Republic of Ireland. I argued that in times of uprooting and conflict, women’s bodies become targets of violence on the basis of gender and ethnicity, and that, therefore, an understanding of the interrelationship between these two elements of identity is integral to a comprehension of the complexity of women’s status in episodes of both war and relative peace. This dstatusT—the particular issues that arise in the post-migratory phase—includes the health care and other services available to women survivors of torture in the countries to which they have migrated.

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Refugees in general, and women refugees who have survived gender- and ethnic-based torture in particular, have specific health care needs that must be addressed by the Irish state. Although the provision of appropriate health services to survivors of torture is a complex and challenging endeavour, its importance to the survivors as well as to their families and the communities of which they have become a part cannot be undermined (e.g., Berdichevsky, 2004). In 2001, the first specialized centre for torture survivors was established in Ireland. The Centre for the Care of Survivors of Torture (CCST) provides culturally appropriate, multidisciplinary health care services to torture survivors. In cooperation with the statutory health services, the CCST acts as a bridge to mainstream services, and provides its clients with both clinical and social inclusion activities (e.g., legal services, vocational and language training, etc.). The establishment of the CCST represents an important and necessary step in the development of appropriate services for torture survivors in Ireland.

Endnotes 1 In 2001, the Centre for the Care of Survivors of Torture, the first specialized centre for torture survivors in Ireland, was established in Dublin. 2 At the time I conducted the primary research upon which this article is based, the Eastern Health Board (EHB) was responsible for the delivery of statutory services, including health and personal social services, for the Dublin population. The EHB was dissolved in March 2000, and replaced by three Area Health Boards in the region, including the Northern, East Coast and South Western Area Health Boards. 3 Although I refer to service provision din IrelandT, the service providers whom I personally interviewed are all based in Dublin, where the most extensive services presently available to refugees in Ireland are found. 4 All interviews and communications were conducted in 2000 and are on file with the author; all identities have been kept anonymous to facilitate reporting. 5 The ICCL’s Women’s Committee emphasises that dthe fact that violence against women is universal and widespread is irrelevant when determining whether gender-specific forms of serious harm constitute persecutionT (ICCL, 2000: p. 6) 6 Among the interviewees, spokespeople from a few government-sponsored services insisted that the EHB psychological services are sufficient because dthere is no waiting listT. Although the availability of services is important, it does not necessarily

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reflect the quality of service provision. Regardless, the SPIRASI spokesperson commented that dthe need is much greaterT than dthe three psychiatristsT the EHB can provide (Interview, 27 March).

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European Council for Refugees and Exiles Task Force on Integration, 1999. dGood Practice Guide on the Integration of Refugees in the European Union: HealthT. Elsass, Peter (1997). Treating victims of torture and violence: Theoretical, cross-cultural, and clinical implications. New York7 New York University Press. Filice, Ivana, Vincent, Christine, Adams, A., & Bajramovic, F (1994). Women refugees from Bosnia–Herzegovina: Developing a culturally sensitive counselling framework. International Journal of Refugee Law, 6(2), 207 – 225. Foucault, Michel (1977). Discipline and punish: The birth of the prison. London7 Penguin Books. Hans, Asha (1997). Sri Lankan Tamil refugee women in India. Refuge, 16(2), 3 – 9. Huff, Robert M., & Kline, Michael V (1999). Promoting health in multicultural populations. Berkeley, CA7 Sage Press. Hughes, Dechan (1997, Winter). Torture survivors in Ireland—An issue to be resolved. Focus, 25 – 27. Irish Council for Civil Liberties Women’s Committee (2000). Women and the refugee experience: Towards a statement of best practice. Dublin7 ICCL Women’s Committee. Jaranson, James M., & Popkin, Michael K. (Eds.) (1998). Caring for victims of torture. Washington, DC7 American Psychiatric Press. Kimmel, Michael, & Messner, Michael (Eds.) (1989). Men’s lives. New York7 Macmillan. Knudsen, John Chr (1995). When trust is on trial: Negotiating refugee narratives. In E. Valentine Daniel, & John Chr. Knudsen (Eds.) Mistrusting refugees (pp. 13 – 35). Berkeley, CA7 University of California Press. Lentin, Ronit (1999). The rape of the nation: Women narrativising genocide. Sociological Research Online, 4(2). Lira, Elizabeth, & Weinstein, Eugenia (1986). ‘La tortura sexual [Sexual torture]’. Paper presented at the Seminario Internacional: Consecuencias de la represion en el Cono Sur. Sus efectos medicos, psicologicos y sociales, Montevideo, Uruguay. Liss, P. E (1998). Assessing health care need: The conceptual foundation. In Steve Baldwin (Ed.) Needs assessment and community care: Clinical practice and policymaking (pp. 9 – 24). Oxford7 Butterworth-Heinemann. Lunde, Inge, & Ortmann, Jbrgen (1992). Sexual torture and the treatment of its consequences. In Metin Basoglu (Ed.) Torture and its consequences: Current treatment approaches (pp. 310 – 329). Cambridge7 Cambridge University Press. McVeigh, Robbie, & Binchy, Alice (1998). Travellers, refugees and racism in Tallaght. Dublin7 West Tallaght Resource Centre. Moussa, Helene (1994). Sowing new foundations: Refugee and Immigrant Women and Support Groups. Refuge, 13(9), 3 – 7. Pearson, Nancy L., Pagaduan-Lopez, June, & Cunningham, Margaret (1998). Recipes for healing: Gender-sensitive care for women survivors of torture. Manila7 University of the Philippines. Reinharz, Shulamit (1992). Feminist methods in social research. New York7 Oxford University Press. Rejali, Darius (1998). After feminist analyses of Bosnian violence. In Lois Ann Lorentzen, & Jennifer Turpin (Eds.) The women and war reader (pp. 26 – 32). New York7 New York University Press.

Saltman, Richard B., Figueras, Joseph, & Sakellarides, Constantino (Eds.) (1998). Critical challenges for health care reform (pp. 26 – 32). Buckingham7 Open University Press. Scarry, Elaine (1985). The body in pain: The making and unmaking of the world. New York7 Oxford University Press. Seifert, Ruth (1994). War and Rape: A Preliminary Analysis. In Alexandra Stiglmayer (Ed.) Mass rape: The war against women in Bosnia–Herzegovina (pp. 54 – 72). Lincoln7 University of Nebraska Press. Stanley, Liz, & Wise, Sue (1993). Breaking out again: Feminist ontology and epistemology. London7 Routledge. Stokes, Maeve (2003). Cultural transitions for women asylum seekers and refugees. Presented at a conference entitled dWomen’s Movement: Migrant Women Transforming IrelandT (Trinity College Dublin, March 2003). Suedfeld, Peter (1990). Torture: A brief overview. In Peter Suedfeld (Ed.) Psychology and torture. New York7 Hemisphere Publishing. Tomkin, Richard (1999). From normalisation to stigma: Approaches to providing health care to refugees in Ireland. New York7 MPhil in Ethnic and Racial Studies, Department of Sociology, Trinity College Dublin. Turner, Bryan S (1996). The body and society. London7 Sage. van Willigen, Loes (1992). Organisation of care and rehabilitation services for victims of torture and other forms of organized violence: A review of current issues. In Metin Basoglu (Ed.) Torture and its consequences: Current treatment approaches (pp. 277 – 298). Cambridge7 Cambridge University Press. Yuval-Davis, Nira (1997). Gender and nation. London7 Sage.

Further reading Baldwin, Steve (Ed.) (1998). Needs assessment and community care: Clinical practice and policymaking. Oxford7 ButterworthHeinemann. Basoglu, Metin (Ed.) (1992). Torture and its consequences: Current treatment approaches. Cambridge7 Cambridge University Press. Cooke, Miriam, & Woollacott, Angela (Eds.) (1993). Gendering war talk. Princeton, NJ7 Princeton University Press. Daniel, E. Valentine, & Knudsen, John Chr. (Eds.) (1995). Mistrusting refugees. Berkeley, CA7 University of California Press. Hutchinson, John, & Smith, Anthony D. (Eds.) (1996). Ethnicity. Oxford7 Oxford University Press. Lorentzen, Lois Ann, & Turpin, Jennifer (Eds.) (1998). The women and war reader. New York7 New York University Press. Reviere, Rebecca, Berkowitz, Susan, Carter, Carolyn C., & Ferguson, Carolyn G. (Eds.) (1996). Needs assessment: A creative and practical guide for social scientists. Washington, DC7 Taylor & Francis. Stiglmayer, Alexandra (1994). Mass rape: The war against women in Bosnia–Herzegovina. Lincoln7 University of Nebraska Press. Stanford, E. Percil (1980). Minority aging: Policy issues for the 80’s. San Diego, CA7 Campanile.

I. Sansani / Women’s Studies International Forum 27 (2004) 351–367 Suedfeld, Peter (1990). Torture: A brief overview. In Peter Suedfeld (Ed.) Psychology and torture. New York7 Hemisphere Publishing. Tantam, Digby, & Birchwood, Max (Eds.) (1994). Psychology and the social sciences. London7 Bell and Bain. Wilson, John, & Raphael, Beverly (1993). International handbook of traumatic stress syndromes. New York7 Plenum Press. World Medical Association (1975). Declaration of Tokyo: bGuidelines for Medical Doctors Concerning Torture and Other

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Cruel, Inhuman or Degrading Treatment or Punishment in Relation to Detention and ImprisonmentQ (Adopted by the 29th World Medical Assembly Tokyo, Japan, October 1975), available at http://www.wma.net/e/policy/c18.htm (last visited September 25, 2004). Zena Project (1999). Report of a survey: Barriers and needs of Bosnian refugee women with regard to education, employment and social inclusion. Dublin7 Women’s Education Initiative. Department of Education and Science.