As an immigrant woman researcher who has primarily worked with female immigrant and refugee communities on socio-cultural barriers to accessing health care, the researcher is familiar with providing the continuation of a deeper understanding for Somali refugee women. Previous research of working with Afghan refugees, have emphasized how critical it is to engage the community in an authentic way in order for the women to tell their stories as an empowering tool for identifying their unique complexities [5Shirazi M, Bloom J, Shirazi A, Popal R. Afghan immigrant womens knowledge and behaviors around breast cancer screening. Psychooncology 2013; 22(8): 1705-17.
[http://dx.doi.org/10.1002/pon.3216] [PMID: 23225210] ]. This research is a preliminary assessment of the women’s stories, particularly the older population who have been significantly underrepresented within the research community.

This paper draws upon trauma theory and feminist theory and empowerment perspectives [6Kubiak SP. Trauma and cumulative adversity in women of a disadvantaged social location. Am J Orthopsychiatry 2005; 75(4): 451-65.
[http://dx.doi.org/10.1037/0002-9432.75.4.451] [PMID: 16262505] , 7Turner RJ, Lloyd DA. Lifetime traumas and mental health: the significance of cumulative adversity. J Health Soc Behav 1995; 36(4): 360-76.
[http://dx.doi.org/10.2307/2137325] [PMID: 8719054] ]. It highlights the cumulative nature of traumatic and adverse events and identifies and centers marginalized voices to explore the impact of systematic oppression in addressing and healing from trauma [8Dietz CA. Responding to oppression and abuse: A feminist challenge to clinical social work. Affilia 2000; 15: 369-89.
[http://dx.doi.org/10.1177/08861090022094001] , 9Kulkarni SJ, Kennedy AC, Lewis CM. Using a risk and resilience framework and feminist theory to guide social work interventions with adolescent mothers. Fam Soc 2010; 91: 217-24.
[http://dx.doi.org/10.1606/1044-3894.3998] ].

“Trauma” may be described as an event that causes intense feelings of horror, fear, vulnerability, and anxiety, such as physical or sexual assault, torture, armed conflict and war, and intimate partner violence [9Kulkarni SJ, Kennedy AC, Lewis CM. Using a risk and resilience framework and feminist theory to guide social work interventions with adolescent mothers. Fam Soc 2010; 91: 217-24.
[http://dx.doi.org/10.1606/1044-3894.3998] ]. Feminist theories have historically been concerned with the disempowering effects of trauma on women and marginalized groups, and have consistently made an effort to recognize these experiences as products of oppressive systems [8Dietz CA. Responding to oppression and abuse: A feminist challenge to clinical social work. Affilia 2000; 15: 369-89.
[http://dx.doi.org/10.1177/08861090022094001] , 9Kulkarni SJ, Kennedy AC, Lewis CM. Using a risk and resilience framework and feminist theory to guide social work interventions with adolescent mothers. Fam Soc 2010; 91: 217-24.
[http://dx.doi.org/10.1606/1044-3894.3998] ].

Additionally, feminist theories recognize that trauma experienced by women, particularly sexual torture, is used as a weapon to destroy family, community, and culture [10Buss D. Rethinking 'rape as a weapon of war'. Fem Leg Stud 2009; 17(2): 145-63.
[http://dx.doi.org/10.1007/s10691-009-9118-5] ]. Emphasizing the personal and political dimensions of oppression, feminist theory provides the necessary framework to better understand the invisibility perceived and experienced by women refugees. Feminist theory also calls for responses to trauma that address systemic roots of violence and construct interpersonal empowerment that highlight self-determination and socio-structural healing relationships [11Harvey MR. Towards an ecological understanding of resilience in trauma survivors. J Aggress Maltreat Trauma 2007; 14: 1-3.
[http://dx.doi.org/10.1300/J146v14n01_01] ]. Applying a feminist lens to recognize the impact of traumatic violence and forced migration on the extended family, culture, language, rituals, and social exchanges is an essential part of developing an informed narrative for working within these communities.

Hein [12Hein J. Ethnic origins: The adaptation of Cambodian and Hmong refugees in four American cities. New York, NY: Russell Sage Foundation 2006.] argues that the social, cultural, and historical background of an immigrant population shapes the ways in which it adapts to resettlement but because of social taboos against adopting culture to explain difficulties, we in the United States instead tend to avoid placing emphasis on immigrants’ culture or pre-migration experience. By definition, refugees resettled in the US have experienced human rights violations, and most have left family, friends, and social networks behind, meaning that depression, PTSD, anxiety and others mental health concerns are disproportionally prevalent in these communities [13Jackson K. Treating trauma in america’s refugees. Soc Work Today 2016; 16(4): 10.]. Jaranson et al. [14Jaranson JM, Butcher J, Halcon L, et al. Somali and Oromo refugees: correlates of torture and trauma history. Am J Public Health 2004; 94(4): 591-8.
[http://dx.doi.org/10.2105/AJPH.94.4.591] [PMID: 15054011] ] highlighted the need to recognize the prevalence of torture among African refugees, particularly women who were tortured at the same rates as men, and develop appropriate resources. Women who reported higher levels of trauma were older, had more family responsibilities, less education, and were less likely to speak English [15Robertson CL, Halcon L, Savik K, et al. Somali and Oromo refugee women: trauma and associated factors. J Adv Nurs 2006; 56(6): 577-87.
[http://dx.doi.org/10.1111/j.1365-2648.2006.04057.x] [PMID: 17118037] ]. Shannon, O’Dougherty, and Mehta [16Shannon P, ODougherty M, Mehta E. Refugees perspectives on barriers to communication about trauma histories in primary care. Ment Health Fam Med 2012; 9(1): 47-55.
[PMID: 23277798] ] found that in a sampling of refugees in the Midwest two-thirds had never discussed their history of trauma with their physicians, and that their physicians had never asked. Additionally, these participants were unaware of the ways in which trauma affects health and, in deference to physicians’ authority, were unlikely to initiate conversations or make requests.

Narrative analysis is particularly suited to the assessment of need. Integrating intersectional feminist theory, aging, and life experience, it places the ‘subject’ as the driver of the inquiry allowing for the increased complexity; indeed Randall [17Randall W. Narrative and chaos: Acknowledging the novelty of lives in time. Interchange 2007; 38(4): 1-24.
[http://dx.doi.org/10.1007/s10780-007-9037-9] ] discusses ageing as individuals increasing rather than decreasing in complexity. Narrative is particularly valuable in feminist scholarship as it allows for “…sequence and consequence: Events are selected, organized, connected, and evaluated as meaningful for a particular audience” [18Riessman C, Speedy J. Narrative inquiry in the psychotherapy professions. In: Clandinin D, Ed. Handbook of narrative inquiry. London: Sage 2007.
[http://dx.doi.org/10.4135/9781452226552.n17] ]. Thus, participants are able to relate their life experience organically allowing, “respondents in various settings, such as interviews, to impose order on the flow of experience to make sense of events and actions in their lives” [19Phoenix C, Smith B, Sparkes A. Narrative analysis in aging studies: A typography for consideration. J Aging Stud 2010; 24: 1-11.
[http://dx.doi.org/10.1016/j.jaging.2008.06.003] ].

The women recognized that current reality and daily lives were shaped by past experiences of trauma. Many repeatedly referred to the events from the Somali civil war that affected the current welfare of their families and their kin. Many had witnessed their homes being attacked and their family members being robbed, tortured, raped and killed. The majority had also experienced trauma during transition in other countries as well as upon arrival and resettlement in the United States. They shared the experience of arriving with no belongings or resources and with significant health problems from the trauma and misery of the civil war.

“In the war, I lost close family members and after all this time many are still missing. I was separated from my daughter and she is still missing. I mourn her every day.”

In addition to recounting their experiences of trauma, the women explained how exposure to past trauma made it more difficult to cope with life’s challenges in the United States.

“All the bad things that happened are still in my memory. I will never forget, never. I try but I can never be fully happy, there is always this heaviness in my heart.”

Despite their experiences, none of the participants conveyed a sense of victimhood. Their present interpretation of themselves was as survivors and agents of hope for their families. They explained the importance of religion, social support, and community resources as coping mechanisms that helped them and their families adjust to the resettlement process and cope with many forms of trauma.

“Our Somali community is very resilient and strong ; we help each other…those with more experience help the new ones. At the mosque, we pray together and the women talk about their problems, and sometimes cry together.”

The women felt very proud of their Somali identity and said they tried hard to raise their children as “Somalis”. One of the women stated, “No matter where your children are born we all want our children to have the Somali culture. We don’t want to lose that.” The women described their experience of loneliness and isolation from being in a new country and the impact of this experience on their health, “Back in Somalia we have the extended family, and there is no such thing as being alone.”

The participants spoke of belonging in terms of their old homes as well as their new homes; how the civil war had made it very difficult to belong to their old home. They spoke fondly of their ways of living and strong kinship and how suddenly they lost everything.

They described old age in Somalia as a time to be free from worries and to be supported by one’s family and children. They recounted a sense of loss associated with not only the loss of material wealth but of their social standing and status. The participants discussed how forced migration had also resulted in the loss of autonomy and referred to the different family structures in the US, which they saw as diminishing their respectability and position within the family.

“In Somalia, old age is something to be proud of. There, old people enjoy respect, but here it is different. I feel alone and helpless. My children are too busy for me. Sometimes I sit home all day with none to speak to. I feel sad and my health is getting worse.”

Social isolation, including the stress of language difficulties, was also exacerbated by the breakup of families in the refugee and resettlement process. Men of the family are disproportionately gone, either killed or forced to remain in refugee camps as women and children were resettled in the United States.

“Many women lost their husbands in Somalia or in refugee camps. Many of us are living as single women. Also the husbands who came to the U.S. are now separated from the women. They (men) don’t help with money, so the women left their husbands”

The participants noted the Somali language is integral to their identity and speaking Somali with parents, older relatives, and community elders is essential for the preservation of a strong family. They felt that the use of their native language at home which preserves the continuity of family structures is slowly disappearing. In addition, viewing of their resettlement as a not necessarily permanent leaving of Somalia heightens the concern for the diluting of language and culture.

“Our language is very important, it is what ties us to our culture…I feel sad that my grandchildren don’t speak Somali, what if they decide to go back one day?”

Somali women’s interactions with the health care system were often described as frustrating and disappointing. The women felt that mainstream providers had little understanding of the complexities of their life and the impact of war trauma on their health. Many of the women suffer from tangible, physical health problems, including diabetes, high blood pressure, and arthritis, but lacked holistic care that addressed their mental health and social isolation in addition to physical concerns. Additionally, they felt that language barriers particularly hampered the inability of health care providers in response to the needs of the Somali women. They related how their lack of proficiency in English posed problems for accessing services, and placed significant limitations on their mobility and in forming new social networks. Many of the Somali women mentioned they had been attending English language classes for years but found learning a new language extremely difficult. As one woman explained, “ I don’t speak English well...this language barrier is one of the most difficult things that we experience. I can’t explain things completely, so it’s not easy to make new friends.” They stressed the need to improve interpretation and translation services, adding that it takes time to build a trusting relationship and be at ease with interpreters and physicians.

“It’s uncomfortable to talk about all your health problems, especially private issues. It should be someone who you see frequently, someone who can explain things correctly.”

While they did want familiar faces in the exam room there was also a concern expressed that, due to a lack of available interpreters, at times family members or people known from the community had to interpret, making frank discussions of personal or sensitive issues, particularly trauma, particularly fraught in a small community.

The participants also identified a lack of understanding of mental health conditions and cultural barriers as impediments to accessing mental health care. They mentioned, “…most of them (physicians) don’t ask about their past experiences of war and trauma”, and that how most Somalis “will not talk about these issues” unless they are asked directly.

There was a strong belief among the participants that they were perceived as the ‘other’. Many discussed a sense of marginalization, and as a result, they were skeptical of the health care system and most service providers. These obstacles deepened their stress around accessing health care services. One of the participants shared, “Sometimes you experience racism, the manner of some of the staff, the way they look at you, the way they speak to you, as if you know nothing.” These realizations point out that it's the social relations of power, not culture that stipulate the contexts and contents of discrimination. Such structural changes involve a call for a change in attitudes, practices, and conceptual frameworks. And as Jiwani implies, this requires health care professionals’ awareness of the larger impact of structural violence, systematic racism, and endorsement of social justice [24Jiwani Y. Discourses of Denial: Mediations of Race, Gender, and Violence. Vancouver: UBC Press 2006.].