Migrant Women-experiences from the Mediterranean Region

3.3.1. Pre-migration

The underlying reasons for women to migrate must be looked for in their country of origin where political, cultural and religious circumstances can push them to escape [16]. In sub-saharian African countries, traditionally woman has got a subordinate position to man; she is less educated, she grows up to become a good wife and to be submissive to her husband; she has got a lower economic status and her main occupation is the management of family and domestic tasks. Often, according to gender norms and values, she is forced to marriage (usually at a very early age) and, in muslim countries [17, 18], to accept polygamous relationships, too.

In this cultural framework, she learns to see violence as a part of the marriage and as a right of husband to exercise control within marriage [19, 20]. Despite existing domestic laws prohibiting these practices, common types of gender-related persecutions are Intimate Partner Violence Against Women (IPVAW), Female Genital Mutilation (FGM), forced marriage or forced abortion or sterilization, rape and war-related violence [21],and hostage-taking’ by policy [22]. Depression, psychoticism [17, 18, 23] and trauma related disorders [24] are common outcomes of these experiences.

Although the magnitude of the issues and related results, it is difficult to have reliable data. For example, phenomenon of forced marriage is still relatively under-reported [25], even it is perpetuated by African immigrant people in hosting countries, too.

More data are available about physical and sexual violence against women. Even if SGBV is a universal reality, it appears to worsen as one goes south in the continent of Africa. Intimate Partner Violence Against Women (IPVAW) is a very common violence exercised by the husband over the woman [26] and, despite the serious consequences in terms of general health and mental health of women, it is still part of the values and norms of the South Africa people.

According to a comparative analysis of 17 sub-Saharan countries, IPVAW is targeted as a justifiable act both by men and women, particularly in case of “neglecting children”, “going out without informing husband”, “arguing back with the husband” or “refuses to have sex with her spouse”. This practice seems to be more acceptable to younger [27], less educated, poorest, living in rural areas, with less access to media women [28]. Moreover, men seem to be consistently less likely to justify wife-beating than women who consider the use of violence a way to define and maintain the difference of male and female roles [29]. The relationship between IPVAW and mental disorders has been explored in a meta-analysis: the weighted mean prevalence of mental health problems women victims of intimate partner violence was 47.6% in 18 studies of depression, 17.9% in 13 studies of suicidality, 63.8% in 11 studies of Post-traumatic Stress Disorder (PTSD), 18.5% in 10 studies of alcohol abuse, and 8.9% in four studies of drug abuse [30].

The Female Genital Mutilation/Cutting (FGM/C), or female circumcision, is another common form of violence against women in sub-Saharan African countries. It is a practice determining the removal of all or part of the external female genital in the absence of medical needs [31].

According to UNICEF data, 200 million girls and women from 30 countries mainly in Africa, the Middle East and Asia suffered this violence and 15 million girls are at risk of experiencing it by 2020 [32]. However, it is a rights violation in the context of international and national policy and can cause physical problems (infection, infertility), and mental health consequences [33].

This violent practice is perpetuated because of specific religious, cultural and traditional variables determining the female gender role, such as: girls’ virginity before marriage, monogamy in marriage, sexual availability to husband, the production of legitimate male heirs in order to insure husband’s patrilineage.Worries about marriageability and social acceptance, and the concern to loss of protection by other women and all the community if a girl refuses to suffer FGM are further reasons why this violence is still going on [34].

Studies conducted in South Africa are aimed at understanding the risk factors related to FGM. In Kenia, a study conducted on 0–14-year-old girls showed that daughters of cut women were highly likely to live the same experience. The likelihood of a girl being mutilated increased with the proportion of women who were cut, who supported FGM/C continuation, and who believed FGM/C was a religious obligation [31]. Achia [35], found a correlation between a woman’s current FGM/C status and her support for the continuation of the practice, among 15-49 years old women.

In Tanzania, it is estimated that 7.9 million women and girls have undergone FGM [36]. According to the findings of Galukande et al. [37], out of the 675 female study participants, 69.2% reported to have been cut at varying ages and 15.8% respondents lived it under the age of 11 years.

Others forms of violence are caused by political conditions: inthe war-torn regions, many women have been raped [25], have witnessed violent deaths and injuries, have lost families or have been victims of sexual abuse. Moreover, population displacement, damage to infrastructure, rising unemployment and erosion of welfare systems resulting from conflict can be a trigger for the development or progression of psychological distress or mental illness in women and in terms of trauma related disorders [24], depressive disorders and anxiety disorders [38].

According to the Euro-Mediterranean Human Rights Network data [39], many innocent women are arrested and become objects of physical, sexual and psychological violence; others are used as bargaining chip for hostage exchange. These traumatic events can determine the onset of psychological diseases and an increasing of internments in psychiatric hospitals [39].

All these experiences are the reasons why women can choose to leave their country, or they are part of their background, and they can be trigger for the development of additional traumatic events and for the onset of further psychological problems.

3.3.2. Migration Journey

Many characteristics of the journey to the host country, including the duration of the journey, cause migrant women to be particularly vulnerable to experiencing psychological distress, violence, and other traumatic experiences. SGBV is part of the journey for most of the women [40], and considering the established link between SGBV and psychological and mental health variables, it is worthwhile examining the documented experiences of violence against migrant women that occur during the migration journey.

Women’s experiences of SGBV on the migrant journey include being forced to have sex by smugglers, being used as a bargaining chip by their family to get a seat on boats, being compelled to sell their bodies in order to buy a seat for their dependents or to avoid torture and violence, or being used as exchange goods in exchange for prostitution or other illegal services [41]. The use of small, run-down, and old boats makes the journey particularly unsafe for women and children, who are often forced to take the worst and most dangerous seats [42]. The unsafe conditions of the journey are often confirmed at landing in the new country. As a case example, 368 refugees died in 2013 when the boat that was being used sank while trying to reach the coast of the Sicilian island of Lampedusa. 50% of those who perished were women and 20% were children, and despite the rescue interventions of the Italian coast guards and fishermen only 160 people could be saved, of which only 15% were women and 5% were children. This was due to their places in the bottom of the boat which placed them at greater risk for drowning, and also because they were thrown into the sea first by smugglers because of their perceived weakness [42, 43].

In a study of women’s experiences of violence during migration, Syrian women on the Euro-Mediterranean transit region reported experiences with violence during the passage [44]. The study also noted that upon arrival at the country of destination, many Syrian women were averse to discussing their experiences with SGBV during their journey and cited cultural barriers and fears as a possible reason for under-reporting [44].

Migrants, including women, are subjected to violence at the hands of the state authorities [45]. An examination of the experiences of migrant women arriving in Kos, Greece as part of their migration journey to Europe in 2015 found that immigration and asylum policies also pose a risk factor for women [5]. Women traveling alone or without male partners “are particularly vulnerable to attack, and there were several accounts of women who had been raped and sexually assaulted on their journeys” [5]. For example, Syrian women, who began increasingly travelling alone or without a male partner, faced particular insecurities and aid workers reported that the experiences of danger on the migration journey led to levels of distress and trauma for women arriving in Kos. The reliance on smugglers on the journey subjected migrant women to exploitation, danger, harm, as well as high economic cost. Aid workers also reported that women traveling with their husbands were at risk of Intimate Partner Violence during the journey as well as upon arrival.

Women were also at risk of attacks by various police or military forces in the countries crossed on the way to Europe [5, 46]. Instances of violence, torture and detention at the hands of officials were experienced by migrants passing through Libya en route to Europe. Migrants are also vulnerable to human trafficking and smuggling industries and women in particular can be subjected to sexual violence during the journey [46].

3.3.3. Post-migration

Refugees are particularly at risk for poor mental health [47, 48]. In the post-migration period, isolation and loneliness are common feelings as underlined in most studies on the mental health of refugee [49]. Social isolation is a salient factor predicting poor mental health, especially among women [50].

The post-migration period can be defined as a long-lasting process of inclusion and acceptance of migrants in the core institutions, relations and statuses of the host countries. It can require enormous resources and personal skills for migrants to activate themselves in a process in which they must quickly learn a new culture, with its rights, and try to access to positions and statuses. Social inclusion process can be very long and opposed by various difficulties such as family separation, the lack of social support, the need to learn language, and facing with discrimination and poverty. Some of those stressors (cultural, social and personal too) are main themes influencing the mental health especially of refugee women [51].

During the post-migration stage, it is also possible that migrants end up in refugee camps for months or even years, where living conditions are highly stressful and can expose them to the development of stress-related disorders, to which women seem particularly at risk of being exposed. Following exposure to a traumatic event indeed, women are approximately twice as likely as males to develop PTSD [52]. The reason can be explained with insufficient social support resources, gender-specific acute psychobiological reactions to trauma [53], or of assaultive violence [52]. According to a systematic review aimed to study violence among Asylum Seekers (AS) to high-income countries, the incidence of SGBV is high in these situations [54]. Over one third (35.7%) of women in detention centers have faced sexual harassment by detention officers, and during medical consultations the rate of sexual violence was reported by AS to be 44.2%. In addition, four studies reported sexual torture among torture victims [55]. Although there is a clear lack of data on the health of African female migrants once they have arrived in a European country, a study performed in Turin has shown that almost all the women reported to be abused in Libya, with sexual violence, one third of women had at least a scar and a lot of them reported a female genital mutilation [56].

Women often do not access treatment following the violence they have suffered not only during the journey but in some cases, even once they arrive in the host country [57].

According to a study conducted to investigate violence experience among immigrants and refugees in Italy, 56% of the women had been victims of at least one form of violence (psychological, physical, economic and sexual) during their permanence in Italy and 28.5% experienced multiple incidents of violence [58]. The reason could be that they are often deprived of social network support, they have no knowledge and awareness of how the psychological and clinical support services work in the host countries, another important barrier to access to care can be language, cultural background and social pressure [59].

MSF aid workers in Kos, Greece also reported that migrant women who experienced Intimate Partner Violence from their husbands or male partners were often unable to leave the abusive relationship due to the high level of social and financial insecurity faced in the country of destination [5].

A study performed in Spain has similarly highlighted that there could be a strong association between immigration status characteristics such as personal, social support, family among immigrant women living in Spain and Intimate Partner violence [60].

Even if the exposure to the risk of suffering further violence once arrived in the host countries for migrant women is very high, very few studies have highlighted this phenomenon [61-63].

A study performed in Pavia has shown that only half (49.7%) of the sample of migrant women receive a diagnostic procedures and/or drug prescription and only a third had a preventive intervention or chronic disease control [64]. There is a clear need to understand and implement new strategies to access and remove barriers to care concerning the model of health-care utilization among immigrants. To facilitate the access support network to national health services, a key role could be played by the third-sector organizations’ given that it is clear that public policies do not completely meet the needs [64].

Some studies have been carried out on the female population host in camps provided in border areas from which the migration process has started.

Studies from refugee camps with Tuareg refugees in Burkina Faso have compared psychological distress in male and female people. The results show higher rates were present in women; particularly over 40 years old women were at higher risk for PTSD symptoms, probably due to their awareness [13, 65].

Depression is present in terms of maternal depression among Syrian refugees in Lebanon, associated with younger age of marriage, illegal residence, increased exposure to domestic violence and a history of mental illness, more than among Lebanese mothers [66].

Several studies implementing psychosocial approaches aimed at improving mental health of migrants have been performed, both in host countries and in borders hot spot. Studies that had been supported or conducted in group setting or with the help of someone of the same communities seem to be considered more effective [67].

Some protocols involved family members or community activation of migrants in the host country and showed their effectiveness in facilitating access to care services [68-70].

Anyway, there is a clear lack of interventions designed to meet the particular care needs of migrant women in order to produce positive mental health outcomes once they arrive in the host countries. Likewise, targeted policies to promote mental health and prevent mental disorders among women migrants offering social, emotional, support to address the barriers against mental health services in Western host countries seem to be totally absent.