Somali - EthnoMed

Author(s): Toby Lewis, MD
Reviewer(s): Khadija Hussein; Kadija Ahmed; Basra Ahmed; Ali Mohammed
Last Updated: March 2009 by Jessica Mooney, Gillian Shepodd and was based on information contributed by eight memebers of Seattle’s Somali community, and was reviewed by a Somali medical interpreter at Harborview Medical Center.

Somali Bantu are a distinct cultural minority subgroup in Somali. See Somali Bantu Refugees for more information.

Geography

Somalia is a long, narrow country that wraps around the Horn of Africa. It has the longest coast of any African nation, bordering on both the Red Sea and the Indian Ocean. The inland areas are predominantly plateaus, with the exception of some rugged mountains in the far north. The northern region is more arid, whereas the southern portion of the country receives more rainfall. Many Somalis are nomadic or semi-nomadic herders, some are fishermen, and some farmers. Mogadishu is the capital and largest city.

History and Politics

Unlike many African nations, Somalia is composed of a single, homogeneous ethnic group. Although Somalis may differ in nuances of local lifestyle, they share a uniform language, religion, and culture, and trace their heritage to a common ancestor.

Colonial rule began in the mid 1800s and divided the land inhabited by ethnic Somalis into several territories. The French controlled the northernmost region (the area that is now Djibouti), the British colonized northern Somalia creating a country called British Somaliland, the Italians governed southern Somalia, creating Italian Somaliland, Ethiopia controlled the inland region of the Ogaden, and Kenya controlled land on its northern border inhabited by Somalis, called the Northern Frontier District (NFD).

In 1960 British Somaliland and Italian Somaliland peacefully obtained independence and were united to form the current borders of Somalia. The Ogaden, controlled by the British after World War II, was designated as part of Ethiopia in a U.N. mediated agreement in 1948. This has been a source of heated contention between the Somali and Ethiopian governments ever since. Twice, in 1964 and again in 1977, military conflict arose between the two countries over control of the Ogaden, resulting in many lost lives on both sides. The land is currently controlled by Ethiopia, though many Somalis believe the region should be reunited with Somalia.

In 1977 Djibouti received independence from the French. Although the government of Djibouti chose not to reunite with Somalia, ties between the countries remain close, as the citizens share a common culture and language. Travel is permitted freely across the border without a visa.

At the time of independence in 1960 a civilian government was established, which then allied itself with the USSR as a way to distance itself from its prior colonial rulers. In 1969, General Mohammed Siad Barre lead a coup, creating a socialist military government with himself as its President. In the early years of his government Barre enjoyed popular support, but as his regime became increasingly more oppressive, his support waned. The Barre government was accused of many human rights violations. In addition, some Somalis felt Barre was not aggressive enough about regaining the Ogaden from Ethiopia.

In the late 1970s and early 1980s clan-based militias developed in order to oppose and overthrow Barre. In 1977 Barre broke ties with Moscow after the Soviets began providing aid to Ethiopia during the Ogaden War. With this realignment, the United States began supplying military and economic aid to Somalia, but eventually suspended these efforts in 1989 because of the Barre government’s human rights record. Outright civil war erupted from 1988-1991, culminating in the exile of Barre in January 1991.

Since 1991, the various militias have fought against each other vying for control of the country. There has been no effective government and the infrastructure of the country has crumbled. Many civilians have suffered from rampant violence. Food supplies have been manipulated for political gain resulting in famine and death from starvation. It was estimated by the US Army that by the fall of 1992, 40% of the population of Baidoa and 25% of all Somali children under the age of five had died because of famine. In late 1992, US and UN forces intervened in Somalia to help alleviate the humanitarian crisis. By March 1994 all foreign troops had withdrawn. At the present time the country remains overwhelmed in inter-clan disputes.

In 1991 people began leaving the country to escape the hunger, rape, and death that had become widespread. Over one million people fled to neighboring countries such as Ethiopia, Kenya, Djibouti, Yemen, and Burundi. Most stayed in large refugee camps that were established to house the Somalis. Resettlement programs have enabled families to move to Europe (Germany, Switzerland, Finland, England) and the United States. Somalis in the US live predominantly in New York, Los Angeles, Washington DC, and more recently San Diego and Seattle.

Language

The universal language in Somalia is Somali, an afroasiatic language that is closely related to Oromiffa and more distantly related to Swahili and the semitic languages of Arabic, Hebrew, and Amharic. Although written for many years, a uniform orthography was not adopted until 1973. The vast majority of the population is Moslem (>99%), and thus Arabic is a second common language. Until the 1970’s, education was conducted in the language of colonial rule, thus older Somalis from northern Somalia are conversant in English and those from southern Somalia are conversant in Italian. The government sponsored literacy campaigns in the 1970s and 1980s and education was free at all levels until 1991.

Interpersonal Relationships

Names, Naming

Somali names have three parts. The first name is the given name, and is specific to an individual. The second name is the name of the child’s father, and the third name is the name of the child’s paternal grandfather. Thus siblings, both male and female, will share the same second and third names. Women, when they marry, do not change their names. By keeping the name of their father and grandfather, they are, in effect, maintaining their affiliation with their clan of birth.

Status, Roles, and Prestige

Opinions vary among Somalis regarding who has high status and is most respected in their communities. Opinions about what contributes to high status include those who: have a strong character, are able to lead, are educated, are wealthy, are able to communicate with everyone, and have knowledge of the Qur’an, tribal and family history. Since the war, tribal affiliations have divided much of the society but unity is still valued (especially when in the U.S.).

Children and elders share mutual respect. When addressing another family member or friend, words for “aunt,” “uncle,” “brother,” “sister,” and “cousin” are used depending on the person’s age relative to the speaker.

Men are usually the head of the household. Women manage the finances and take care of the children. It is considered culturally unacceptable for a man to not be perceived as being in charge of his home. At the wedding ceremony, the groom is told by the elder/sheik/father/father-in-law that he is responsible for feeding his family and respecting his wife.

Most women in Somalia now work outside the home, due to increasing financial hardships primarily caused by war and resulting inflation. In Somalia, working women tend to have more flexibility and community support than in the U.S. and maintaining a household and obtaining childcare is not as stressful as in the U.S.

In the U.S., it is also common for women to work outside the home. It can be difficult for women to balance homemaking and childcare responsibilities without the type of support available in Somalia. Because men traditionally don’t contribute to caring for children and housework, excess strain on the relationship can lead to divorce.

Family is extremely important in the Somali community. The focus of Somali culture is on the family; family is more important than the individual in all aspects of life. Somalis will live with their parents until they get married. In times of sickness or marriage, all resources are pooled and it is understood that whatever you have is not only yours. Somalis who have immigrated to the U.S. will send money back to their families and even to close friends and neighbors.

The civil war is based on interclan and interfactional conflicts. When addressing Somali culture, it is considered disrespectful to refer to “clans” or “tribes.” It is a very sensitive issue that is best avoided when in the United States and some in the community will deny their existence. Tribes were names originally given in order to place families and locate people, but now they reinforce prejudices produced by the civil war. When in the U.S., tribal lines may sometimes disappear for the greater goal of living in the new country.

Greetings and Displays of Respect

Many social norms are derived from Islamic tradition, and thus may be similiar to other Islamic countries. The common way to greet someone is to say salam alechem (roughly translated as “God bless you”) and to shake their hand. Due to Islamic tradition, men and women do not touch each other. Thus men shake the hands of other men, and women shake each other’s hands. When departing, the common phrase is nabad gelyo (“goodbye”). Respect is paid to the elders of the community. Elders are addressed as “aunt” or “uncle,” even if they are strangers.

Phrases of Courtesy in Nine Languages: A Tool for Medical Providers

This language learning tool features videos of native speakers saying phrases of courtesy in nine languages, including Somali. Phrases of greeting, introduction, acknowledgment, departure and for emergency situations in a clinical setting can be played at a normal speed and at a learning speed. The goal of this tool is to provide a jumping-off point for developing rapport in the interpreted health encounter. View Somali videos.

General Etiquette

The right hand is considered the clean and polite hand to use for daily tasks such as eating, writing, and greeting people. If a child begins to show left-handed preference, the parents will actively try to train him or her to use the right hand. Thus left-handedness is very uncommon in Somalia.

As proscribed by Moslem tradition, married women are expected to cover their bodies including their hair. In Somalia, some Somali women wear veils to cover their faces, but few do in the U.S. as they find this a difficult custom to adhere to in American society. Pants are not a generally accepted form of attire for women, but may be worn under a skirt.

The traditional womens dress is called a hejab, and the traditional clothing for a man is called a maawis. The snug-fitting hat that men wear is a qofe.

Marriage, Family and Kinship

Marriage

Marriages can either be arranged or be a result of personal choice. The common age of marriage is around 14 or 15 years old. Men who can afford to do so, may have up to 4 wives, as is customary in Islamic tradition. However, not all wealthy men exercise this option. In urban areas, a man with multiple wives provides separate homes for his different families. Whether these families interact or not depends on the preference of the individuals involved. In rural areas, it is more common for a man with more than one wife to have a single household, where the families care for the farm or livestock together.

Gender Roles

As in many Islamic cultures, adult men and women are separated in most spheres of life. Although some women in the cities hold jobs, the preferred role is for the husband to work and the wife to stay at home with the children. Female and male children participate in the same educational programs and literacy among women is relatively high.

Family and Kinship Structure

There are several main clans in Somalia and many, many subclans. In certain regions of the country a single subclan will predominate, but as the Somalis are largely nomadic, it is more common for several subclans to live intermixed in a given area. Membership in a clan is determined by paternal lineage. Marriage between clans is common. When a woman marries a man of another clan, she becomes a member of that clan, though retains connection with her family and its clan.

Extended Families

Living with extended families is the norm. Young adults who move to the city to go to school live with relatives rather than live alone. Similarly, people who do not marry tend to live with their extended families. Divorce does occur, though proceedings must be initiated by the husband.

Reproduction

Pregnancy

Childbearing usually commences shortly after marriage. A woman’s status is enhanced the more children she bears. Thus it is not unusual for a Somali family to have seven or eight children. The concept of planning when to have or not to have children has little cultural relevance for Somalis.

Child Birth

Expectant and newly-delivered mothers benefit from a strong network of women within Somali culture. Before a birth, the community women hold a party (somewhat like a baby shower) for the pregnant woman as a sign of support. Births most frequently occur at home, and are attended by a midwife.

Post-Partum Practices

Newborn care includes warm water baths, sesame oil massages, and passive stretching of the baby’s limbs. An herb called malmal is applied to the umbilicus for the first 7 days of life (malmal is available in the U.S. in some Asian markets).

When a child is born, the new mother and baby stay indoors at home for 40 days, a time period known as afatanbah. Female relatives and friends visit the family and help take care of them. This includes preparing special foods such as soup, porridge, and special teas. During afatanbah, the mother wears earrings made from string placed through a clove of garlic, and the baby wears a bracelet made from string and malmal (an herb) in order to ward away the Evil Eye (see Traditional Health Practices below). Incense (myrrh) is burned twice a day in order to protect the baby from the ordinary smells of the world, which are felt to have the potential to make him or her sick.

At the end of the 40 days there is a celebration at the home of a friend or relative. This marks the first time the mother or baby has left the home since the delivery. There is also a naming ceremony for the child. In some families this occurs within the first 2-3 weeks of the baby’s life, in other families, the naming ceremony is held at the same time as the celebration at the end of afatanbah. These ceremonies are big family gatherings with lots of food, accompanied by the ritual killing of a goat and prayers.

Infancy, Childhood, and Socialization

See also Refugees Families from Somalia: A cultural background resource focusing on early childhood, published by BRYCS (Bridging Refugee Youth and Children’s Services) and the Office of Head Start’s National Center on Cultural and Linguistic Responsiveness (NCCLR).

Infant Feeding and Care

Breastfeeding is the primary form of infant nutrition. It is common to breastfeed a child until 2 years of age. Supplementation with animal milks (camel, goat, cow) early in the neonatal period is common. This is especially true during the first few days of life, as colostrum is considered unhealthy. Camel’s milk is considered to be the most nutritious of animal milks. A few Somalis use bottles, but more commonly, infants, including newborns are offered liquids in a cup.

A mixture of rice and cow’s milk is introduced at about 6 months of age, and subsequent solid foods after that. Most Somali women are uncomfortable with the Western idea of pumping breastmilk. They believe that human milk shouldn’t be stored because it will go bad.

Child Rearing Practices

Diapering is not common in Somalia. When the baby is awake, the mother will hold a small basin in her lap and then hold her baby in a sitting position over the basin at regular time intervals. Somali mothers claim that within a short period of time infants are trained to use the “potty.” At nighttime, a piece of plastic is placed between the mattress and the bedding. The bedding and plastic are cleaned daily.

Adolescence, Adulthood, and Old Age

Adulthood is considered to begin around the age of 18, though it is acceptable to marry and have children around the age of 15. Mothers begin to prepare girls to run a household when they are between seven and nine years old. At this time, girls are expected to accept considerable responsibility around the house.

There is a great difference between rural and urban life. In rural areas, it is typical to follow a family trade. Some children may be able to attend school for a few years and then join the family trade. Impoverished people work hard to gain financial security and seek the most profitable employment. If a family lives in an urban center, they are more likely to have received more education.

Education

The civil war in Somalia has completely decimated the educational system. Now the focus is on survival. Before the war, the educational system was similar to that of the U.S., though the curriculum was more advanced. Children started school around the age of five or six and attended four years of elementary school, four years of middle school, and four years of high school. The Qur’an is taught in school and children may also receive private religious tutoring, which typically begins at three or four years of age.

Before the war, there were both public and private schools, but now only private schools are available for those who can afford it. College or higher education can be pursued after the age of 17, if affordable. Prior to the war, higher education was free.

Old Age

Somalis feel that it is good to keep the mind and body active, so they will work until they are no longer physically able. Those with government jobs can retire after 25 years. However, because the economy is based on individual entrepreneurship, it is essential for most to keep working to maintain their businesses. Social security, welfare, and elderly-care institutions do not exist in Somalia. When elderly parents stop working, it is usually a daughter that cares for them in her home. If there is no daughter, other children or extended family will care for them.

Though elders may live with a daughter, other children will contribute to the care of their parents, both financially and by providing other types of assistance, such as taking them to medical appointments. Elders are highly respected, so they receive the best of care. Elders expect to be sought out by other members of their community for advice on personal and community matters. Those living in the U.S. find that community ties here aren’t that strong. It can often be difficult for elders to come to the U.S. where most of their family is working and there is little to no interaction with their community. Grown children often depend upon their elder parents to care for grandchildren, due to the necessity for women to work. Some elders express feelings of isolation and this can contribute to poorer health.

Nutrition and Food

Breastfeeding is the predominant form of nutrition for children under the age of 2 years. Southern Somalia has a large agricultural and international trading component to its economy, thus, in southern Somalia diets are richer in green vegetables, corn, and beans. Southern Somalis, especially those in the cities are more familiar with Western foods such as pasta and canned goods. Northern Somalia’s nomadic lifestyle fosters a diet that is heavier in milk and meat. Diets there also have a large component of rice, which is obtained through trade.

For beverages, there are black and brown teas (largely imported from China) and a coffee drink that is made from the covering of the coffee beans rather than from the beans themselves.

See related:

Drinks, Drugs, and Indulgence

Qat,(also spelled khat, chat, kat) is a mild stimulant used by some Somali’s. It is derived from fresh leaves from the catha edulis tree. When the leaves are chewed, the active stimulant ingredient, cathinone, is released. Qat is felt to make ones thoughts sharper and is often used in conjunction with studying. It is only used by men, and it’s use is more common in Northern Somalia and the Ogaden. Qat historically has been listed by the DEA as a schedule IV drug (unrestricted), however recently it was changed to a schedule I drug (most restricted) due to concerns for potential abuse.

The King County Somali Health Board discussed hookah/shisha at their August 2014 meeting, revisiting the topic discussed at a meeting a year earlier, to talk more about the health effects of hookah and shisha and to shed light on a tragedy that occurred outside one of the hookah bars in Seattle in which a young Somali man was shot and killed.

See also: Hookah/Shisha – The Big Myth. This PowerPoint presentation by Paul Zemann (Tobacco Prevention Program, Public Health, Seattle & King County) compares health risks of smoking cigarettes and smoking from a waterpipe. See presentation’s annotated speaker’s notes (toggle on/off via icon on slides with notes) in addition to the slides.

Religious Beliefs and Practices

Almost all Somalis are Sunni Moslems. For those who practice Islam, religion has a much more comprehensive role in life than is typical in the Americas or Europe. Islam is a belief system, a culture, a structure for government, and a way of life. Thus in Somalia, attitudes, social customs, and gender roles are primarily based on Islamic tradition. For example, the Islamic calendar is based on the lunar month and begins numbering from the year Mohammed arrived in Medina; both this and the Julian calendar are officially recognized and used.

Islamic theology and religious practice is complex, and is the object of intense study and scholarship within the Islamic community. When Moslems try to convey the fundamental aspects of their religious beliefs to non-Moslems, they emphasize the belief in one God, Allah, and dedication to the study of the teachings of Allah’s prophets. The prophet Mohammed is central among these, though other respected prophets include the Biblical patriarch Abraham and Jesus. Moslems are quick to point out that while Mohammed is revered and his teachings form the core of Islamic thought and practice, he is not worshipped as God in the way that Christians worship Jesus.

Important religious holidays include Ramadan, Id al-Fitr, Id Arafa, and Moulid. Ramadan is the 9th month of the lunar calendar. During the 30 days of the holiday, people pray, fast and refrain from drinking during the day and eat only at night. An important aspect of this holiday for medical providers to be aware of, is that medications will often be taken only at nighttime. Pregnant women, people who are very ill, and children (usually interpreted as under 14 years old) are exempted from the fast. Some religious observance of Ramadan extends the fast for an additional 7 days.

Immediately following Ramadan is the holiday of Id al-Fitr which marks the end of the fast. This celebration involves big family gatherings and gifts for children. Id Arafa ( also called Id al-Adhuha) is the most important holiday of the calendar year. This is the time for making pilgrimages (hajjia) to Saudi Arabia. Moulid is another important holiday, occurring in the month after Ramadan. It commemorates the birth and death of the Prophet Mohammed.

Many religious holidays involve the ritual killing of a lamb or goat. In Seattle, families travel to a farm in Sumner, Washington, where they purchase the needed animal and perform the ritual slaughter. Islamic tradition forbids eating pork or drinking alcohol.

Somalis observe several secular holidays as well, these include a Memorial Day, Labor Day, an Independence Day (July 1) commemorating the 1960 independence and unification, and Mother’s Day.

For a short historical review about health care in Muslim experience, as well as current general information about Muslim people and their main observances and concerns in the Western health care system, see: Health Care in Islamic History and Experience.

Death and End of Life

When informing the patient of a poor prognosis, providers should know that in Somalia there are no confidentiality laws and the family is informed instead of the patient. The family of a Somali patient may feel distrustful of clinicians if they are not informed of their family member’s prognosis. Somalis feel it is important to tell the immediate family first if there is a poor prognosis so they can be prepared in order to work together and comfort the patient. They may also seek to protect the patient, so as not to scare them with a poor prognosis and cause them to lose hope and die, as a result. Some Somalis believe that supernatural causes such as the “evil eye” or aume cause illness but may not share this with providers. Religious leaders are contacted when a serious illness is diagnosed.

When bad news is delivered, it is important to deliver it in as compassionate a way as possible.

In Islam, life is considered sacred and belongs to God (Allah). It is believed that all creatures die at a time determined by God and that no one knows when it is his or her time to die except Allah (EthnoMed, 2008). For this reason, when a patient is determined to be terminally it, it is best not to offer a timeframe for when death might likely occur. Likewise, the provider could say, “According to us, we have done all that we can.” This will demonstrate respect for religious beliefs.

Somali patients may prefer same-gender medical staff when available, and appreciate it when clinicians provide information in detail about medications and procedures. Medical technology is often intimidating and may incite fear and suspicion. This is an opportunity to broker trust with the patient and the family over treatment. Because medical practice in the West is so different than in Somalia, issues such as life support are new concepts and require in-depth explanations.

In addition, some Somalis may feel that they are not offered the same quality of treatment as Westerners or may even be suspicious of being the subjects of experimentation. Going into further detail regarding treatment can help providers bridge cultural gaps and build trust with their patients.

It is common for providers who have gained the trust of their Somali patients to be referred to others in the community. Community members may seek out that provider, once word spreads.

There is much discussion about the acceptability of life support in Somali culture and religion. While Somalis appreciate every effort to preserve life, there is controversy regarding at what point life support may interfere with God’s will and extend life artificially. Yet, some Somalis don’t feel they can make the decision to remove life support because that too would be interfering with God’s will. As a result, Somalis may have complicated spiritual issues surrounding life support.

Organ donation at the time of death is traditionally not practiced in Somalia, but Somalis would still like to be given the option. Traditionally, Somalis believe the body should be buried intact. Donating an organ while still alive or receiving a transplanted organ may be considered more acceptable. Since there are no specific codes on transplant and organ donation in Islamic law, there are different approaches to treatment. Most Muslim jurists and their followers accept organ donations because it is in harmony with the Islamic principle of saving lives (EthnoMed, 2008). (For more information about organ donation and Islam, see Health Care in Islamic History and Experience.)

When death is imminent, Somalis read from the Qur’an. The patient, family, and community members take turns reading passages.

There are many different opinions regarding when death has occurred. The definition of death in Islam is the departure of the soul from the body in order to enter the afterlife. The Qur’an does not provide any specific explanation of the signs of this departure. The common belief is that death is the termination of all organ functions (EthnoMed, 2008). (For more information about death and Islam, see Health Care in Islamic History and Experience.)

See article: For ill Somalis, healing distrust - StarTribune.com, an article about some of the cultural issues for Somalis about organ donation in Minneapolis, MN.

Bereavement and Grief

After death occurs, loved ones may be comforted by passages from the Qur’an. Somalis accept death as God’s will and excessive emotion, while not frowned upon, can sometimes be interpreted as interfering with God’s will. Although there is no traditional mourning period, widows may show that they are in mourning by wearing white clothes or a white head covering for four months and ten days, as required in Islam. During this period, women are also to abstain from wearing perfume or putting oil in their hair.

In Somali culture, community support is an integral part of the bereavement process. Community members cook, baby-sit, and pitch-in financially to cover funeral costs and help family members of the deceased. Though Western expressions of sympathy such as sending cards and flowers are appreciated, giving money is the Somali tradition. Community members visit with family members and provide comfort. Even if the deceased is not personally known, every effort is made to express condolences to the family.

Birthdays are not celebrated; rather the anniversary of someone’s death is commemorated.

See related EthnoMed articles about death in the Somali culture:

Traditional Medical Practices

Somali traditional medicine is practiced by “traditional doctors” who are usually older men of the community who have learned their skills from older family members. They are especially adept at treating hepatitis, measles, mumps, chicken pox, hunch-back, facial droop, and broken bones. Modalities used include, fire-burning, herbal remedies, casting, and prayer.

Fire-burning is a procedure where a stick from a special tree is heated till it glows and then applied to the skin in order to cure the illness. It is commonly used for hepatitis (identified as when the eyes, skin, and nails turn yellow and the urine turns dark), where the heated stick is applied once to each wrist and 4 times to the abdomen. It is also commonly used for malnutrition (marasmus); when the head seems to be large out of proportion with the body, the heated stick is applied to the head in order to reduce the head size.

Pneumonia is treated with fire-burning, herbs, and sometimes percutaneous removal of fluid from the chest. Seizures are treated with herbs and readings from the Koran. Stomach-aches and back-aches are treated with the herb habakhedi, while rashes and sore throats are treated with a tea made from the herb dinse.

Traditional doctors are also responsible for helping to cure illnesses caused by spirits. Somalis have a concept of spirits residing within each individual. When the spirits become angry, illnesses such as fever, headache, dizziness, and weakness can result. The illness is cured by a healing ceremony designed to appease the spirits. These ceremonies involve reading the Koran, eating special foods, and burning incense. The illness is usually cured within 1 or 2 days of the ceremony.

In Somali culture there also exists the concept of the “Evil Eye.” A person can give someone else an Evil Eye either purposefully or inadvertently by directing comments of praise at that person, thereby causing harm or illness to befall them. For example, one does not tell someone else that they look beautiful, because that could bring on the Evil Eye. Similarly, Somali mothers cringe when doctors tell them that their babies are big and fat, out of fear the Evil Eye will cause something bad to happen to their child. More acceptable comments are to say that the child is “healthy” or “beautiful.”

Currently, there are no traditional doctors in Seattle.

Circumcision

Circumcision is universally practiced for both males and females. It is viewed as a rite of passage, allowing a person to become a fully accepted adult member of the community. It is commonly viewed as necessary for marriage, as uncircumcised people are seen as unclean.

Male circumcision is performed at various times between birth and 5 years of age. It is accompanied by a celebration involving prayers and the ritual slaying of a goat. It is performed either by a traditional doctor (see Traditional Medical Practices above) or by a nurse or doctor in a hospital.

Female circumcision is a practice common in equatorial Africa that is unfamiliar to many Westerners. Included under the term “female circumcision” are several different procedures in which varying amounts of genital tissue are removed. Procedures include the removal of the clitoral hood, leaving the rest of the genitalia intact (known as “sunna” circumcision), removal of the clitoris and anterior labia minora, and removal of the clitoris, the entire labia minora, part of the labia majora, and suturing of the labia majora – leaving a posterior opening for passage of urine and menstrual flow.

This latter procedure is known as infibulation, and is the most common form of female circumcision in Somalia. In Somalia, the procedure is usually performed by female family members but is also available in some hospitals. It is usually performed between birth and 5 years of age.

In the last twenty years much attention has been focused on the medical and psycho-social complications of female circumcision. (See references) However most Somali women view circumcision as normal, expected, and desirable. It has become the center of a debate about potentially harmful traditional cultural practices, and as such, has become a complex and emotionally charged subject.

For Somali women in the United States there are many concerns about how their circumcisions will be cared for during childbirth and about whether they will be able to have their daughters circumcised. There are women in the Somali community in Seattle who are knowledgeable in how to perform infibulations, however, due to fear of legal reprisals have not performed them here.

Western practitioners need to recognize that this is an important yet sensitive issue for Somali women, and strive to keep the lines of communication open in order to best serve the needs of their patients. See articles: Female Genital Cutting: An Evidence-Based Approach to Clinical Management for the Primary Care Physician, and Female “Circumcision”.

Experience with Western Medicine

Most Somalis have had some experience with Western-style medicine in Somalia. The concept of using the medical system to keep people healthy, such as with routine prenatal care, well child care or other similar care may not be familiar, depending on whether a person comes from a rural or urban area. Regardless, there is a general desire to receive treatment in the form of medications or other tangible goods like injections or vitamins.

The most common illnesses taken to Western hospitals in Somalia are diarrhea, fever (usually representing malaria), and vomiting. Families almost universally receive an antibiotic at the hospital, setting a precedent for expectations in the United States. Oral rehydration therapy is common and familiar. Families are aware of colds, ear infections, and asthma (called asma or nef), though these are not common conditions. Families will bring their children to the hospital for a cold and receive oral medication which is effective against the symptoms, again, setting a precedent that they expect to be followed in the U.S.

In Seattle, families are often very unhappy when they travel a long distance, wait to be seen in clinic, and are sent home with instructions that the illness will self-resolve. There frequently is confusion about antibiotics and when it is appropriate to prescribe.

Parasitic illness is relatively common, especially shistosomiasis with terminal hematuria. In a recent screening study at Harborview Medical Center, 72% of East African children (inclusive of Somali and other ethnic groups) had pathogenic fecal parasites. Most common were roundworms, giardia, ameba, and hymenolepsis nana. Somalis also describe a prevalent disease where small worms crawl under the fingernails (perhaps tungiasis?).

Somalis are familiar with tuberculosis. In Somalia, if a person develops tuberculosis they are quarantined to a special TB hospital for many months. Many Somalis were exposed to TB in the refugee camps where TB control was poor. See also: Somali Tuberculosis Cultural Profile

AIDS is a recognized but uncommon illness (<1% incidence) in Somalia compared to other East African nations. A Seattle Times article reports on efforts in the Seattle area to help African immigrants learn to talk openly about HIV/AIDS. The article includes information about a trend toward higher rates of disease in African immigrant women compared to African immigrant males.

Reportedly, Somalis in the U.S. who are diabetic so strongly dislike the idea of taking insulin shots that they may be motivated to adopt lifestyle changes to avoid them.

Available research has suggested that refugees are at risk for the development of a variety of psychological disturbances including depression, anxiety and posttraumatic stress disorder (PTSD). See articles on EthnoMed about common Somali beliefs about mental illness, traditional treatment approaches, and advice for healthcare providers working with this population:

Relaxation techniques familiar to Somalis such as reading the Quran at sunrise and sunset or before bed, deep breathing and touch massage may be effective complimentary treatments of anxiety disorders. Massage is known to be used by Somali women in Seattle for relief of physical pain and stress. “Daryel” is an exercise, massage-therapy and social support group for Somali women in Seattle. Read more about this group in this Seattle Times article. Also view video below about Daryel, produced in July 2019 by the Seattle Channel.

Seattle Community Life

Community Organizations

There are a number of Somali service agencies, community organizations and businesses in and around the Seattle area. For more complete information visit Somali Community Organizations in Seattle.

Neighborhoods

In the Seattle metropolitan area, the Somali community has predominantly settled in the Central Area, Rainier Beach, and in SeaTac.

Common Acculturation Issues

There are several areas where the differences between Somali and American culture are apparent and cause difficulties. For example, American apartments are rarely large enough to accommodate families of 9 or 10 people. In practice, this means that many Somali families have been divided between 2 or more apartments. This places emotional strains on families that are often struggling financially. In addition, due to Moslem prohibitions against interactions between adult men and women, Somali women have a strong preference to work with female interpreters and health care providers.

However, thus far, Somalis in Seattle state they have not encountered significant problems associated with acculturation. As recent immigrants with a strong religious and cultural heritage, most families have found it easy to continue traditional dress and cultural practices. At those times when Somali adolescents feel the pressure to assimilate more strongly than their parents, usually a mutually acceptable compromise can be accomplished. For example, several Somali families feel comfortable letting their children go to school in Western clothes (as long as this does not include shorts), as long as the children change into Somali clothing when they come home from school.

Families send their children to religious school on evenings and weekends in order to preserve Islamic education and tradition. Some attend a Pan-Islamic school at 25th Ave and Cherry. Others attend the newly created Somali Islamic school at Rainier and Brandon.

Resources

Somali Refugee Health Profile - CDC
The information in this refugee health profile is intended to help resettlement agencies, clinicians, and public health providers understand the health issues of greatest interest or concern pertaining to Somali refugee populations in the United States, as well as their cultural background and circumstances.

References

Toubia, N., “Female Circumcision as a Public Health Issue” NEJM , Sept 15, 1994, vol 331, no 11, p 712-716.

Some historical information obtained from the U.S. Dept. of the Army, Somali Area Handbook, Jan 1994, Dept. of Commerce, Economics, and Statistics Division’s National Trade Data Bank (NTDB), CD-ROM, SuDoc, c1.88:994/1/v.