The findings presented below are from the Washington State Coalition's Fatality Review Project, which is staffed by Kelly Starr, Fatality Review Project Coordinator, Joanne Gallagher, Fatality Review Project Specialist, and Margaret Hobart, Fatality Review Project Advisor.

The Domestic Violence Fatality Review Process

Domestic violence fatality reviews are a grand experiment in effective systems change. Domestic violence advocates and systems representatives examine a battered woman's homicide, but not from the viewpoint of "What was wrong with the abuser?", "Was she a drinker?", or other attempts to understand the violence by looking just at the victim or perpetrator.  Instead, the fatality review process is designed to ask, "What are the circumstances that surrounded the woman's death?" and to view the homicide from a systemic, not just personal, framework.

In Washington, our statewide fatality review project is set up to examine the death through the victim's eyes, looking at how the system responded to her attempts to get help and to keep herself and her children safe. The fatality review process is also designed to identify how criminal justice and other systems attempted to hold the batterer accountable, by collecting and examining related data, such as protection orders and prior arrest history. When we review a fatality, project staff enter the information into a comprehensive database and then create a chronology of events, to trace the times the victim attempted to get help, and when either party interacted with the system. Protection orders, tapes and transcripts of 911 calls are some of the items in the public record that we may track down. Also, we may add information received from local domestic violence programs, clergy or other individuals who knew something about the people involved and the homicide. The information reported by individuals in local programs might differ from the official accounts.

The statutes related to domestic violence fatality review in Washington State require the review team to include law enforcement officials, medical examiners, the prosecutor's office, and other institutional representatives, as well as community advocates. We also attempt to involve other community members, such as the woman's clergyperson. It is an interesting experience to hear review panelists talk about the case, because often the policies and procedures that institutional representatives describe are different from what we as advocates experience. Fatality reviews are an opportunity to engage in dialogue about policy versus actual practice.

We also try to contact the victim's family in a non-intrusive manner, by sending a letter to let them know that we are looking at the case. We offer an opportunity to share information with us, if they so choose. It is important for families to know that someone cares about what happened.

A Cascade of Multiple Systems Failure

In our state, we have examined several fatalities of limited English speaking women, primarily Asians and Latinas. Many of the victims made extraordinary attempts to get help from the criminal and civil justice systems, which failed them dramatically and repeatedly. My colleague Margaret Hobart, the original staff for our fatality review project, has called this "a cascade of multiple failures."

The cases we have looked at during the fatality reviews have not thus far indicated what some call a "cultural" problem of domestic violence. Most of the barriers identified indicate a lack of appropriate institutional response to the danger that these women faced. These are the typical system failures faced by battered women in general, and in particular, by those who are immigrant, refugee, limited English-speaking, or of color:

• A lack of access to helping systems;
• A lack of appropriate advocacy and intervention;
• A lack of a strong criminal justice intervention to hold the perpetrator accountable and prevent further victimization.

Consistent Themes Regarding Experiences of Women with Limited English Proficiency

This section is from a report by Washington State Coalition Against Domestic Violence, Margaret Hobart, Fatality Review Project Advisor.

• Law enforcement agencies failing to provide translation at the scene even when their official policy is to call the AT&T Language Line [for interpretation by telephone], resulting in a lack of prosecution.
• Lack of advocacy in the woman's first language within protection order offices and/or prosecutor's offices.
• In several cases, women had made multiple attempts to enlist the assistance of the criminal justice or civil justice systems.
• It appeared that immigrant women resorted to calling law enforcement only when they felt that their lives or the lives of their children were literally endangered.
• When limited English speaking abusers were convicted, they often were not required to attend batterer's treatment because none existed in their language - but they did not face any alternative consequence (such as jail time), so from the victim's point of view, "nothing happened."
• Many of the cases we reviewed involved active homicide and suicide threats with loaded guns prior to the murder, but prosecutions and follow-up to these threats by the criminal justice system did not adequately respond to the seriousness of these threats.
• Contacts with the criminal justice system were critical points of intervention for the battered woman, but generally did not result in women getting support or realistic safety planning because of a lack of court-based advocates.

"Culture" - or Systems Failure?

A common statement made about battered women from our communities-particularly refugees and immigrants-is that, "They won't get help, they won't call the police." However, the women in the cases we reviewed made repeated attempts to get protection orders, to call 911, and to do everything they could to get help and safety - but they did not encounter an adequate institutional response. While it is well established that oppressive cultural values and gender roles sustain domestic violence in any culture (including mainstream American culture), API cultural beliefs and practices did not seem to be the root problem in the homicides we examined.

A tendency exists in the majority culture in the U.S. to blame domestic violence fatalities in immigrant/ refugee communities on "culture." Such characterizations distract from the significant problems identified: lack of access to services, lack of meaningful advocacy, and lack of strong criminal justice intervention to domestic violence generally. One of the common threads between cases involving immigrants/refugees and cases involving U.S.-born individuals was a general lack of effort by the criminal and civil justice systems to control the batterer and keep the victim safe. A focus on an immigrant/refugee's culture also ignores the fact that the bulk of domestic violence murders in Washington are committed by white, U.S. born, English-speaking men. (Hobart, p. 45)

Our findings point to institutionalized racism, and a failure of the system in general to hold safe victims of any background.

Thirteen percent of the reviewed cases (n=4) involved victims and families who spoke English as a second language, and were immigrants or refugees to this country. While all the murdered women faced significant barriers in attempting to access help from law enforcement, courts, medical providers, social services, and domestic violence programs, review panels noted that this set of victims also faced additional and daunting barriers, including:

• The reasonable expectation of encountering bias and racism when seeking help
• Institutional and individual racism on the part of professionals involved in the community response to domestic violence
• A lack of translation
• A lack of language-accessible, culturally appropriate services. (Hobart, p. 45)

Our government - and we as a movement - have invested significant resources in creating a criminal justice response that does not work for many battered women. This is not to say that arrest, prosecution, and court ordered treatment or jail time never stops a batterer's abuse; thousands of women have found safety through the system and we should never forget that. However, so much more must be done to compliment the criminal justice approach to stopping abuse, and to make this system focus on victim safety.

Doing so will require more advocacy outreach, more systems advocacy, and more work within our own communities to hold batterers accountable. It also may require pushing the criminal justice system, publicly funded health care providers, and social services to offer basic translation and interpretation services, at least to the minimum levels provided for in their own policies. Our priorities for ensuring interpretation should be for law enforcement response at domestic violence scenes, 911 responses, and health care.

If we look at institutional response to battering through the eyes of those who experience it, we see that institutions are sometimes not enforcing even their own policies and procedures about domestic violence. We must find constructive ways to address this. For example, we should let the police chief know when a 911 operator does not follow guidelines in responding to a limited-English speaker's emergency, or when officers use children to interpret at the scene of a domestic violence incident.

As safety audits have shown, the helping systems that victims and perpetrators encounter are not truly set up to prioritize women's safety and to hold the perpetrator accountable. This is a "good people working in bad systems" issue, where our expertise and advocacy can make a change. For example, we as a movement have said that protective orders can help victims be safer. However, there may significant barriers for limited English speaking women to obtain court orders. Say an immigrant woman decides to request an order: she has to find someone who reads and writes English well to go with her, take a break from work, find the courthouse and the appropriate line, and after all that, may not have time to obtain or complete the paperwork before returning to work. Will she ever try again? Advocates should examine the process of actually asking for help, in order to see what changes would support API women's attempts to stop the abuse.

How Does the Community Organize to Protect Women?

Fatality reviews are just one of the tools available to the community to take action. Others include lawsuits, pickets and protests. Fatality reviews, along with safety audits and task forces, are experiments and only part of the total approach needed to ensure that:

• The ways that institutions respond to domestic violence are based on community needs
• Battered women's safety and access to justice are central to everyone's efforts
• Advocates have a place at the table when funding and policy decisions are made.

Let's look at some of the community-based responses, in addition to fatality review.

The most common community-based response is what women living with the violence do to protect themselves. Before a murder, women often have a clear understanding of the danger posed by their abuser. They are creating their own safety plans, however limited in scope, with their friends, families, and co-workers. We know that only a small percentage of all battered women are calling us, the community advocates who can help them navigate the system, as well as assess lethality, find shelter, find help for their children, get financial assistance, and provide support. In the cases of LEP victims that we examined, many of the murdered women had not contacted a battered women's program. Many of them did not seem to know about us. We need to connect better with women's homegrown responses, and with the people who are helping them. We will need more money to do this, given the high prevalence of domestic violence versus our small programs and budgets.

In my own experience at an API community-based program, after a domestic violence murder in the API community, there is so much that community members want to do to help. For example, holding vigils, forums, and dialogues among the leadership. Sometimes there is intensive media attention, usually focused on cultural reasons for the murder, rather than the ones described above. There may be a community spur for new kinds of responses, new kinds of services, and new kinds of commitment. This is an incredible opportunity for us as API advocates and organizers to seek change, to let them know that domestic violence happens all the time, not just in this one case, and to do some organizing and mobilization.

Here also are some tremendous challenges. Frequently, our ethnic community leaders are very interested in stopping violence and murders. Most of them can agree that these are bad things. But they are not necessarily interested in gender equality. They are not usually demanding women's liberation. Sometimes it seems that the only way for us to get communities interested in this issue is when a woman dies.  And yet, is that the only way?

Battered women's deaths raise important questions for us as activists: How do we hold the formal leadership accountable, especially the elder male leaders? How do we ensure the community's response is based on a woman's safety and her own decision-making, and that we are not just transferring control over her from the batterer to community leaders? How do we hold ourselves accountable for working effectively in our own community, when it is so hard? What are we concretely doing to create leadership opportunities for survivors, and for young men who are interested in being part of the solution?

Implications for Advocacy

What can API domestic violence homicides teach us about advocacy?  I suggest that there are implications for systems advocacy, suicide and lethality screening, and safety planning.

First, we need to be more complex in our thinking about limited English speaking women and getting help from law enforcement. It is important for us to challenge the idea that limited English speaking women will not call 911. I have been guilty of perpetuating this idea myself, in an attempt to advocate for a culturally appropriate response, i.e., "Our women don't call the police, so alternative methods are required for intervention." The data in our state suggests that LEP women are indeed calling the police - but perhaps only when LEP women believe their lives are in immediate danger. We should think about what it means if women in our community do make that kind of contact, and what systems changes are required so that their desperate calls for help are not in vain. For example, should we have a discussion with law enforcement that says, "If you get this kind of call, it means that the situation is even worse than you are seeing with mainstream women, and this is what we want you to do."?

Second, in regards to Chic Dabby's presentation on API homicide and suicide, we should routinely screen for suicidal ideation, especially by the abuser, and perhaps by the victim, in the same way we ask women about sexual abuse from their partners. Are we warning women about the danger that a suicidal abuser poses to them? When we ask what her abuser says about committing suicide, are we also asking if she's thought herself about suicide or killing her children in order to protect them from abuse?

Our fatality review research has found that suicidal abusers pose a high level of danger to their victims, and that there is a pattern of inadequate response from professionals and institutions to this risk. In regards to API suicidal abusers, what do we need to know and do? Among other actions, perhaps we should advocate for some kind of Tarasoff warning for mental health professionals who come in contact with suicidal abusers. This would require them to warn the woman of the lethal danger she may face. 

Third, we need to find out if there are lethality factors significant and specific to APIs. For example, what does it means for a woman from a particular culture and home country experience to disclose partner sexual abuse to law enforcement - what is she telling us about the danger she is facing?

Lastly, with our safety planning, we should consider speaking more frankly with women about the possibility of their deaths. How do we do this in a way that does not make the women seeking our help turn away from us? What does it mean to do safety planning around this issue with those API women who are very unlikely to leave their abusers?

There is so much that we do not know, but must find out. We need to collect and analyze data about these cases. Even small programs can help. When I worked at an API domestic violence program in Seattle, we collected newspaper clippings of API domestic violence homicides, and discussed these with the domestic violence coalition (where I now work) every year. The coalition provided data for our community education work, which helped us show the API community that domestic violence does happen in our families, and is not just an "American" problem.

Lastly, I have a question for you as advocates. What do you all need to better address API domestic violence homicides in your community? What do you need from the Institute and from others? For example, do you want a packet on what to do after a death in your community, or training on working with the media, or support for working with API community organizations? What is it that we could be doing to assist you?

Judy Chen is a Program Coordinator at the Washington State Coalition Against Domestic Violence.  Previously, she was Director of the Asian & Pacific Islander Women & Family Safety Center, Seattle.