LGBTQI + Refugees’ and Asylum Seekers’ Mental Health: A Qualitative Systematic Review

As of December 2020, consensual same-sex sexual conduct is illegal in 67 UN member states; capital punishment is legally prescribed and applied in six countries. In five additional UN member states, capital punishment may occur despite legal uncertainties (ILGA, 2020). Trans identity or expression is explicitly criminalized in thirteen countries (ILGA, 2019). The long-discredited “conversion therapy,” in which people's sexual orientation, gender identity, or gender expressions are attempted to be altered through harmful methods, is still inflicted on queer people in many parts of the world (ILGA, 2020).

Increasing awareness and documentation of the LGBTQI + global situation over the last 20 years have prompted some countries to expand asylum protection to people fleeing persecution on the grounds of sexual orientation and gender identity (United Nations High Commissioner for Refugees, 2008).

LGBTQI + asylum seekers ¹ report pressure of legal prohibitions and socio-cultural stigma in their countries of origin (Jansen, 2014; Shidlo & Ahola, 2013). They experience multiple traumatic events across their lifespan, ranging from family rejection and harassment to conversion therapy, persecution, and violence (Alessi et al., 2018b; Bachmann, 2016; Jansen, 2015; Shidlo & Ahola, 2013). In the process of their move, LGBTQI + asylees are exposed to different forms of violence and exploitation. Many of them leave their countries through trafficking to escape state prosecution. They are more likely to be financially disadvantaged due to SOGIESC-based labor market discrimination in their countries of origin (Merkle et al., 2017) and lack of family or community support (Bennett & Thomas, 2013; Shidlo & Ahola, 2013). They are particularly vulnerable within asylum systems, where they are pressed to “act gay” to support their asylum claim (Jansen, 2014, 2015). As described by Yoshino (2006), they are expected to uncover their innermost and sometimes suppressed part of their identity. In the asylum process, their right to privacy and dignity is not always respected (Kara & Çalık, 2016). They should prove the credibility of their sexual orientation, gender identity, persecution, or a well-founded fear of persecution despite having to be discreet ² about their SOGIESC status (Aygün, 2019; Bachmann, 2016; Giametta, 2018; Jansen, 2014). They often are not in a position to provide such evidence (Dustin, 2018; Zappulla, 2018). Due to fear, internalized shame, or cultural and linguistic differences, LGBTQI + asylum seekers might be unable or unwilling to speak up or describe their gender or sexuality with the same western terminology used by the immigration system of host countries (Borges, 2019). Transgender asylum seekers are more invisible due to the binary discourse of gender inherent in legal systems (Van der Pijl et al., 2018). They may encounter significant barriers in obtaining gender-affirming care (Namer & Razum, 2018). In detention centers, LGBTQI + asylees frequently face discrimination from staff members or hostile attitudes and bullying from fellow asylum seekers (Aygün, 2019; Zappulla, 2018), especially when their gender expression does not conform to social and cultural norms of gender binary. After resettlement, along with sexual minority status, they struggle with cultural barriers and language problems like other refugees (Kahn et al., 2017).

LGBTQI + forced migrants face multi-layered discrimination in various settings in host countries (e.g., employment, housing, healthcare system) due to the intersection of race, ethnicity, gender, sexuality, religion, and nationality. The concept of minority stress, developed mainly by Brooks (1981) and Meyer (2003), refers to intense chronic stress experienced by members of stigmatized minority groups.

Meyer (2003) described the stress formation process in the model along a continuum from distal stressors, which are objective situations, to proximal stressors, which refer to personal and subjective stress as perceived by each marginalized group member. It has been established that holding multiple marginalized identities (Meyer, 2003) increases psychological distress (Alessi, 2018a; Borges, 2019; Chavez, 2011). Minority stress has a significant structural component: institutional heteronormativity and cisnormativity, social exclusion mechanism (such as prosecution and persecution) impact health over the life course (Fredriksen-Goldsen et al., 2014).

Over the past two decades, research on LGBTQI + refugees' mental health has been predominantly focused on trauma, depression, and suicidality (Alessi, 2016), while other aspects of their experiences have not been sufficiently addressed. We intended to provide a more comprehensive and contextualized analysis of the mental health condition of LGBTQI + refugees by exploring their accounts as reflected in the scientific literature. Therefore, this systematic review aimed to retrieve, critically appraise, and synthesize the evidence from qualitative data broadly relevant to mental health in the LGBTQI + forced migrants.

The data from a total number of 200 LGBTQI + refugees or asylum seekers and 66 service providers or activists (age range:18–59 years) from 21 studies were extracted and synthesized.

Data analysis revealed four broad themes linked to distress, and mental health challenges in LGBTQI + forced migrants. These themes have been visualized in Fig. 2. Table 5 shows the themes derived from each study.

The psychological well-being of forced migrants is a growing public mental health concern worldwide. This systematic review explored qualitative evidence of mental health and healthcare issues among LGBTQI + refugees and asylum seekers.

Several themes of this review are consistent with components of the minority stress model.

The theme of discrimination/violence in our research is similar to prejudice events and conditions, so-called distal stressors conceptualized by Meyer. People who experience prejudice vigilantly expect rejection, leading to proximal stressors such as fear, mistrust, avoidance, and isolation. These feelings were reported by participants of reviewed studies frequently. Having multiple marginalized identities (such as being a person of color, a trans woman, and a refugee) increases the exposure to prejudice-related events. It imposes multi-layered stress on the person (Meyer, 2003).

While engaging with the diaspora community is associated with quality of health (WHO African Region, 2018) and well-being (Schweitzer et al., 2006) in refugees and can improve their sense of belonging, findings suggest queer refugees might not necessarily benefit from such connections. Many participants avoided their diaspora to protect themselves from hostile attitudes and behaviors. Few others only kept in touch with select ally members of their community or stayed connected with their fellow citizens or religious communities at the expense of remaining in the closet. For some queer refugees, finding one community meant losing another.

Challenges of participants in asylum systems reveal fundamental gaps between policy and practice. UNHCR repeatedly warns against making assumptions based on stereotypical, inaccurate, or inappropriate perceptions of LGBTI individuals⁵ (UNHCR Guideline 9, 2012). Despite numerous arguments of SOGIESC asylum cases of the US and European courts (e.g., ICJ, 2018), it remains a frequently reported problem. It has been widely discussed that stereotyping in the asylum system ties up with the discretion requirement. For example, the asylum system often assumes male applicants who do not look “gay enough” (do not seem “effeminate” enough) can live in safety in their countries and would not need protection (Jordan, 2009; Miles, 2010; Morgan, 2006).

Although this is the first qualitative systematic review of LGBTQI + forced migrants' mental health, our study has some limitations.

First, more than one published article resulted from the same study project. While each paper has different aims and results (themes), the sample and methodology are the same in the following articles: (Alessi et al., 2016; Alessi, 2016, Alessi et al., 2017), (Alessi et al., 2018a, b), (Kahn et al., 2017; Kahn & Alessi, 2017; Kahn et al., 2018) (Lee & Brotman, 2011, 2013).

Second, the overall synthesis of the results might be skewed because of frequent papers of two authors (Alessi and Kahn) on the topic; however, this is an expected limitation in under-researched fields. Additionally, there was no contradiction among various appeared themes across data of different studies.

Regarding the critical appraisal stage, it is worth mentioning that CASP, like any other assessment tool, might be insufficient to measure the quality of diverse qualitative studies. For instance, document review as a secondary data analysis does not get the score on the reflexivity criterion (the relationship between researcher and participants).

Another potential limitation is publication bias. As we only included published papers, invaluable grey literature such as policy briefs, recommendation papers, and NGO reports were excluded. Consequently, more practical field experience may not be reflected in the overall synthesis.

Moreover, in several studies, the lack of bisexual participants and lower number of trans and lesbian participants were reported as a limitation that may lead to overlooking the experiences of these sub-groups. Also, some studies did not specify the LGBTQI + sub-groups themselves. As Alessi and his colleagues (2017) noted, there is no official data estimation of queer refugees or asylees. Therefore, it is impossible to find whether the sample of studies reflects real demographics of LGBTQI + forced migrants or there are other reasons for underrepresentation of lesbian, bisexual and trans participants. Furthermore, it is more probable that such studies attract volunteers with a higher level of self-acceptance and higher engagement in queer organizations and support groups.

Although we included intersex in our search terms, our review has not yielded any findings on intersex people. Therefore, our evidence-based recommendations may not be extended to people who seek asylum based on sex characteristics.

Despite these limitations, the current systematic review underscores complex psycho-social experiences of LGBTQI + forced migrants and structural challenges they face before, during the move, and after resettlement.

This systematic review aimed to synthesize qualitative studies about mental health of LGBTQI + refugees and asylees by considering their pre-and post-migration experiences. The results reveal that violence or discrimination and subsequent unresolved mental health problems, hurdles of access to mental health services, and ineffective asylum system are principal sources of distress in queer forced migrants’ lives. These findings shed fresh light on intertwined factors that influence the well-being of the target population in their countries, during asylum journeys, and after resettlement.

This section offers a glimpse into possible solutions for post-migration problems, which could be preventable in host countries' health and asylum systems. Based on review findings, we make the following recommendations to the health and asylum system:

- Refugees and asylum seekers are entitled to the right to the highest attainable standard of physical and mental health (WHO African Region, 2018). Policymakers should eliminate restrictions on healthcare entitlements of this population, regardless of their legal residency status (Ooms et al., 2019; Razum & Bozorgmehr, 2016); Universal Health Coverage (UHC) should be aspired to.

- In light of anti-migrant crimes (DW, 2020) and vandalization, anti-LGBTQI + harassment (Alessi et al., 2018a), and hate-motivated assaults against this population (NLtimes, 2020), the safety and security of queer refugees in temporary shelters must always be of paramount consideration, and potential hazards should be predicted and addressed.

- Even for asylum applicants who have not experienced heavy traumas such as torture, prosecution, or physical attack, revealing innermost feelings about one’s gender or sexuality that have been suppressed for years as a survival strategy is a complex and emotionally painful experience (Kahn & Alessi, 2017). While this process seems inevitable for LGBTQI + asylum applicants to prove their “genuine” asylum claim, authorities should address the triggering nature of hearing process in their evaluation. Consideration of asylum seekers’ dignity should be central to all hearings and proceedings.

- Authorities should be aware of different possible emotions that might be observed during interviews. While some people might show mild to severe distress, others may have flat affect while recounting traumatic incidents to emotionally distance themselves from trauma (Jordan, 2009). Emotional reaction should never be considered a reliable factor to invalidate asylum claims.

- Mental health service providers across sectors should be trained for LGBTQI + affirmative, culturally sensitive, anti-racist, and intersectional practice.

- Principles of trauma-informed approach (Alessi, 2016; Kahn & Alessi, 2017) should be a mandatory part of training for all service providers working with refugees and asylum seekers, including lawyers, interpreters, and community advocates. All providers should be able to recognize signs of trauma and appropriately respond to it in a manner that avoids re-traumatization (Substance Abuse & Mental Health Services Administration, 2014).

- Transgender asylum seekers who need gender-affirming healthcare (e.g., hormone replacement and blockers) should be provided with such services in the early weeks of their arrival. Considering this issue will reduce the risk of suicidality (Abramovich et al., 2020).

- Service providers should demonstrate their LGBTQI + affirmative approach using symbols such as a rainbow flag or inclusive posters or slogans in their office, training their staff, and de-gendering bathrooms (Namer & Razum, 2018). They should be aware of their cultural biases and familiarize themselves with diverse forms of gender and sexual expression as well as partnership/family constellations in various cultures. Also, they need to actively practice using inclusive language and reduce their internalized hetero/cisnormative assumptions of love, intimacy, and sex (APA manual, 2019).

- Service providers need to acknowledge gender pronouns and family relations that are not legally recognized. They should find out local LGBTQI + refugee or migrant's networks as referral points and learning resources (Namer & Razum, 2018).

-Mental health professionals need to normalize and destigmatize mental illness to encourage queer refugee clients to discuss their symptoms openly with them. LGBTQI + refugees, as Kahn and colleagues (2018) discussed, are accustomed to covering their stigmatized sexual or gender identities. Consequently, they might hide other stigmatized aspects of themselves, including mental health problems.

- Disseminating learning materials in numerous languages about state equality and anti-discrimination policies can reduce discrimination against LGBTQI + refugees in host countries. Intersectional training plans need to acknowledge racial, gender-based, and other forms of discrimination and target local and diaspora communities to ensure everyone who has contact with forced migrants, from education and health systems to detention centers and integration courses, knows LGBTQI + rights and the zero-tolerance discrimination policy. Such training plans can make newcomer LGBTQI + asylees aware of their rights in host countries and empower them to break their silence and complain against discriminatory behaviors.

- In countries with no tolerance or protection for LGBTQI + people, the media propaganda portrays queer people in extremely demonized ways. Narrative interventions (Garagozov & Gadirova, 2019) based on person-to-person contact between volunteer queer persons and newcomer refugees in safe and monitored spaces can be utilized as counter-narratives. Such programs can reduce prejudice, enhance tolerance, resolve potential ideological conflicts in refugee camps, and benefit queer refugees to build meaningful relationships with non-queer members of their diaspora without fear of rejection.

- Queer support organizations and NGOs in host countries by employing queer migrants as staff members can facilitate a sense of belonging in newly arrived LGBTQI + asylees, make the community multi-cultural and encourage community engagement. By interrupting the dominant western culture of the queer organizations in host countries, more refugees and asylum seekers will be motivated to attend support sessions, and it helps them overcome feelings of alienation and isolation.

- Given that the media shape public discourses that can reinforce or dismantle stereotyping, queer representations in the western media need to be changed. The media should avoid reproducing hetero/cis-normative interpretations of LGBTQI + people's relationships and appearance. Instead, they need to portray a more diverse, multi-cultural, yet accurate image of queer community.

- Integration requires learning language and ongoing engagement with local community. Such activities might be challenging for queer refugees who are affected by trauma. In such conditions, pushing them for “quick integration” would not be efficient. Instead, their demands for healing and reconciliation of their new aspects of identity as queer migrant trauma survivors should be recognized.

- Finally, service providers, activists, and researchers should be cautious not to re-stigmatize queer forced migrants within the discourse of “vulnerable” or “traumatized” queer refugees or asylum seekers. The authentic account of resilience and resistance of LGBTQI + forced migrants should be addressed, recognized, and borne witness.