Trauma-Informed Evaluation of LGBTQIA+ Asylum Seekers

• Understand the unique conflicts and complications specific to LGBTQIA+-identifying asylum seekers

• Recognize how trauma can affect a patient’s health status

• Learn how to provide care for a LGBTQIA+ immigrant/refugee patient in a trauma-informed way

• Identify required routine screenings for this specific patient

According to the International Lesbian, Gay, Bisexual, Trans, and Intersex Associate, consensual same-sex acts are punishable by imprisonment in 69 UN member states concentrated mostly in countries of Africa, Asia, Latin America, the Caribbean, and Oceania. Six UN member states currently have a death penalty for same-sex acts: Sudan, Somalia, Nigeria, Iran, Saudi Arabia, and Yemen [1, 2]. For individuals who identify as LGBTQIA+, migration can be a matter of life or death.

In one retrospective chart review of self-identified lesbian, gay, and bisexual patients who sought asylum, 98% had experienced persecution because of their sexual orientation, 84% were survivors of torture, and all had symptoms of depression and anxiety [3]. Persecution of LGBTQIA+ individuals can be relentless and pervasive, and can be at the hands of family, the community, policy, or military in the home, school, workplace, or church [2]. This persecution can come in the form of humiliation, verbal or physical abuse, sexual assault, including “corrective rape”, or murder and can occur regardless of whether same-sex activity is criminalized [2]. As a result, LGBTQIA+ individuals can struggle to consolidate their sexual orientation and gender identity and can have issues with sexual functioning, self-esteem, relationships, and internalized homophobia [2].

The United States recognizes LGBT identity and HIV status as grounds for political asylum [4]. In 1994, the U.S. Attorney Janet Reno released an order that stated “an individual who has been identified as homosexual and persecuted by his or her government for that reason alone may be eligible for relief under the refugee laws on the basis of persecution because of membership in a social group,” effectively opening asylum in the U.S. to gay and lesbian people [2]. Later in 2000, the U.S. Court of Appeals of the 9th Circuit held that the petitioner “a gay man with a female sexual identity, who may be considered a transsexual” was entitled to asylum and withholding of deportation in the asylum case of Hernandez-Montiel v. INS in California, opening asylum in the U.S. to transgender persons [2].

Until LGBTQIA+ rights are respected around the world, asylum remains a lifeline for those fleeing persecution. It is therefore crucial for clinicians to be trained in recognition of trauma and in the longitudinal care of this population.

You are a medical student working at an outpatient family practice clinic. You have a new patient, Sandra, who is here to establish care. She is a 30-year-old female who recently immigrated from El Salvador.

You introduce yourself to the patient: “Hi, I am the medical student working with Dr. Smith today.” You state your name and say, “My pronouns are _______. By what name and pronouns would you like me to address you?”

Pronouns options include (but are not limited to) the following

• she/her/hers

• he/him/his

• they/them/theirs

• Other: leave space for user to write their preferred pronouns

By introducing yourself with your preferred name and pronouns you are making it safer and more comfortable for others who might not use “traditional” pronouns to come out in that space. Additionally, by asking the patient how they would like to be addressed, you are respecting their chosen identity and not jumping to conclusions based on their appearance.

Sandra responds, saying she prefers to be called “Sandra” and uses she/her/hers pronouns. She has not had a visit in a few years and immigrated to the United States from El Salvador five months ago. Dr. Smith asks you to discuss if she has any current concerns, update her past medical history, and think about what screening care she needs as a 30-year-old cisgender female.

You: “Do you mind if I ask you a few questions to see how you are doing?”

Sandra: “Sure, that’s okay.”

Learning Point #1: By asking the patient for permission to begin the interview, you are making it clear that you will ask for their consent and giving them the autonomy to decline answering questions that may be difficult for them.

You: “What brought you in today?”

Sandra: “I haven’t seen a doctor in a few years, and I just moved here from El Salvador so I thought I should come and get checked out. Otherwise, I feel fine.”

You: “Do you have any chronic medical problems or are you taking any medications?”

Sandra: “I don’t have any medical concerns that I know of, and I am not taking any medications.”

You: “Have you had any previous surgeries?”
Sandra: “I had a C-section 4 years ago when my daughter was born.”

You: “How is the health of your family members?”

Sandra: “I haven’t been in touch with my family in a long time, so I do not know how their health is.”

*You notice that Sandra hesitated to answer your questions and seems uncomfortable, avoiding eye contact with you and fidgeting.

You continue asking more about her medical history and notice that Sandra gets increasingly more uncomfortable as you ask about her gynecological and obstetric history and her social history. She continues to avoid eye contact and crosses her arms over her abdomen. Your findings are summarized below.

Past Medical History: No chronic medical conditions. Surgical history notable for a Cesarean delivery 4 years ago.

Obstetric and Gynecological History: G1P1001, G1 was a Cesarean delivery at full term. Periods began at the age of 13 and are regular. She has never had an abnormal pap smear but noted that her last pap smear was 4 years ago when she was pregnant with her daughter. She has never had any STIs.

Medications: none

Family History: unknown

Social History: Lives alone with her four-year old daughter. She denies alcohol, tobacco, or recreational drug use. She works as a waitress and receives health insurance through her job. She admits that she does not know many people in the community she recently moved to. She hesitates to answer questions about her sexual history and asks if you can move on.

At this point, does anything concern you about your interview with Sandra?

Answer (Highlight the following text for the answer): She mentioned that she is estranged from her family and recently moved to the U.S. with her daughter. She has not yet established a support system in her new community. She deflects questions about her sexual history and seems visibly uncomfortable and agitated by some of the topics you are discussing. Avoidance of certain topics and fearful body language, such as her limited eye contact and self-protective posture, can be signs of re-traumatization for patients who have experienced past trauma [5].

You thank Sandra for answering your questions. You tell her you will go discuss with Dr. Smith and you will return with him for the physical exam and the remainder of the visit.

You discuss your findings with Dr. Smith, mentioning your concern for certain elements of Sandra’s history. You remember that screening for depression and suicide risk in adults is a Grade B recommendation by the U.S. Preventive Services Task Force (USPSTF) [6]. You ask if you can administer a Patient Health Questionnaire-9 (PHQ-9) to Sandra.

Question

What other screening should Sandra receive as a 30-year-old cisgender female? More than one answer choice can be chosen.

A. Breast Cancer Screening

B. Cervical Cancer Screening

C. Chlamydia and Gonorrhea Screening

D. Hepatitis C Virus Infection Screening

E. HIV Infection Screening

F. Hypertension

G. Intimate Partner Violence (IPV) Screening

H. Type 2 Diabetes Screening

Answer (Highlight the following text for the answer): Cervical Cancer Screening, Hepatitis C Virus Infection Screening, HIV Infection Screening, Hypertension, Intimate Partner Violence Screening

Explanation:

• Breast Cancer Screening is recommended for women after the age of 50 [7]

• The USPSTF recommends cervical cancer screening in women aged 30-65 via cervical cytology alone every 3 years and via HPV co-testing alone or HPV co-testing with cervical cytology every 5 years [7]

• Chlamydia and Gonorrhea Screening is recommended in sexually active women 24 years or younger or in women 25 years or older who are at increased risk of infection [7]

• Hepatitis C Virus infection should be screened in adults aged 18-79 [7]

• HIV infection should be screened in adults aged 15-65 [7]

• Hypertension should be screened in adults over the age of 18 with office blood pressure measurement [7]

• IPV should be screened in women of reproductive age [7]

• Screening for Type 2 Diabetes does not begin until the age of 35 [7]

Sandra completes a PHQ-9 form and her total score is 14, which is consistent with moderate depression [8]. You decide to ask additional questions to find out more, but do not want to make her feel more uncomfortable or distrustful of you.

How can you make Sandra feel more comfortable while asking her personal questions about her social and psychiatric history?

Answer (Highlight the following text for the answer): 

• You can normalize the situation and tell the patient that you ask all patients these questions. 

• It helps to explain why you are asking these questions and that your goal is to help them [9, 10]

• Remind the patient that the conversation will remain confidential [9]

• Let the patient drive the process, as the extent to which her history is explored is dependent on her comfort level [5]

• Make it clear that you can stop at any time she wants to

Learning Point #2: People who have experienced past trauma can find it difficult to believe that people want to help them and can get hypervigilant and fearful if they encounter someone who reminds them of their tormentors. The interview process itself can induce feelings of trauma because it can make them feel as though they are still under investigation and scrutiny [11, 12].

You: “Has anything occurred in the past few months since your move that could be making you feel this way?”

Sandra: “Well, I felt unsafe in my home country so I’m relieved that I moved, but things are so different here. And I’m here with just my daughter and I need to take care of her. I don’t feel that comfortable being involved with the Salvadoran community here. I don’t really feel like I belong at all.”

You: “Is there a reason you don’t feel comfortable with this particular community?”

Sandra: “I was tormented and persecuted in El Salvador, which is why I had to leave. It’s hard for me to trust Salvadorans here because I fear they will do the same thing to me again.”

Learning Point #3: People who flee their home country due to persecution can struggle to feel at ease with members of their ethnic community post-migration. This, in turn, can limit their support system in their new home [11]. LGBTQIA+ individuals specifically can suffer from “double marginalization” post-migration: they feel marginalized from their ethnic community because they are the same people who persecuted them and they feel marginalized from LGBTQIA+ communities in the country they migrate to due to their refugee or immigrant status [2].

You: “I am so sorry to hear that you went through that. I noticed when I asked you some questions about your sexual history earlier, you asked me to move on. We do not have to discuss anything that is uncomfortable for you, but is there anything in particular that is bothering you?”

Sandra discloses to you that she was sexually assaulted and forced to have non-consensual intercourse with a man from her community in El Salvador because she was caught in an intimate relationship with another young woman. Her 4-year-old daughter was born as a result of that “corrective rape”. Her family did not support her and allowed her to be persecuted by the rest of her community. She was forced to cut off contact with her partner and feared for her life. She was eventually able to flee and apply for asylum in the United States.

Learning Point #4: Asylum seekers who identify as LGBTQIA+ are unique from other persecuted groups in that their families can often contribute to the persecution they face and they sometimes need to continue to be “closeted” from their family of origin and community about the basis of their asylum status [2, 11]. LGBTQIA+ individuals are forced to live with their fear and guilt while adhering to religious and societal norms. This discrimination can, in turn, breed assault [12].

She tells you that she is currently applying for asylum and that the asylum process is hard because she feels like she is living in limbo and is worried she will be sent back to El Salvador [12]. She is also constantly questioned during the process and feels as though people are trying to make her define her sexual orientation. She is worried the asylum officers and judges will also be judgmental of her past, especially her assault and relationship with another young woman [2].

Learning Point #5: Individuals can struggle to “convince” adjudicators that they are part of the LGBTQIA+ community because they themselves do not have the space or freedom to work through the internal processes necessary to allow them to integrate the multiple aspects of their sexuality in a safe environment [11]. Additionally, it is very common for LGBTQIA+ individuals to experience developmental changes in their identity after migration [11].

When interviewing LGBTQIA+ asylum seekers, it is important to ask them about features of their identity rather than fixating on a label or the gender of their partner. Such features include sexual feelings, sexual fantasy, crushes and falling in love, romantic relationships, and more [11]. Ahola & Shidlo (2011, updated 2020 by Ahola, Shidlo and Wozniak) developed an assessment tool to assist in defining sexual orientation and gender identity and to document developmental events in sexual orientation and gender identity in asylum seekers. [13]

The screening tool can be found here: https://static1.squarespace.com/static/5f32b6b841796024eb295de2/t/6151be62d448400716e4b4ea/1632747107266/Sexual+Orientation+and+Gender+Identity+Assessment+in+LGBTI+Asylum+Seekers+and+Refugees.pdf 

For LGBTQIA+ individuals, the first year of their arrival is the first time they can catch their breath, but they can also experience symptoms of cumulative trauma catching up with them. This could lead to episodes of major depression and PTSD [2].

As a victim of trauma, what is Sandra at risk for?

A.   Disruptions in memory and concentration

B. Re-experiencing her trauma

C. Panic disorder

D.   Substance abuse

E. All of the above

Answer (Highlight the following text for the answer): All of the above [2, 11] and more.

Victims of trauma can have disruptions in their memory and concentration, hopelessness, difficulty trusting, detachment from emotional responses, shame when recounting her trauma. She can struggle with emotional dysregulation, cognitive deficits, and sleep disorders. This can increase her risk for recurrent depression, dissociated disorders, panic disorder, generalized anxiety disorder, social anxiety, substance abuse, and suicide. This can further threaten their physical health [12].

What are some resources you can provide for the patient?

Emergency Resources

• Crisis Text Line: https://www.crisistextline.org/texting-in

  • Text HOME to 741 741

• National Suicide Prevention Lifeline: https://suicidepreventionlifeline.org

  • 1-800-273-TALK

• SAMHSA National Helpline: www.samhsa.gov/find-help/national-helpline

  • 1-800-662-HELP

Mental Health Provider Organizations and Directories

• International Society for Traumatic Stress: https://istss.org  

  • “Find a clinician” tool

• EMDR International Association: https://www.emdria.org

  • Searchable database of trained therapists

• Postpartum Support International: https://www.postpartum.net 1-800-994-4773

  • Text 503-894-9453

• American Psychological Association: https://locator.apa.org 

  • American Psychiatric Association: http://finder.psychiatry.org/ 

LGBTQ-specific Resources 

• The Trevor Project: https://www.thetrevorproject.org/ 

  • 1-866-488-7386

• Parents, families and friends of Lesbians and Gays (PFLAG): https://pflag.org/get-support/ 

Intimate Partner Violence and Sexual Assault

• National Domestic Violence Hotline: https://thehotline.org

  • 1-800-799-SAFE

• Love is Respect (for teens): www.loveisrepsect.org

  • Text LOVEIS to 22522 1-866-331-9474

• Rape, Abuse & Incest National Network: https://www.rainn.org 

  • 1-800-656-HOPE

Provider Toolkit

• Council of Patient Safety in Women’s Health Care Support after a Severe Maternal Event Bundle: https://safehealthcareforeverywoman.org/patient-safety-bundles/support-after-a-severe-maternal-event-supported-by-aim

After thanking Sandra for sharing her story with you, you and Dr. Smith step outside to discuss the next steps in her care. Dr. Smith tells you that he would like to do a basic physical exam but would like to defer a pelvic exam and pap smear until he is able to build more rapport with Sandra.

Learning Point #6: In conducting a clinical examination of a victim of torture, it is important to first offer the patient choice in the gender of their healthcare provider, if possible. Studies have shown that most victims of sexual assault, both male and female, preferred their clinician to be female [14]. Obtain informed consent from the patient for each part of the exam performed and ask the patient for their preferences in positioning or comfort [15]. It is also recommended to have a neutral person present, like having a female chaperone if a male is examining a female patient, for example [16]. Prior to beginning a physical exam, the provider should meet with the patient before they disrobe, and ask them to only disrobe when necessary or only partially disrobe [15]. If the examination includes a head-to-toe assessment, use recognized draping techniques to keep as much covered as possible during the examination [16]. 

Physical Exam:

Vital signs:

·  Temperature: 98.7 F

·  Pulse: 76 bpm

·  Respiratory rate: 12 breaths/minute

·  Blood pressure: 125/78 mmHg

·  Weight: 143 lbs

·  Height: 5’5’’

·  BMI: 23.8

General: Sandra is well-appearing and in no acute distress.

HEENT: all unremarkable.

Cardiovascular: regular rate and rhythm, normal S1 and S2. No murmurs, rubs, or gallops appreciated.

Respiratory: lungs clear to auscultation bilaterally

Abdominal: soft, nontender, nondistended. Normal bowel sounds. No rebound tenderness or guarding.

Musculoskeletal: normal range of motion of all joints.

Neurological: cranial nerves intact, normal strength and sensation, reflexes are equal and symmetrical, normal gait.

After assuring Sandra that everything looks normal on her physical exam, Dr. Smith sits down to discuss the next steps with her. He tells her that he would like to send her for some routine blood work to establish her baseline. He asks to follow up with her in two weeks to discuss the results of her blood work and asks her to consider if she would like to have her pap smear done at that visit. He discusses whether she is interested in speaking with a psychiatrist and if she would like to be treated for depression.

Sandra tells us she will think about it, but will schedule her appointment in two weeks to see Dr. Smith again.

As exemplified by Sandra’s case, asylum seekers who identify as LGBTQIA+ face challenges that are unique to them. As clinicians, our responsibility is to use techniques that minimize re-traumatization for our patients [11]. According to the Istanbul Protocol, clinicians should have cultural humility and transcultural perspective [14]. Patients are more likely to disclose important details of their past only once meaningful rapport has been established [10]. The clinician needs to recognize and acknowledge that diversity is normal and not a mental illness, address the individual by their chosen name and pronouns, and not ask the individual to “explain” their sexual orientation or identity [14]. Especially when it comes to LGBTQIA+ patients, clinicians must be prepared to listen to what may be the first time the patient is disclosing these pieces of their identity in what could be a cathartic event [10]. If the individual is able to build this trust with their provider, it could have an instrumental effect on their overall mental and physical health.

1. Mendos LR, Botha K, Lelis RC, López de la Peña E, Savelev I, Tan D. State-Sponsored Homophobia 2020: Global Legislation Overview Update. https://ilga.org/downloads/ILGA_World_State_Sponsored_Homophobia_report_global_legislation_overview_update_December_2020.pdf. Geneva: ILGA; December 2020.  

2. Ahola J. The Mental Health Evaluation of the LGBTI Asylum Seekers and Documentation of Findings 2022. PowerPoint slideshow. 2022. 

3. Piwowarczyk L, Fernandez P, Sharma A. Seeking Asylum: Challenges Faced by the LGB Community. J Immigr Minor Health. Jun 2017;19(3):723-732. doi:10.1007/s10903-016-0363-9

4. Tiven RB, Neilson V. Working with lesbian, gay, bisexual, and transgender immigrants. In: Chang-Muy F, Congress EP, eds. Social work with immigrants and refugees. Springer; 2016:257-267v.

5. Ades V, Wu SX, Rabinowitz E, et al. An Integrated, Trauma-Informed Care Model for Female Survivors of Sexual Violence: The Engage, Motivate, Protect, Organize, Self-Worth, Educate, Respect (EMPOWER) Clinic. Obstet Gynecol. Apr 2019;133(4):803-809. doi:10.1097/aog.0000000000003186

6. Depression and Suicide Risk in Adults: Screening. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-depression-suicide-risk-adults

7. A & B Recommendations. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations

8. Spitzer RL, Williams JBW, Kroenke K. Patient Health Questionnaire-9. Pfizer Inc.

9. Simone MJ, Appelbaum JS. Addressing the Needs of Older Lesbian, Gay, Bisexual, and Transgender Adults. Clinical Geriatrics. 2011;19(2):38-45. 

10. Nakamura N, Skinta M. LGBTQ Asylum Seekers: How Clinicians Can Help. American Psychological Association. https://www.apa.org/pi/lgbt/resources/lgbtq-asylum-seekers.pdf. 

11. Shidlo A, Ahola J. Mental health challenges of LGBT forced migrants. Forced Migration Review: Sexual orientation and gender identity and the protection of forced migrants. 2013. p. 9-11.

12. Kostenius C, Hertting K, Pelters P, Lindgren E-C. From Hell to Heaven? Lived experiences of LGBTQ migrants in relation to health and their reflections on the future. Culture, Health & Sexuality. 2021;doi:10.1080/13691058.2021.1983020

13. Ahola J, Shidlo A. Sexual Orientation and Gender Identity Assessment in LGBTI+ Asylum Seekers and Refugees. Research Institute Without Walls; 2020.

14. Chowdhury-Hawkins R, McLean I, Winterholler M, Welch J. Preferred choice of gender of staff providing care to victims of sexual assault in Sexual Assault Referral Centres (SARCs). J Forensic Leg Med. Aug 2008;15(6):363-7. doi:10.1016/j.jflm.2008.01.005

15. Subramanian S, Green JS. The General Approach and Management of the Patient Who Discloses a Sexual Assault. Missouri Medicine. 2015;112(3):211–217.  ​​

16. Herath JC, Pollanen MS. Clinical Examination and Reporting of a Victim of Torture. Acad Forensic Pathol. Sep 2017;7(3):330-339. doi:10.23907/2017.030

17. Office of the High Commissioner for Human Rights. Istanbul Protocol: Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. Refworld. 2022.