LGBTQI + refugees and asylum seekers experience enormous distress during their lifespan. Ill-effects of socio-cultural stigma, systemic violence, and forced migration due to sexual orientation, gender identity or expressions, and sex characteristics (SOGIESC) are not their only challenge. The cumbersome asylum process in host countries negatively affects their mental health and well-being. The objective of this systematic review was to retrieve, critically evaluate and synthesize the evidence from qualitative data relating to mental health conditions of LGBTQI + forced migrants before, during, and after resettlement.
Seven Databases (Web of Science, PubMed, Taylor, and Francis online as well as MEDLINE, PSYNDEX, PsycINFO, and PsycArticles via EBSCO) were queried with relevant search terms between January and April 2020. To be included in the analysis, studies had to be qualitative and published in peer-reviewed journals between 2002 and 2020. Of 410 records, 23 of them met the inclusion criteria. Two low-score records were removed after critical evaluation with the CASP (Critical Appraisal Skills Program). Data from 21 studies were extracted. Qualitative meta-aggregation was implemented as the data synthesis strategy.
Four emerged themes were linked to distress: Violence/discrimination, mental healthcare access barriers, asylum system challenges, and unaddressed mental health difficulties. Coping strategies and support resources were two other relevant themes across and within the data.
Experiencing violence and deprivation of equitable mental health services in countries of origin due to SOGIESC status, difficulties in the asylum process, limited care in detention centers, cultural and financial barriers in host countries, and finally, discrimination based on multiple marginalized identities explain how the mental health condition of LGBTQI + forced migrants is inextricably intertwined with structural discrimination.
Host countries need to ensure migrant and local communities are aware of state equality and LGBTQI + anti-discrimination policies. Service providers in both asylum and health systems need to be trained for affirmative, culturally sensitive, and intersectional approaches in their practice and avoid treating queer clients against their expectations and stereotypes. Also, they should address the authentic accounts of resilience and resistance of LGBTQI + forced migrants.
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 Footnote 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 Footnote 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.
Framework and Search Strategy
Considering PCO (population, context, outcome) as a framework (Table 1) and following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher et al., 2015), a systematic exploratory English language search was undertaken by two reviewers (AN and YN) independently on seven electronic databases (Web of Science, PubMed, Taylor & Francis online as well as MEDLINE, PSYNDEX, PsycINFO, and PsycArticles via EBSCO). Studies published between January 2002 Footnote 3 and April 2020 (the time of the search) were queried. The systematic review was registered with PROSPERO, the international register of systematic reviews (Record ID: CRD42020183824). EndNote X9.2 (EndNote Team, 2013) was utilized as a reference management tool to organize search records.
Examples of Database Search
Web of Science
(LGBTQIA OR LGBTQIAGNC OR LSBTQ OR LGBT OR GLBT OR LGB OR LG OR homosexual* OR bisexual* OR transgender* OR transsex* OR trans OR queer OR lesbian OR gay OR gender-nonconform* OR intersex OR "sexual minorit*") AND TOPIC: (refugee* OR "forced migra*" OR "asylum seek*") AND TOPIC: (mental health). Indexes = SCI-EXPANDED, SSCI, A&HCI, ESCI Timespan = 2002-2020
Taylor & Francis Online
[[All: lgbtqia] OR [All: lgbtqiagnc] OR [All: lsbtq] OR [All: lgbt] OR [All: glbt] OR [All: lgb] OR [All: lg] OR [All: homosexual*] OR [All: bisexual*] OR [All: transgender*] OR [All: transsex*] OR [All: trans] OR [All: queer] OR [All: lesbian] OR [All: gay] OR [All: gender-nonconform*] OR [All: intersex] OR [All: "sexual minorit*"]] AND [All: "mental health"] AND [[All: refugee*] OR [All: "asylum seeker"] OR [All: "forced migra*"]] AND [Publication Date: (01/01/2002 TO 12/31/2020)].
(LGBTQIA OR LGBTQIAGNC OR LGBTQ OR LGBT OR GLBT OR LGB OR LG OR homosexual* OR bisexual* OR transgender* OR transsex* OR trans OR queer OR lesbian OR gay OR gender-nonconform* OR intersex OR "sexual minorit*") AND (refugee* OR "forced migra*" OR "asylum seek*") AND (mental health) Filters: from 2002-2020.
Inclusion and Exclusion Criteria
Details of the search terms and inclusion criteria are illustrated in Tables 2 and 3.
After removing duplicates and three phases of screening (by title, by abstract, and by full text), from a total of 410 records (17 records from citation chaining and unsystematic bibliography screening and 393 records from databases), 23 records met the inclusion criteria.
From the total number of 410 records, 387 were excluded in different screening phases. Excluded records were mainly grey literature, editorials, reviews, commentaries, and conference abstracts or studies with samples that do not meet the inclusion criteria (e.g., unspecified refugees rather than LGBTQI + refugees). Employing a solely quantitative research method was another exclusion criterion, as can be seen in Fig. 1.
Quality Assessment (Critical Appraisal)
The critical appraisal skills program (CASP) Singh, 2013) Footnote 4 for qualitative studies was used for assessment of included records which were undertaken by two reviewers independently to reduce the risk of bias. We chose CASP since it is the most commonly adopted tool for quality appraisal in health-related qualitative evidence syntheses, endorsed by Cochrane Qualitative and Implementation Methods Group (Long et al., 2020). Minor discrepancies were discussed to reach an agreement; however, no significant difference was found between the scoring of the two independent evaluators (AN, YN). The third author (OR) was available to discuss and comment on disagreements throughout the review process. He critically revised the protocol and the manuscript for intellectual content.
Two low score records were removed after critical appraisal to enhance the quality of the review. We considered six as a cut-off point following a scoring system suggested by Butler and colleagues (2016). Two papers (Keuroghlian et al., 2017 and Giametta, 2018) received scores lower than 6. Table 4 depicts characteristics of all records which met inclusion criteria.
Over 410 records, 23 studies met the inclusion criteria, and 21 studies were qualified for data extraction. First, a detailed cross-study analysis was undertaken to generate a coding frame; Then, we identified a set of overarching themes across the records. Data were extracted using MAXQDA 2020 (VERBI Software, 2019) prior to qualitative synthesis. Data refer to first-order constructs (participants and service providers quotes), case presentations, and evaluation parts of case studies. We did not extract researchers' interpretations and statements or assumptions to capture the first-hand accounts of research participants. We utilized meta-aggregation as a method of synthesis. Meta-aggregation synthesis aims to categorize findings into groups based on similarities in meaning and summarize them to produce a cross-study overview (Munn et al., 2014; Pearson et al., 2011).
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.
Discrimination or Violence
The theme widely covers various forms of individual misconduct or structural discrimination or violence that participants reported in pre-and post-migration stages. The theme is divided into two sub-themes that describe perpetrators (e.g., individuals or institutions) and the stage when violence or discrimination happens (before/during asylum, after resettlement).
Before the asylum process, at an interpersonal level, study participants reported being subjected to violence by family, neighbors, or members of their communities at home, school, or work. These experiences of violence were often mentioned as reasons for the decision to leave their countries (Alessi et al., 2018b; Gowin et al., 2017). At a structural level, violent treatment by law enforcement, such as police officers, was also frequently reported, often attached to prosecution experiences (Alessi et al., 2017; Cheney et al., 2017; Gowin et al., 2017; Jordan, 2009). Participants described experiences ranging from verbal assaults (Abramovich et al., 2020; Alessi et al., 2016; Cheney et al., 2017; Gowin et al., 2017) and violent physical attacks (Abramovich et al., 2020; Alessi et al., 2016; Alessi et al., 2018b; Cheney et al., 2017; Gowin et al., 2017; Macdonell & Daley, 2015; Ward, 2018) to sexual harassment, rape, or torture in their countries (Alessi, 2016; Alessi et al., 2016; Gowin et al., 2017; Jordan, 2009; Macdonell & Daley, 2015; Nguyen et al., 2019).
In the asylum process, participants reported being subjected to exploitation by traffickers (Alessi et al., 2018b), bullying in the asylum detentions (Alessi et al., 2018a, 2018b; Chavez, 2011; Kahn et al., 2017) or misconduct and abuse by service providers (Jordan, 2009; Kahn, 2015).
Inappropriate comments, questions, or presumptions of authority figures such as immigration and government officials or service providers in host countries (Jordan, 2009; Kahn et al., 2017; Lee & Brotman, 2013) were examples of structural discriminations.
Following resettlement, rejection, or prejudice by members of diaspora community (Alessi et al., 2018a; Kahn & Alessi, 2017: Lee & Brotman, 2011) appeared to be common. Racial discrimination (Alessi, 2016; Alessi et al., 2018a), daily life challenges, including discrimination in housing (Abramovich et al., 2020; Logie et al., 2016), and employment (Alessi, 2016; Lee & Brotman, 2011), were examples of participants post-migration victimization experiences.
Despite various perpetrators, severity, or types (verbal or physical violence, racial or SOGIESC-based discrimination or prejudicial assumptions or biases), violence or discrimination appeared to be constant elements of refugees' and asylees' lives before leaving their countries, during their journey to the host country, in the process of seeking asylum, and following resettlement.
Access Barriers to Mental Healthcare
This theme refers to hurdles and system shortages that prevent participants from seeking or receiving adequate mental healthcare or support in host countries. Participants shared common challenges of other (non-LGBTQI +) asylees or refugees, such as language or cultural barriers (Abramovich et al., 2020; Alessi, 2016) or financial concerns (Abramovich et al., 2020; Chavez, 2011; Kahn et al., 2018). [Free or affordable mental health services are not always included in health packages or insurance schemes offered to refugees or asylees].
Lack of appropriate health insurance, especially for undocumented or rejected asylum seekers who often live without legal protection in host countries, caused considerable concerns. Undocumented participants were unwilling to seek help due to impossible access to health services without identity documents or fear of the police investigation and deportation (Chavez, 2011; Gowin et al., 2017).
Besides shared concerns with non-LGBTQI + forced migrants, participants reported SOGIESC-specific concerns when navigating the mental healthcare system. They were hesitant or avoidant to seek help and disclose their SOGIESC status in health settings due to internalized shame or fear of discrimination (Kahn et al., 2018). Moreover, some participants were reluctant to seek help from health providers or interpreters belonging to their diaspora communities because of mistrust, fear of unwanted coming out among fellow citizens, and further (anticipated) stigma (Kahn et al., 2018).
Living in suburbs or small towns far from LGBTQI + friendly service providers and support groups (Jordan, 2009; Kahn et al., 2018) was also reported as an access barrier.
Challenges in the Asylum System
Another source of pressure among LGBTQI + forced migrants was the difficulty of navigating the asylum system. Several participants reported that they were unaware of the possibility of seeking asylum based on SOGIESC status when they entered the host country (Alessi, 2016; Gowin et al., 2017; Jordan, 2009). Moreover, they mainly considered the asylum process, especially the interview, so-called hearing, as the primary source of distress (Kahn & Alessi, 2017). They reported expectations to comply with a stereotypical westernized notion of the LGBTQI + identity (Lee & Brotman, 2011), such as presenting specific gender expressions (Jordan, 2009) or labels (Borges, 2019) to be considered “credible”.
Participants were expected to portray their gender or sexuality as an intrinsic, essential, and stable trait (Jordan, 2009), narrate a coming-out story (Kahn & Alessi, 2017), and comfortably disclose the most private details of their intimate lives to relevant authorities (Kahn, 2015).
Furthermore, participants had to prove experiences of danger or persecution and provide a migration trajectory that conforms with fugitive’s flight presumption (Alessi et al., 2018a, 2018b; Jordan, 2009; Lee & Brotman, 2011).
Queer asylum seekers felt pressure to live “out and proud” and demonstrate evidence of LGBTQI + community engagement in the host country to be accepted as a “valid” case (Jordan, 2009; Kahn & Alessi, 2017).
Unaddressed Mental Health Difficulties
The last source of pressure for LGBTQI + refugees and asylees was their unaddressed mental health conditions. Participants frequently reported trauma symptoms such as hypervigilance, avoidance, depression, suicidality, and social alienation. (Alessi et al., 2016, 2018b; Gowin et al., 2017; Jordan, 2009; Kahn & Alessi, 2017; Nguyen et al., 2019). Mistrust and fear were two common negative feelings reported by participants due to consecutive calamitous stress-inducing life events (i.e., persecution, humiliation, arbitrary arrest, torture, brutal beating, and rape, mainly before asylum). (Alessi, 2016; Alessi et al., 2017; Cheney et al., 2017; Gowin et al., 2017; Jordan, 2009; Kahn & Alessi, 2017; Kahn et al., 2017; Macdonell & Daley, 2015; Nguyen et al., 2019). Almost all included studies addressed trauma. Two case reports (Abramovich et al., 2020; Nguyen et al., 2019) specifically described traumatic symptomatology, including anxiety, grief, and suicidality.
Coping strategies and support resources were two other emerged themes across data. Various coping mechanisms such as drinking or using drugs (Gowin et al., 2017; Macdonell & Daley, 2015), ignoring discrimination (Borges, 2019), hope and staying positive (Alessi, 2016), community engagement (Logie et al., 2016), activism (Alessi, 2016; Borges, 2019; Jordan, 2009; Lee & Brotman, 2011), and religious activities (Alessi, 2016) were adopted by participants to relieve distress. Participants utilized different strategies to negotiate their interactions with their community; staying in the closet in their countries and avoiding diaspora community after migration were two common strategies to avoid stigma and discrimination (Kahn, 2015; Kahn et al., 2017). Some participants either hid or negotiated their queer identity with diaspora to maintain connections (Lee & Brotman, 2011). Ally friends or relatives, affirmative service providers, and LGBTQI + organizations were considered sources of support (Alessi, 2016; Logie et al., 2016).
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 individualsFootnote 5 (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).
Barriers of access to mental health services such as financial or insurance difficulties highlight the significance of social determinations of mental health. Low socio-economic status prevents access to primary and preventive care, leading to more chronic symptoms of mental disorders. Having a mental health condition will diminish the chances of learning a new language, integration into the host country, and employment for LGBTQI + forced migrants and perpetuate the vicious cycle of their marginalization.
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.
Studies included in the review also have limitations. First and foremost, queer forced migrants are a hard-to-reach population, and non-probability sampling has been used in all included studies (convenience, purposive, or snowball).
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.
Recommendations for Policy and Practice
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.
MAXQDA file will be available on Zenodo:10.5281/zenodo.6176286.The review protocol has been published on: PROSPERO https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020183824
An Asylum seeker or asylee refers to a person in the asylum process and before granting the asylum status. A refugee refers to someone who has been granted asylum status. The term forced migrant widely includes refugees, asylum seekers, and undocumented migrants with a withholding of removal status. Therefore, we used the last term to refer to all groups regardless of their legal residency status in most parts of the text.
According to UNHCR (October 2012), the possibility of discretion (avoiding persecution by concealing or by being “discreet” about one’s sexual orientation or gender identity) is not a valid reason to deny refugee status. ̔LGBTQI + people are as much entitled to freedom of expression and association as non-LGBTQI + people. However, Discretion reasoning is still persistent and appears in many forms and with many different faces in asylum systems.
Sexual orientation was first mentioned in the 2002 United Nations High Commissioner for Refugees (UNHCR) Gender Guidelines as a gendered ground for persecution and thus seeking asylum. Gender identity was added in the 2008 UNHCR Guidance Note.
The CASP tool was developed by the Public Health Resource Unit of the National Health Service in collaboration with the U.K. Centre for Evidence-Based Medicine and the Birmingham critical appraisal skills program. CASP is a checklist containing ten questions. It evaluates aim, appropriateness of research design, congruity between the research aim and design, congruity between the research aim and recruitment strategy, explicitly of data collection, reflexivity (the relationship between researcher and participants), ethical issues, rigor in data analysis, results explicitly and, research implications (knowledge or theory production, implications for practice or policy). Each criterion may score 1 (YES), 0 (No) or 0.5(Unsure). If a qualitative research report meets the full criteria, it will get 10.
Two reviewers independently re-assessed case studies with two other assessment tools: Critical Appraisal of a Case Study (Center for Evidence-Based Management) and Critical Appraisal Guideline for Case Studies (Atkinson & Sampson, 2002) to ensure the quality of case studies. We obtained very similar scores within these three tools that affirm the reliability of CASP for case study assessment.
The UNHCR used the LGBTI in guideline number 9 (2012). We used the same acronym when citing this reference. However, in other parts of the text, we prefer the LGBTQI+ to include those who identify as queer and non-binary and add a plus (+) to consider local and indigenous people who may use non-western terms (such as hijra in Indian culture or Mamluk in Egypt).
References Marked With an Asterisk Indicate Studies Included in the Systematic Review
Aygün, E. (2019). Practice, Prospects, and Challenges of NGOs Working with LGBTIQ Asylum-Seekers in Germany: Homonationalism as a Practice Informing Concept for International Social Work with LGBTIQ Asylum-Seekers and Refugees. [Unpublished master’s thesis]. University of Applied Sciences Würzburg-Schweinfur.
Atkins, C., & Sampson, J. (2002). Critical Appraisal Guidelines for Single Case Study Research. ECIS. https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.97.8700&rep=rep1&type=pdf
*Abramovich, A., Lam, J. S. H., & Chowdhury, M. (2020). A transgender refugee woman experiencing posttraumatic stress disorder symptoms and homelessness. Canadian Medical Association Journal, 192(1), 9–11. https://doi.org/10.1503/cmaj.190974
*Alessi, E. J. (2016). Resilience in sexual and gender minority forced migrants: A qualitative exploration. Traumatology, 22(3), 203–213. https://doi.org/10.1037/trm0000077
*Alessi, E. J., Kahn, S., & Chatterji, S. (2016). 'The darkest times of my life': Recollections of child abuse among forced migrants persecuted because of their sexual orientation and gender identity. Child Abuse & Neglect, 51(?), 93–105. https://doi.org/10.1016/j.chiabu.2015.10.030
*Alessi, E. J., Kahn, S., & Van Der Horn, R. (2017). A qualitative Exploration of the premigration victimization experiences of sexual and gender minority refugees and asylees in the United States and Canada. Journal of Sex Research, 54(7), 936–948. https://doi.org/10.1080/00224499.2016.1229738
*Alessi, E. J., Kahn, S., Greenfield, B. Woolner, L., & Manning, D. A. (2018a). Qualitative Exploration of the Integration Experiences of LGBTQ Refugees Who Fled from the Middle East, North Africa, and Central and South Asia to Austria and the Netherlands. Sexuality Research and Social Policy, 17(?),13–26 (2020). https://doi.org/10.1007/s13178-018-0364-7
*Alessi, E. J., Kahn, S., Woolner, L., & Van Der Horn, R. (2018b). Traumatic Stress Among Sexual and Gender Minority Refugees From the Middle East, North Africa, and Asia Who Fled to the European Union. Journal of Traumatic Stress, 31(6), 805–815. https://doi.org/10.1002/jts.22346
Bachmann, C. L. (2016). No safe refuge. Experiences of LGBT asylum seekers in detention. UK Lesbian & Gay Immigration Group: Stonewall.
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77–101. https://doi.org/10.1191/1478088706qp063oa
Brooks, V. R. (1981). Minority stress and lesbian women. Lexington.
* Borges, S. (2019). “We have to do a lot of healing”: LGBTQ migrant Latinas resisting and healing from systemic violence. Journal of Lesbian Studies. https://doi.org/10.1080/10894160.2019.1622931
Butler, A., Hall, H., & Copnell, B. (2016). A Guide to Writing a Qualitative Systematic Review Protocol to Enhance Evidence-Based Practice in Nursing and Health Care. Worldviews on Evidence-Based Nursing, 13(3), 241–249. https://doi.org/10.1111/wvn.12134
Bennett, C. & Thomas, F. (2013). Seeking asylum in the UK: lesbian perspectives. Forced Migration Review, 42(4), 25–29
Center for evidence-based management (CEBMA). Critical Appraisal of a Case Study: https://www.cebma.org/wp-content/uploads/Critical-Appraisal-Questions-for-a-Case-Study.pdf
Charmaz, K. (2006). Constructing Grounded Theory: A Practical Guide through Qualitative Analysis. Sage.
Charmaz, K. (2014). Constructing grounded theory (2nd ed.). Thousand .Sage
* Chavez, K. R. (2011). Identifying the needs of LGBTQ immigrants and refugees in Southern Arizona. Journal of homosexuality, 58(2), 189–218. https://doi.org/10.1080/00918369.2011.540175
* Cheney, M. K., Gowin, M. J., Taylor, E. L., Frey, M., Dunnington, J., Alshuwaiyer, G., Huber, K Camero Garcia, M., & Wray, G. C. (2017). Living outside the gender box in Mexico: Testimony of transgender Mexican Asylum Ssekers. American Journal of Public Health, 107(10), 1646–1652. https://doi.org/10.2105/ajph.2017.303961
Dustin, M. (2018). Many Rivers to Cross: The Recognition of LGBTQI Asylum in the UK. International Journal of Refugee Law, 30(1), 104–127. https://doi.org/10.1093/ijrl/eey018
Deutsche Welle news (DW). (2020). Germany: More than 1,600 crimes 'targeted refugees and asylum-seekers' Deutsche Welle: https://www.dw.com/en/germany-more-than-1600-crimes-targeted-refugees-and-asylum-seekers/a-52935715
EndNote Team. (2013). EndNote X9 [computer software]. Clarivate Analytics. https://endnote.com
Fredriksen-Goldsen, K. I., Simoni, J. M., Kim, H. J., Lehavot, K., Walters, K. L., Yang, J., Hoy-Ellis, C. P., & Muraco, A. (2014). The health equity promotion model: Reconceptualization of lesbian, gay, bisexual, and transgender (LGBT) health disparities. The American Journal of Orthopsychiatry, 84(6), 653–663. https://doi.org/10.1037/ort0000030
Giametta, C. (2018). New asylum protection categories and elusive filtering devices: the case of ‘Queer asylum’ in France and the UK. Journal of Ethnic and Migration Studies, 46(1), 1–16. https://doi.org/10.1080/1369183X.2018.1500172
Glaser, B. G. & Strauss, A. (1967). The Discovery of Grounded Theory. Aldine.
* Gowin, M., Taylor, E. L., Dunnington, J., Alshuwaiyer, G., & Cheney, M. K. (2017). Needs of a Silent Minority: Mexican Transgender Asylum Seekers. Health Promotion Practice, 18(3), 332–340. https://doi.org/10.1177/1524839917692750
Garagozov, R., & Gadirova, R. (2019). Narrative intervention in interethnic conflict. Political Psychology, 40(3), 449–465. https://doi.org/10.1111/pops.12531
Hsieh, H. F., & Shannon, S. E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15(9), 1277–1288.
International Lesbian, Gay, Bisexual, Trans and Intersex Association (ILGA) world. (2019). Trans Legal mapping report: Recognition before the law. https://ilga.org/downloads/ILGA_World_Trans_Legal_Mapping_Report_2019_EN.pdf
International Lesbian, Gay, Bisexual, Trans and Intersex Association (ILGA) Europe. (2020). Annual review of the human rights situation of lesbian, gay, bisexual, trans, and intersex people in Europe and Central Asia. https://www.ilgaeurope.org/annualreview/2020
International Lesbian, Gay, Bisexual, Trans and Intersex Association (ILGA) Europe. (2020). A world survey on legal regulation of so-called "conversion therapies." https://ilga.org/downloads/ILGA_World_Curbing_Deception_world_survey_legal_restrictions_conversion_therapy.pdf
International Commission of Jurists (ICJ). (2018). SOGI Casebook chapters Archives: Asylum and immigration. https://www.icj.org/sogicasebookchapters/asylum-and-immigration/
* Jordan, S. (2009). Un/Convention(al) Refugees: Contextualizing the accounts of refugees facing homophobic or transphobic persecution. Refuge, 26(2),165–182.
Jansen, S. (2014). Good practice related to LGBTI asylum applicants in Europe. ILGA Europe.
Jansen, S. (2015). Introduction: Fleeing homophobia, asylum claims related to sexual orientation, and gender identity in Europe. In T. Spijkerboer (Ed.), Fleeing Homophobia: Sexual orientation, gender identity and asylum (pp. 1–32). Routledge.
* Kahn, S. (2015). Cast Out: “Gender role outlaws” Seeking asylum in the West and the quest for social connections. Journal of Immigrant & Refugee Studies, 13(1), 58–79. https://doi.org/10.1080/15562948.2014.894169
* Kahn, S., Alessi, E., Woolner, L., Kim, H., & Olivieri, C. (2017). Promoting the well-being of lesbian, gay, bisexual and transgender forced migrants in Canada: providers' perspectives. Culture Health & Sexuality, 19(10), 1165–1179. https://doi.org/10.1080/13691058.2017.1298843
* Kahn, S., & Alessi, E. J. (2017). Coming out under the gun: Exploring the psychological dimensions of seeking refugee status for LGBT claimants in Canada. Journal of Refugee Studies, 31(1), 22–41. https://doi.org/10.1093/jrs/fex019
* Kahn, S., Alessi, E. J., Kim, H., Woolner, L., & Olivieri, C. J. (2018). Facilitating mental health support for LGBT forced migrants: A qualitative inquiry. Journal of Counseling and Development, 96(3), 316–326. https://doi.org/10.1002/jcad.12205
Keuroghlian, A. S., McDowell, M. J., & Stern, T. A. (2018). Providing Care for Lesbian, Gay, Bisexual, and Transgender Immigrants at Health Centers and Clinics. Psychosomatics, 59(2), 193–198. https://doi.org/10.1016/j.psym.2017.10.008
Kara, H., & Çalık, D. (2016). “Tekin olmayi” beklerken: LGBTİ mültecilerin ara durağı Türkiye. Ankara: KAOS GL.
*Lee, E. O. J., & Brotman, S. (2011). Identity, refugeeness, belonging: Experiences of sexual minority refugees in Canada. Canadian Review of Sociology., 48(3), 242–274.
*Lee, E. O. J., & Brotman, S. (2013). SPEAK OUT! Structural Intersectionality and Anti-Oppressive Practice with LGBTQRefugees in Canada. Canadian Social Work Review., 30(2), 157–183.
* Logie, C. H., Lacombe-Duncan, A., Lee-Foon, N., Ryan, S., & Ramsay, H. (2016). "It's for us -newcomers, LGBTQ persons, and HIV-positive persons. You feel free to be": a qualitative study exploring social support group participation among African and Caribbean lesbian, gay, bisexual and transgender newcomers and refugees in Toronto, Canada. BMC International Health and Human Rights, 16(1), 18. https://doi.org/10.1186/s12914-016-0092-0
Long, H. A., French, D. P., & Brooks, J. M. (2020). Optimising the value of the critical appraisal skills programme (CASP) tool for quality appraisal in qualitative evidence synthesis. Research Methods in Medicine & Health Sciences, 1(1), 31–42. https://doi.org/10.1177/2632084320947559
Munn, Z., Tufanaru, C., & Aromataris, E. (2014). JBI’s systematic reviews: Data extraction and synthesis. The American Journal of Nursing, 114(7), 49–54. https://doi.org/10.1097/01.NAJ.0000451683.66447.89
Moher, D., Shamseer, L., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., Shekelle, P., Stewart, L. A., & PRISMA-P Group. (2015). Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic Reviews, 4(1), 1. https://doi.org/10.1186/2046-4053-4-1
Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674–697. https://doi.org/10.1037/0033-2909.129.5.674
* MacDonnell, J. A., & Daley, A. (2015). Examining the development of positive space in health and social service organizations: A Canadian exploratory study. Journal of Gay & Lesbian Social Services, 27(3), 263–301. https://doi.org/10.1080/10538720.2015.1040186
Miles, N. (2010). No going back: Lesbian and gay people and the asylum system. Stonewall.
Morgan, D. A. (2006). Not gay enough for the government: Racial and sexual stereotypes in sexual orientation asylum cases. Law & Sexuality: A Review of Lesbian, Gay, Bisexual, and Transgender Legal Issues, 15, 135–162.
Merkle, O., Reinold, J., & Siegel, M. (2017). A gender perspective on corruption encountered during forced and irregular migration. Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ)GmbH.
* Nguyen, M., Handoko, R., Asabor, E., & McKenzie, K. C. (2019). A gay Nigerian man's journey to asylum in the USA. British Medical Journal Case Reports, 12(4), e227637. https://doi.org/10.1136/bcr-2018-227637
Namer, Y. & Razum, O. (2018). Access to primary care and preventive health services of LGBTQ+ migrants, refugees, and asylum seekers. In A. Rosano. (Ed). Access to Primary Care and Preventative Health Services of Migrants. (pp. 43–55). Springer.
Netherlands times (NLtimes). (2020). Over 60 incidents of anti-LGBTQ violence in asylum centers; Gov't called to do something. https://nltimes.nl/2020/08/21/60-incidents-anti-lgbtq-violence-asylum-centers-govt-called-something
Ooms, G., Keygnaert, I., & Hammonds, R. (2019). The right to health: from citizen's right to human right (and back). Public Health, 172, 99–104.
Pearson, A., Rittenmeyer, L., & Robertson-Malt, S. (2011). Synthesizing qualitative evidence. Lippincott Williams & Wilkins.
Publication Manual of the American Psychological Association (APA). (2019). Seventh Edition.
Razum, O., & Bozorgmehr, K. (2016). Restricted entitlements and access to health care for refugees and immigrants: The example of Germany. Global Social Policy, 16(3), 321–324.
Substance Abuse and Mental Health Services Administration. (2014). Concept of trauma and guidance for a trauma-informed care approach. U.S. Department of Health and Human Services.
Singh, J. (2013). Critical appraisal skills programme. Journal of Pharmacology and Pharmacotherapeutics, 4(1), 76–77. https://www.jpharmacol.com
Shidlo, A., & Ahola, J. (2013). Mental health challenges of LGBT forced migrants. Forced Migration Review., 42(4), 9–11.
Schweitzer, S., Melville, F., Steel, Z., & Lacherez, P. (2006). Trauma, postmigration living difficulties, and social support as predictors of psychological adjustment in resettled Sudanese refugees. Australian & NewZealand Journal of Psychiatry, 40, 179–187. https://doi.org/10.1080/j.1440-1614.2006.01766.x
Strauss, A., & Corbin, J. (1990). Basics of Qualitative Research: Grounded Theory Procedures and Techniques. Sage.
United Nations High Commissioner for Refugees. (2002). Guidelines on International Protection No. 1: Gender-Related Persecution within the Context of Article 1A(2) of the 1951 Convention and/or Its 1967 Protocol Relating to the Status of Refugees, UN Doc. HCR/GIP/02/01. https://www.unhcr.org/publications/legal
United Nations High Commissioner for Refugees. (2008). Guidance note on refugee claims relating to sexual orientation and gender identity. https://www.refworld.org/docid/48abd5660.html
United Nations High Commissioner for Refugees. (2012). Guideline on international protection No 9. Claims to Refugee Status based on Sexual Orientation and/or Gender Identity within the context of Article 1A(2) of the 1951 Convention and/or its 1967 Protocol relating to the Status of Refugees. UN Doc. HCR/GIP/12/09. https://www.unhcr.org/publications/legal/
VERBI Software. (2019). MAXQDA 2020 [computer software]. VERBI Software. https://www.maxqda.com
Van der Pijl, Y., Oude Breuil, B. C., Swetzer, L., Drymioti, M., & Goderie, M. (2018). “We do not matter”: Transgender migrants/refugees in the Dutch Asylum System. Violence and Gender, 5(1), 1–11. https://doi.org/10.1089/vio.2017.0009
*Ward, J. (2018). ‘Prove it’ working with LBGTQ+ Asylum seekers who must prove their sexuality to stay in the UK. Dramatherapy, 39(3), 141–151.
WHO African Region. (2018). Health of refugees and migrants: practices in addressing the health needs of refugees and migrants. https://www.who.int/migrants/publications/AFRO-Practices.pdf?ua=1
Yoshino, K. (2006). Covering: The hidden assault on our civil rights. Random House.
Zappulla, A. (2018). Forgotten twice: the untold story of LGBT refugees. World Economic Forum. https://www.weforum.org/agenda/2018/01/forgotten-twice-lgbt-refugees/
We would like to thank Saygın Önal for his help in diagramming.
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Nematy, A., Namer, Y. & Razum, O. LGBTQI + Refugees’ and Asylum Seekers’ Mental Health: A Qualitative Systematic Review. Sex Res Soc Policy 20, 636–663 (2023). https://doi.org/10.1007/s13178-022-00705-y
- LGBTQI +
- Forced migration
- Mental health
- Access barriers