As immigration is increasingly contested on the political stage, asylum has become an important topic with repercussions for public health and medical professionals. Asylum seekers, or asylees, flee persecution in their nations of origin for many reasons. Under United States law, asylum may be granted for persecution based on race, religion, nationality, political opinion, or membership in a social group. Health professionals can play a vital role to asylees by corroborating the sequela of past mistreatment with a forensic examination followed by testimony in their application for asylum.
Among no group is this more important than sexual and gender minorities (SGM). Globally, SGM experience criminalization and legal discrimination, cultural stigma and community violence. Seventy UN member-states criminalize same-sex acts, 11 with death and another 26 with 10 or more years of imprisonment. In response to discrimination in their home countries, SGM individuals are increasingly applying for asylum in the US.
Compared to non-SGM peers, SGM asylees are three times as likely to have experienced sexual violence, twice as likely to have been minors at the time of their first experience of trauma, and twice as likely to have been mistreated by family. Furthermore, SGM commonly report forced disclosure of their gender identities in their communities or are compelled to hide their sexual identity through multiple means, including relationships to conceal their sexual orientation. They are diagnosed with high rates of major depressive and post-traumatic stress disorders.
The accumulation of multiple stressors, including poor health, legal challenges, and social isolation, often exacerbates psychological morbidity and engenders reticence to seek medical care. In US asylum proceedings, SGM may face difficult and triggering questions from government attorneys. SGM asylees may therefore feel required to “reverse cover,” or overemphasize aspects of their identity to “prove” their gender or sexual orientation.
By providing a trauma-informed evaluation, we hope to reduce re-traumatization of our clients while advocating for adequate legal protections for these individuals.
The stressors faced by SGM asylees may be exacerbated by an overwhelmed asylum system that is becoming increasingly restrictive due to policies adopted by the Trump administration. New asylum applications have grown since 2011, and in 2017 reached levels not seen since the early 1990s. Between 2010 and 2019, pending asylum cases have grown from 6,496 to 325,277, concurrent with growing unrest and conflict worldwide. Further, recent government policies have aimed to restrict asylum eligibility.
The Trump administration has limited qualifications for asylum, eliminating eligibility for those seeking protections out of fear of gang or domestic violence, declaring that individuals are not eligible for asylum if they passed through another country without seeking protection there, and diverting asylum seekers to Honduras, El Salvador and Guatemala. In addition to restricting potential applicants, denials within the court system are on the rise. In 2018, 42,224 cases were decided in court and 65% were denied. This rate of denial is increased compared to both the Bush and Obama administrations.
As restrictive policies further stretch an overburdened asylum system, the role of the health professionals in the asylum process has never been more important. A 2008 study in the US found that professional evaluations increased the probability of being granted asylum to 89% from 37.5%. Since its inception in 2017, the Massachusetts General Hospital Asylum Clinic has provided evaluations for hundreds of clients, of whom 25% are SGM. With this vulnerable population in mind, we have begun educating our clinic volunteers about a trauma-based approach for evaluations of SGM clients.
This initiative emphasizes curiosity and humility, familiarity with the experiences of SGM worldwide, and in-depth evaluations for mental sequela of chronic trauma, such as dissociative disorders, complex post-traumatic stress disorder, and interpersonal symptoms. By providing a trauma-informed evaluation, we hope to reduce re-traumatization of our clients while advocating for adequate legal protections for these individuals.