Meeting the Health Needs of Queer Immigrants Use hashtags: #QI4 #Health4QueerImmigrants Meeting the Health Needs of Queer Immigrants Panelists: Michael Clark, Amro Alsoleibi & Mark Messih MD MSc

QUEER IMMIGRANTS BECOME HIV-POSITIVE WITHIN 3 YEARS OF RESETTLEMENT 2 out of 5 QUEER IMMIGRANTS BECOME HIV-POSITIVE WITHIN 3 YEARS OF RESETTLEMENT

Introductions Michael Clark Amro Alsoleibi Mark Messih Group Introductions

Outline Intros Pre-Flight Flight Resettlement & Acculturation Syndemics Recommendations Conclusion Outline

Pre-Flight Events Stigma Assault Insufficient Care

Pre-Flight Pre-flight traumas occur in one’s country of origin. LGBT refugees may have lived through years of persecution within their family or broader community. Documented violence corrective rape, honor killings, beatings and imprisonment. This abuse can be longstanding, starting in early childhood, or more recent. Adults who have suffered childhood sexual abuse are at increased risk of depression and anxiety. Patients may present with symptoms of Post-Traumatic Stress Disorder (PTSD) including depersonalization, de-realisation and negative alterations in cognition (guilt, shame, fear). Presentation can also include re-experiencing traumatic events, avoidance of reflecting on trauma hyper-vigilance and anxiety.

“So when you go to the clinic, the people talk and point “So when you go to the clinic, the people talk and point. They look at you, and ask who is that? Is this a man or a female? By the time you finally see the doctor, you don't open up yourself because already you are having that heartbreak with the people talking about you.” (22yo transgender female from Rwanda) “Often I miss a month at a time or more. I get worried about not taking my medicine but... I am scared to go. The few times I have been, the reaction when they service me was not positive or friendly. I am not so encouraged by that.” (21yo gay male from Burundi) “I was raped in Congo, and when I reached Nakivale, I was supposed to get medicine to prevent exposure to HIV (PEP) and they looked at me and said "we don't have medicine for you" and I knew it was because I was transgender, so I never received treatment.” (26yo transgender male from DRC)

Predisposing Risk Factors to Psychological Symptoms & Disorders Pre-Flight/Migration Post-Flight Exposure to war Loss of family members State-sponsored violence Prolonged separation Oppression Stress of adapting to new culture Torture Low SES/underemployment Internment in Refugee camps Physical displacement to a new country Human trafficking

Flight (Journey into Exile) Increased risk of abuse, imprisonment and exclusion from basic protections Alienation from government and NGO organizations - Resiliency Access to community resources and group activity correlates with better outcomes than patients in isolation

Post-Flight Sponsoring Agency Imprisonment Cultural Norms Trauma & Trust Sexual Health Drugs, Hookup Culture, Desire to Fit In

Resettlement & Acculturation “Cultural Bereavement” Loss of familiar social structures, values and even language. Identity, anxiety and Isolation Preflight trauma is connect to post flight trauma, impacting self worth, and adaptability

Syndemics Theory Theoretical model used in behavioral HIV research that suggests multiple psychosocial components may interact to increase HIV acquisition among sexual minorities. The theory says that HIV vulnerability comes from social inequalities and oppression such as homophobia, system heterosexism and denied human rights. As risks increase additively → HIV acquisition increases multiplicatively Examples of syndemic effects come from minority stress, depression, poly-drug use, traumatic childhood events and violence from a close member of the family. I believe that displacement is a syndemic event. What’s that mean? We cannot address just one component but prevention must be “bundled” and addressed as a whole Ferlatte, O., Hottes, T. S., Trussler, T., & Marchand, R. (2013). Evidence of a Syndemic Among Young Canadian Gay and Bisexual Men: Uncovering the Associations Between Anti-gay Experiences, Psychosocial Issues, and HIV Risk. AIDS and Behavior, 18(7), 1256-1263. doi:10.1007/s10461-013-0639-1

Syndemic Production Stall R, Friedman MS, Cantania JA. Interacting epidemics and gay men’s health: a theory of syndemic production among urban gay men. In: Wolitski RJ, Stall R, Valdiserri RO, editors. Unequal opportunity: health disparities affecting gay and bisexual men in the United States. New York: Oxford University Press;2008. p. 251–74.

Discussion What can we do? What has worked for you? What has not worked? Who is doing it right?

Recommendations

Conclusions There is a rising proportion of refugees that identify as LGBT who present with a range of mental health conditions ranging from PTSD, depression and anxiety to substance abuse Individuals face multiple stressors due to their LGBT identity and their refugee status, stressors that may hinder access to care and block access to social and medical supports People will present with complex history comprising trauma at home, in transit and while acclimatizing to their new lives. Establishing safety, preparing clients for the asylum seeking process and empowering individuals are important considerations in the treatment plan Broader social, cultural and legal aspects of mental illness should be considered by the mental health worker to understand the patient’s experience. The role of therapy is two-fold: to navigate the past, and prepare for the future. Treatment and prevention must be looked at as a whole and services should be bundled.

Contacts Michael Clark: embee.clark@gmail.com @HealthLGBTQ Amro Alsoleibi: alsoleibi.amro@hotmail.com Mark Messih: mark.messih@gmail.com Contacts