Preparing clinicians for the international anti-LGBTQI+ crisis

Lesbian, gay, bisexual, transgender, queer, intersex and additional sexual and gender minority (LGBTQI+) people in every region of the world face marginalization and oppression. At least 67 countries ban sexual conduct between consenting adults of the same sex. According to a report from the United Nations High Commissioner for Refugees on LGBTQI+ people in forced displacement and statelessness, regressive laws that foster hostile environments for LGBTQI+ persons will most likely result in increasing numbers of such people fleeing their home countries and seeking sanctuary elsewhere.

While safety can sometimes be sought in neighboring countries, LGBTQI+ refugees and asylum-seekers often choose to migrate to countries with laws that explicitly protect their rights. "The journey to destinations perceived as safe can be perilous for LGBTQI+ migrants and asylum-seekers and reception in those countries can also result in further trauma and human rights violations. Consequently, clinicians need to be prepared to assess these unique stressors and how they affect the health of their refugee and asylum-seeking patient population," say Carl G. Streed, Jr., MD, MPH, FACP, FAHA and Sarah Kimball, MD, both assistant professors of medicine at Boston University Chobanian & Avedisian School of Medicine, in a perspective published in the New England Journal of Medicine.

Streed and Kimball believe clinicians need to be prepared to provide support for LGBTQI+ refugees and asylum-seekers facing the unique issues related to legal, social, and cultural persecution based on their sexual orientation and gender identity. Clinicians need to know how to probe and document experiences of childhood trauma; verbal, emotional, physical and sexual abuse; assault; discrimination; harassment; wrongful imprisonment and rape, by employing a trauma- and culturally informed approach.

"Through documentation of these issues at the individual and clinic-level, the picture of what LGBTQI+ individuals and communities face emerges," say Streed and Kimball, who are the research lead for the GenderCare Center and Director of the Immigrant & Refugee Health Center at Boston Medical Center, respectively.

In the context of rising anti-LGBTQI+ interpersonal violence and legislative hostility, the health care setting can serve as a safe and reparative space for refugees and asylum-seekers according to Streed and Kimball. "Beyond individual clinician training and patient care, clinics that serve LGBTQI+ refugees and asylum-seekers should develop medico-legal partnerships to ensure that immigration legal needs are addressed. Such partnerships have shown success in numerous critical outcomes, such as reducing patient stress and visits to the emergency room, while also improving housing outcomes and economic prospects in the communities they serve," they add.

For clinicians seeking more training on how to complete assessments and engage in this work, Streed and Kimball point out that there are opportunities to connect within the Society of Refugee Healthcare Providers as well as Rainbow Railroad—organizations that provide advocacy, education and networking opportunities within refugee and asylee health.