How to Support African LGBTQ Immigrants at Risk for HIV in the U.S.

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Immigrants to the United States are, generally, highly resilient. As people who had the motivation and abilities to relocate with great effort and expense across long distances to work and study in the U.S., many immigrants prove to be highly adaptive and entrepreneurial and are able to draw on social and family networks in the U.S. to start small businesses and advance in education and employment.

Many African immigrants fit into this pattern of initiative, entrepreneurship, and education. For example, compared to 31% of U.S.-born Americans who have at least a college education, 39% of African immigrants have bachelor's or higher degrees, with the highest rates of advanced education and training among immigrants from Egypt (64%), Nigeria and South Africa (57%), Kenya (44%), and Ghana (40%).

But migrants fleeing violence and persecution and seeking asylum in the U.S., and particularly LGBTQ migrants seeking asylum, are different in that many come with histories of pre-migration trauma. Furthermore, many LGBTQ asylum seekers have migrated independently from family, experience stigma and discrimination from family and immigrant communities in the U.S., and have specific needs for trauma-informed health care, targeted social services, and community-building.

Research and public media have typically overlooked the ways in which these needs of LGBTQ asylum seekers are different from those of the general asylum-seeker population. Filling this gap, several recent studies have looked at the health needs of African-born LGBTQ migrants in the U.S. and their needs for targeted, trauma-informed services to engage them in mental health care, sexual health care, and other health and social services.

Factors Impacting Mental Health of African LGBTQ Immigrants

Traumatic histories from Africa: Homosexuality is highly stigmatized in many African settings, as evidenced by current national laws in more than 25 African countries that make same-sex sexual activity illegal. LGBTQ migrants from Africa describe high rates of rejection from family and community, harassment, blackmail, violence, and sexual violence, all of which contribute to ongoing mental health issues, such as depression or other post-traumatic stress disorders.

Lack of support from African migrant communities in the U.S.: African LGBTQ migrants who fled their countries because of violence or persecution related to their sexuality or gender frequently migrate independently from family. This means that they lack the family and community support that helps many other immigrants in resettling and accessing work and education. Many African LGBTQ immigrants also experience or fear homophobia from family members and African communities in the U.S. This "sexual minority stress" includes actual or anticipated discrimination and rejection and a dynamic in which people live closeted lives, concealing core aspects of their emotional, social, and sexual lives.

Migration-related stress: Migration is stressful, especially for refugees who have fled their countries with few resources and face initially insecure employment and housing, social isolation in a new place, and anxiety and depression deriving from the effort to navigate a new language, new cultures, and new systems.

The Combined Effect of Trauma on Health

The combination of these multiple traumas pre- and post-migration and lack of support networks in the U.S. has consequences for people's health. Traumatic histories, minority stress, and migration-related stress together cause a greater likelihood of mental health issues, including substance use and addiction disorders.

For example, a recent study interviewing 70 African-born gay and bisexual men living in New York City in 2015 found that immigrant African gay and bisexual men who had post-traumatic stress disorder (PTSD) were more likely to experience depression. Men in the study who had histories of homophobia or sexual violence in their home countries, had internalized homophobia, and/or had economic issues such as housing instability in the U.S. were significantly more likely to have substance use and addiction issues.

"The interrelatedness of these factors points to the need for interventions that address both home and host country experiences that contribute to the current disposition of this highly resilient community," says Adedotun Ogunbajo, co-author of the study.

Despite these needs, with limited family, social, or community supports, African-born LGBTQ migrants who have fled their countries may not know of available services, may not be able to navigate access to appropriate services, or may not trust or may fear rejection from service providers. This is especially true of LGBTQ Africans who are undocumented migrants seeking asylum in the U.S.

Evidence-Based Components of Effective Services for African LGBTQ Immigrants

Engagement of African LGBTQ asylum seekers: Open social and cultural events and regular support groups are an important strategy to help asylum seekers link to social networks, social services, and health care. Community advisory groups can also be formed to advise about program design, implementation, and evaluation, and to help develop health education messages that are culturally and linguistically appropriate, disseminate information through social media and peer networks, and help asylum seekers to access and navigate services.

Sexual health services for LGBTQ asylum seekers: LGBTQ migrants need high-quality sexual and reproductive health services that are affordable and accessible for undocumented migrants, and attentive to and centered on people's needs. HIV and other sexually transmitted infections (STIs) are a specific health concern for African gay and bisexual men in the U.S. Relatively high HIV and STI prevalence has been documented among gay men across all regions of Africa, including major countries of origin for migrants to the U.S., such as Ethiopia, Ghana, Kenya, and Nigeria. Beginning in 2010, HIV was lifted as an exclusion criterion for people seeking to come to the U.S. African gay and bisexual men in the U.S. may also be at elevated risk for HIV and other STIs for the same reasons as U.S.-born African Americans, notably, high background STI prevalence within sexual networks and a lack of high-quality affirming sexual health services targeted to gay and bisexual men.

Clinical and social service programs that are trauma-informed: Trauma-informed services are defined as services with protocols and training to recognize and identify signs and symptoms of trauma, provide access to appropriate services and support, and avoid practices that re-traumatize people. For African LGBTQ immigrants, trauma-informed services emphasize trust, safety, and peer support; specifically recognize and address mental health issues related to migration and/or sexuality and gender identity; and promote people's recovery and resilience.

Like countless waves of immigrants coming before, African-born LGBTQ people in the U.S. bring a rich diversity of talents, cultures, and life experiences to the United States and have abilities and resilience rooted in their willingness to uproot and move long distances to forge new creative and entrepreneurial lives in this country.

The experiences and voices of African LGBTQ people in America, and particularly of those fleeing persecution and seeking asylum in the U.S., are centrally important in informing and improving health services and community-based services.

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