Intervention

ARTICLE
Year
: 2021  |  Volume : 19  |  Issue : 2  |  Page : 187--196

A Preliminary Framework for Understanding Suicide Risk in LGBTQ Refugees and Asylum Seekers


Aaron Burgess1, Miriam Potocky2, Edward J Alessi3,  
1 Department of Social Work, University of North Alabama, Florence, Alabama, USA and School of Social Work, Florida International University, Miami, Florida, USA
2 School of Social Work, Florida International University, Miami, Florida, USA
3 School of Social Work, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA

Correspondence Address:
PhD, MSW Aaron Burgess
Department of Social Work, University of North Alabama, Florence, AL 35632
USA

Abstract

Lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ) individuals continue to experience pervasive violence and victimisation, which has been associated with a host of negative mental health problems, including suicide. However, there is a gap in knowledge about LGBTQ refugees and asylum seekers, an especially vulnerable subgroup of both the LGBTQ and refugee/asylum seeker population. The aim of this study was therefore to develop a preliminary theoretical framework to identify factors that may contribute to suicide risk among LGBTQ refugees and asylum seekers, and those that may buffer this risk. We conducted a review of literature on the lived experiences of LGBTQ refugees and asylum seekers. We then used cumulative disadvantage and minority stress theories to conceptualise their risk for suicide and queer migration theory to highlight protective factors. Finally, this review provides practice implications for supporting the psychosocial and mental health needs of LGBTQ refugees and asylum seekers.



How to cite this article:
Burgess A, Potocky M, Alessi EJ. A Preliminary Framework for Understanding Suicide Risk in LGBTQ Refugees and Asylum Seekers.Intervention 2021;19:187-196


How to cite this URL:
Burgess A, Potocky M, Alessi EJ. A Preliminary Framework for Understanding Suicide Risk in LGBTQ Refugees and Asylum Seekers. Intervention [serial online] 2021 [cited 2022 Jan 17 ];19:187-196
Available from: https://www.interventionjournal.org/text.asp?2021/19/2/187/325805


Full Text



Key implications for practice

The study presents a preliminary theoretical framework for understanding factors contributing to suicidality in LGBTQ refugees and asylum seekers across the lifespan.The study applies this framework to gatekeeper suicide prevention for humanitarian workers, NGO staff members, direct service providers and clinical practitioners.The study integrates this framework into LGBTQ-affirming clinical practice and mental health services.

 Introduction



Worldwide 69 countries criminalise same-sex relations, including most countries in the Middle East and North Africa (ILGA World, 2020). Eleven of these nations also consider same-sex relations punishable by death in some cases (ILGA World, 2020). Under international law, lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ1) people who have a credible fear of persecution qualify for asylum under the “membership in a social group” category. Although it is challenging to quantify the number of LGBTQ refugees and asylum seekers, as nation-states and United Nations High Commissioner for Refugees (UNHCR) do not publish such data (UNHCR, 2012), evidence from human rights reports suggests that the number of individuals seeking asylum based on sexual orientation or gender identity may be rising (e.g. European Union Agency for Fundamental Human Rights, 2017; Organization for Refuge, Asylum, and Migration, 2015). The gravity of the situation is urgent and requires increased humanitarian attention to attend to the unique, and often overlooked, needs of LGBTQ refugees and asylum seekers.

Given that LGBTQ refugees and asylum seekers have experienced severe and prolonged trauma prior to migration (Hopkinson et al., 2017) and continue to face adversity in the host country, there has been increased focus on providing services that address their mental health and psychosocial support needs (Alessi et al., 2018), including their increased risk for suicide. Although prevalence of suicidality among LGBTQ refugees and asylum seekers is unavailable, numerous studies have shown that both LGBTQ people (Adams et al., 2017; Mereish et al., 2019; Meyer et al., 2021) and refugees/asylum seekers (Akinyemi et al., 2015; Refugee Health Technical Assistance Center, 2011; Wasserman, 2017) are at higher risk of suicidality compared to the general population. It is then logical to assume that individuals whose identities intersect both groups (i.e. LGBTQ and refugee/asylum seeker) may be expected to experience as much if not greater risk of suicidality.

Emerging conceptual/clinical articles (Alessi & Kahn, 2017; Heller, 2009; Reading & Rubin, 2011) and qualitative studies (Alessi et al., 2016, 2017; Brice, 2011; Gowin et al., 2017; Kahn, 2015; Kahn et al., 2017; Logie et al., 2016) on LGBTQ asylum seekers have indicated that they experience numerous risk factors for suicidality, including traumatic stress and low social support. To our knowledge, however, information about suicidality among LGBTQ refugees and asylum seekers is extremely limited. Exploring factors related to suicidality is of critical importance for improving mental health and psychosocial support services for LGBTQ refugees and asylum seekers, who experience violence related to their sexual orientation and gender identity, in addition to trauma related to war, political strife and natural disaster (Alessi et al., 2018). Therefore, the purpose of this study is to review the literature related to the lived experiences of LGBTQ refugees and asylum seekers, to identify relevant theories related to suicide risk and protective factors and to develop an integrated framework that can be used to guide mental health and psychosocial support services and future research with this population.

 Theoretical Perspectives



In the following proposed theoretical framework, suicidality is conceptualised as the experiences of both suicidal ideation and suicide attempt. Klonsky and May (2015) proposed a three-step theoretical model to demonstrate the progression from ideation through potential attempt. According to this framework, suicidal ideation first arises from feelings of pain and hopelessness. Second, among those experiencing both pain and hopelessness, connectedness is a key protective factor against increasing ideation. Finally, a combination of genetic, acquired and practical factors influence whether an individual proceeds from ideation to attempt (Klonsky & May, 2015).

Building upon this foundational general framework, this article aims to identify theory-based risk and protective factors for suicidal ideation specific to the LGBTQ refugee/asylum-seeker population, as a step towards developing relevant interventions to reduce progression from suicidal ideation to attempt. Based on a critical review of the literature on LGBTQ refugees and asylees, three relevant theoretical perspectives were identified: (a) cumulative disadvantage theory, (b) minority stress theory and (c) queer migration theory.

Cumulative disadvantage theory (Ferraro & Kelley-Moore, 2003) explains the complex nature of cumulative trauma on an LGBTQ individual’s later self-concept and emotional regulation. It starts with experiences of childhood adversity and contextualises these experiences from pre- to postmigration. Exposure to severe and prolonged trauma may lead to mental health difficulties, in particular complex post-traumatic disorder. Minority stress theory (Meyer, 2003) focuses on four specific minority stress processes (prejudice and discrimination, perceived stigma, internalised stigma and sexual orientation concealment) to explain how excess stress among sexual minorities causes higher prevalence of mental health disorders among this population when compared to heterosexuals. Queer migration theory (Luibhéid, 2008) serves to demonstrate how the experiences of LGBTQ refugees and asylum seekers are shaped − implicitly and explicitly − by cisnormativity and heteronormativity and other structural forces that marginalise and erase their identities. The recognition of these oppressive forces allows for an interrogation of the power structures that perpetuate them and in turn centres the narratives and experiences of LGBTQ refugees and asylum seekers (Shakhsari, 2014).

Together, these theories are integrated in an attempt to explain suicide risk among LGBTQ refugees and asylum seekers (cumulative disadvantage, minority stress), as well as the protective elements that have the potential to buffer this risk (queer migration). The following sections outline these theories as well as present evidence in the literature that may be applied to LGBTQ refugees and asylum seekers.

 Cumulative Disadvantage Theory



Cumulative disadvantage theory (or cumulative inequality theory) underscores the impact that early advantage or disadvantage may have on short- and long-term outcomes, such as mental health, social and interpersonal relationships and employment (Ferraro & Kelley-Moore, 2003). Ferraro and Shippee (2009) detailed five characteristics of cumulative disadvantage: (a) social systems generate inequality, which is manifested over the life course through demographic changes and developmental processes; (b) disadvantage increases exposure to risk, whereas advantage increases exposure to opportunity; (c) life course trajectories are shaped by the accumulation of risk, available resources and human agency; (d) the perception of life trajectories influences subsequent trajectories and (e) cumulative inequality may lead to premature mortality (Ferraro & Shippee, 2009).

Fundamentally, this theory postulates that disadvantage that occurs in one life domain, particularly early in life, increases the likelihood that further disadvantage or negative outcomes may happen both within that same life domain, in addition to the potential for increased risk in other areas of an individual’s life (Heap et al., 2017). When both internal and external factors are available to increase an individual’s capacity for resilience or to adapt to adversity, then future risk or negative outcomes may be attenuated (Schafer et al., 2009). However, when these internal and external factors are not present, risk may likely continue to accumulate. Since its introduction in the literature, cumulative disadvantage theory has been increasingly included in sociological research, especially in discussions of racial and ethnic disparities and negative health and mental health outcomes (Crystal et al., 2017; Nurius et al., 2015).

Trauma, distress and adversity that occur in the lives of LGBTQ refugees and asylum seekers have both immediate impact as well as short- and long-term negative outcomes on their mental health and psychosocial wellbeing. In the following subsections, childhood adversity and complex posttraumatic stress disorder (PTSD) are presented to demonstrate how trauma in childhood can potentially cause increased risk of disadvantage, in particular suicidality.

 Adversity in Childhood



Childhood adversity is related to harmful developmental outcomes in a variety of domains across the lifespan (Kessler et al., 1997; Strong et al., 2016). Numerous studies have examined childhood adversity such as parental loss, familial disruption, poverty (McLaughlin, 2016) and various types of child maltreatment (St Clair et al., 2015). The concept of childhood adversity considers the accumulation of multiple events that contribute to future negative outcomes, rather than the relationship between a single adverse event and a single negative mental health outcome (Evans et al., 2013; McLaughlin, 2016).

Evidence demonstrates associations between childhood adversity and suicidality. Dube and colleagues (Dube et al., 20012001) found that the risk of attempting suicide increased by 60% for every additional adverse childhood experience among 17,337 adults. A high level of childhood adversity, coupled with a lack of protective factors, has been further associated with poor mental health outcomes, especially when exposed to traumatic stressors later in life (Ports et al., 2017). LGBTQ individuals who have experienced childhood adversity are particularly prone to experiencing suicidality as well. For example, a study of 4955 high school students found that sexual minority youth with greater exposure to childhood adversity experienced suicidal ideation and attempts at disproportionately higher levels than their straight counterparts (Clements-Nolle et al., 2018).

Research has begun to identify human rights violations and war experiences as forms of childhood adversity in refugee and asylum-seeking youth (Hanes et al., 2017; Mehrabani, 2013). Additionally, a study by Opaas and Varin (2015) investigated the impact of childhood adversity relative to premigration experiences of human rights violations on the mental health and wellbeing of 54 adult refugees resettled in Norway. The results of this study indicated a high level of childhood adversity among the adult refugee participants. Further, there was evidence that these experiences had directly contributed to current symptoms of PTSD. This was true even when controlling for the human rights violations that they had experienced, suggesting that refugees may contend with a variety of traumatic events, not just those related to flight (Opaas & Varvin, 2015). As it pertains to LGBTQ individuals specifically, Alessi and colleagues (2016) explored via qualitative interviews the premigration child abuse experiences of 26 LGBTQ refugees and asylees. Participants reported that they experienced severe and prolonged experiences of child abuse in their countries of origin, which they connected to a host of poor mental health outcomes, including suicidal ideation and attempts, throughout the lifespan.

This body of evidence suggests that childhood adversity may contribute to short-term and long-term experiences of distress and potential suicidality among LGBTQ refugees and asylum seekers. Likewise, childhood adversity may contribute to cumulative risk factors and disadvantage from early in the lifespan for individuals to experience a lifetime of unique pressures, trauma, risk and complex posttraumatic stress.

 Complex Trauma



There has been increased recognition of the complex ways in which individuals experience trauma and how these complexities impact their lives and functioning. In 2018, the World Health Organization (WHO) 11th version of the International Classification of Diseases (ICD-11) formally recognised complex PTSD (CPTSD) within its diagnostic taxonomy (Hyland et al., 2018). While the symptoms of PTSD must be present (fear and re-experiencing the trauma), Cloitre and colleagues (2013) have described CPTSD as having at least one of the “three additional diagnostic features that reflect the impact that trauma can have on systems of self-organisation, specifically problems in affect regulation, self-concept, and interpersonal relational domains” (p. 2). Further, these symptoms can present across different relationships, situations and contexts, regardless of their similarity or closeness to the original traumatic reminder or event (Cloitre et al., 2013). CPTSD is rooted in traumatic events that stem from prolonged trauma and interpersonal violence that can include more direct forms of abuse, neglect and intimate partner violence as well as larger structural trauma such as war, torture and exploitation (Mahoney et al., 2019).

Recent studies with refugees and asylum seekers have contributed to the understanding of CPTSD among vulnerable populations. Hyland and colleagues (2018) described the presence of PTSD and CPTSD in 110 Syrian refugees living in Lebanon. They found a significantly higher prevalence of CPTSD (36.1%) than PTSD (25.2%) in the sample. This study was particularly important because it not only provided evidence for differences between PTSD and CPTSD, but also demonstrated that the ICD-11 model for CPTSD may be applicable with diverse vulnerable population. Further, it recognised the potential disturbances in self-organisation, which makes CPSTD uniquely different from PTSD (Hyland et al., 2018).

Further, Alessi and Kahn (2017) conceptualised the experiences of CPTSD in LGBTQ refugees and asylum seekers to be rooted in the cumulative nature of severe trauma beginning in childhood. The experience of prolonged trauma in early development can lead to more severe trauma later in life than when an individual is exposed to a single-event traumatic experience (Cloitre et al., 2009). For LGBTQ refugees and asylum seekers, this is notable as evidence indicates that they may experience severe cumulative trauma in their childhood (Alessi et al., 2016, 2018).

 Minority Stress Model



The minority stress model (Meyer, 2003) is critical to understanding the context in which LGBTQ refugees and asylum seekers experience their identity in environments that endorse cis- and heteronormativity and how this can lead to mental health problems such as suicidality. Although initially applied to sexual minority populations (Meyer, 2003), the minority stress model is currently also used to explain the high prevalence of mental health problems among transgender individuals (Hendricks & Testa, 2012).

The model asserts that LGBTQ people experience four processes due to their stigmatised status: (1) traumatic or stressful events involving prejudice; (2) the expectation of experiencing stigma; (3) the internalisation of this stigma and (4) identity concealment (Meyer, 2003). As such, the minority stress model posits that the mental health disparities that LGBTQ individuals face are attributable to their exposure to stigma and discrimination. This stigma can be defined as perceptions and experiences of prejudice and discrimination in a hostile environment that lends itself to the development of acute and chronic stressors and mental health problems, including suicidality (Burton et al., 2013).

The impact of stigma may be particularly evident within the family systems of LGBTQ people. Ryan and colleagues (2009) reported that level of family acceptance for LGBTQ children was a predictor of mental health outcomes. They found that LGBQ young individuals who experienced rejection from their families were almost nine times more likely to attempt suicide than their peers who either experienced low or no levels of family rejection (Ryan et al., 2009).

LGBTQ people also experience stigma and discrimination as they navigate interpersonal and other social relationships (Burton et al., 2013). Given these experiences, the individual may respond with “vigilance, expectations of prejudice, identity concealment for self-protection and internalization of stigma” (Walch et al., 2016, p. 38). There is consistent evidence that exposure to these experiences of stigma and discrimination is associated with greater psychological distress (Institute of Medicine, 2011). Additionally, the regions in which LGBTQ individuals live also contribute to varying levels of structural and institutional stigma and discrimination (Walch et al., 2016). Recognising the negative consequences of structural and institutional stigma allows for greater insight into how it impacts LGBTQ individuals (Hatzenbuehler et al., 2013), especially through poorer mental health outcomes (e.g. generalised anxiety disorder, PTSD and dysthymia; Hatzenbuehler et al., 2009).

There has also been research to examine the components of the minority stress model in relation to suicidality. One such study demonstrated that sexual minority youth are 1.7 times more likely to be assaulted while in school and 2.4 times more likely to have avoided going to school due to fear of assault than their heterosexual peers (Friedman et al., 2011). This type of victimisation was associated with a 5- to 6-times higher likelihood of attempting suicide compared to sexual minority individuals who did not experience the same level of victimisation (Burton et al., 2013). In terms of differences based on race/ethnicity, findings are mixed. One study showed that Black and Latino/a lesbian, gay and bisexual (LGB) individuals in the United States reported more history of suicide attempts than their white (LGB) counterparts, even though Black and Latino/a LGB individuals did not have higher prevalence of mental health disorders (Meyer et al., 2008). However, another study in the United States showed no racial/ethnic differences in suicide behaviours among a diverse sample of LGBT youth ages 16–20 years old (Mustanski et al., 2010).

The minority stress model can provide context for understanding the stigma and associated risk factors that LGBTQ refugees’ and asylum seekers’ experience. This model takes into consideration the multitude of stressors that LGBTQ individuals experience and the subsequent impact that this may have in contributing to negative health and mental health outcomes (Gowin et al., 2017), including the aforementioned complex PTSD (Alessi & Kahn, 2017) and suicidality. A recent study used minority stress theory to explain the high levels of mental distress and social isolation among 308 LGBTQ asylum seekers in the United States and Canada (Fox et al., 2020). Social isolation and LGBTQ identity disclosure were associated with mental distress (Fox et al., 2020). These findings suggest that LGBTQ asylum seekers experience new challenges in the host country, which may exacerbate premigration trauma and impact their mental health and psychosocial functioning (Alessi et al., 2018).

For example, LGBTQ asylum seekers from Central America currently face barriers seeking asylum along the southern border of the United States. In addition to reports of harassment and violence along their migration journey (Del Real, 2018), LGBTQ individuals in US Immigration and Customs Enforcement (ICE) detention were found to be 97 times more likely to be sexually assaulted while making up only 0.14% of the detention population and had reported 12% of the total sexual assault claims in 2017 (Moreau, 2018). The American Civil Liberties Union, Las Americas Immigrant Advocacy Center and the Santa Fe Dreamers Project also documented that at least 12 gay and transgender individuals in ICE detention have experienced sexual assault and physical abuse from fellow detained individuals, harassment from ICE guards, denial of hormone therapy and solitary confinement as retaliation for speaking out about their negative treatment (Moore, 2019). Further, a 2018 letter from 37 Democratic Congress members referred to similar treatment of gay and transgender detainees, including 13% of 300 transgender individuals placed in solitary confinement in 2017 (Moore, 2019).

In addition to encountering stigma and discrimination in the United States, Alessi and colleagues (2018) documented the experiences of traumatic stress of 38 LGBTQ refugees and asylees from the Middle East, North Africa and Asia who were seeking refuge in Austria and The Netherlands. Study participants reported feeling the same urgency to conceal their LGBTQ identities due to experiences of victimisation which were similar to what they had experienced in their countries of origin. Experiences of isolation compounded with little access to affirming services left study participants, particularly those who spent time in refugee camps, feeling especially vulnerable to feelings of hopelessness and suicidality. Participants also reported experiencing victimisation by refugees who were not LGBTQ, diaspora community members, and European immigration officials throughout migration (Alessi et al., 2018). Special consideration must also be given to transgender refugees and asylum seekers, whose needs may sometimes vary from those of their LGB counterparts (Camminga, 2017). For example, they may still have difficulty accessing gender affirming services in host countries and experience cisgenderism and transphobia, making it more difficult to secure housing, employment and transgender affirmative mental health care (Alessi et al., 2020; Cerezo et al., 2014), which may, in turn, contribute to psychological distress and suicidality.

The combination of these studies clearly demonstrates that LGBTQ refugees and asylum seekers may experience stressors related to their sexual orientation and/or gender identity, as well as stressors (e.g. racism) related to their multiple intersecting identities; that is, race, ethnicity, social class, religion, migration status, etc. Researchers have used intersectionality theory (Crenshaw, 1989) to conceptualise these stressors among LGBTQ refugees and asylum seekers (see Alessi et al., 2020; Lee & Brotman, 2011). Stressors may include experiencing intersecting stigmas based on, for example, racism, homophobia, religion and xenophobia, which may create excess risk because trauma precipitated in the country of origin is magnified by what is occurring in the host country. Unlike other refugee groups, LGBTQ refugees usually cannot rely on diaspora communities or mainstream communities, thus increasing social isolation (Alessi, 2016; Fox et al., 2020; Kahn, 2015; Logie et al., 2016), all of which can compound minority stress and potentially contribute to suicide risk.

 Queer Migration Theory



The concept of queer migration is based on the notion that the policies and practices surrounding migration studies are rooted in cis- and heteronormativity, thus intentionally and unintentionally erasing, excluding or suppressing the voices and experiences of LGBTQ individuals (Luibhéid, 2008). Queer migration theory attempts to expand the concept of migration beyond space and time to include intersections of diversity and social membership in the narratives of identity and settlement (Luibhéid, 2008). It also seeks to interrogate the ways individual bodies and movements are perceived, with the intent of highlighting the impact that structural oppressions have on reinforcing traditional values and dictating societal interaction and functioning (Murray, 2014). This interrogation is critical, as it allows LGBTQ individuals to develop narratives rooted in their individual lived experiences (White, 2014), rather than conform to externally imposed perspectives or frameworks.

Queer migration theory seeks to further challenge the traditional normative perspective by including the voices and perspectives of diverse individuals themselves, including women of colour, queer-identified individuals and others whose voices are typically unheard in the dominant discourse (Chavez, 2013; Epstein & Carrillo, 2014). This provides a space for LGBTQ refugees and asylum seekers to share their own experiences in their own words, rather than attempting to configure their story into a way that fits the expectations of the dominant culture in which they are seeking asylum (Ormsbee, 2006), including the challenges that come with sharing their stories during the asylum claims process (Akin, 2017; Shakhsari, 2014). For example, there has been ongoing concern that LGBTQ refugees and asylum seekers must prove their membership in a particular social group (i.e. that they are, in fact, lesbian, gay, bisexual or transgender) in ways that adhere to Western conceptualisations of sexual orientation and gender identity, which is considered oppressive in and of itself (Camminga, 2017; LaViolette, 2004). Further, the need to appear credible to immigration adjudicators has been reported to, at times, be so stressful that it may retraumatise LGBTQ refugees and asylum seekers and even increase suicidality (Kahn & Alessi, 2018).

In general, social and psychological theories have been constructed from a particular lens that may or may not apply across cultures and contexts; in fact, there is a risk of neocolonialism and homonationalism (Puar, 2007) even in our attempt to apply these theories to LGBTQ refugees and asylum seekers (Yee et al., 2014). Queer migration theory can be used to connect these broader concepts in ways that are nuanced and culturally relevant. It does so by prioritising the narratives and lived experiences of LGBTQ refugees and asylum seekers. Doing so can provide them a source of empowerment and also increase understanding among humanitarian workers and other agents working directly with these individuals.

When the identities, experiences and triumphs of LGBTQ refugees and asylum seekers are honoured in this way, it may be protective. A study by Alessi (2016) showed that there were several factors that fostered resilience, including support from friends and chosen family, staying optimistic, doing whatever it takes to survive, using affirmative community resources, and, for some, maintaining spirituality. These protective factors (particularly trusting relationships and recognition of identity) could serve as a critical first step to buffer the negative effects of pre- and postmigration trauma among LGBTQ refugees and asylum seekers.

 Practice Implications



The integration of these three theoretical perspectives has the potential to impact the way individuals providing mental health and psychosocial support to LGBTQ refugees and asylum seekers understand and respond to suicidality among this population. [Figure 1] summarises the three theories in this preliminary framework.{Figure 1}

This preliminary framework does not substitute for conducting a suicide risk assessment, which should focus on such areas as previous suicide attempt, comorbid diagnoses, severity of illness and demographics, as well as protective factors such as support networks and links to mental health treatment (for an in-depth discussion, see Fowler, 2012). Nonetheless, this integrated theoretical framework can serve as a paradigm through which humanitarian workers, NGO staff members and clinical practitioners can better understand suicide risk. This framework also provides a context that can be used to foster resilience as well as honour the identities, experiences and triumphs of LGBTQ refugees and asylum seekers along their journeys, and also acting as a “gatekeeper”. A gatekeeper is “anyone who is strategically positioned to recognise and refer someone at risk of suicide” (Suicide Prevention Resource Center, 2012, para. 1). Further, a gatekeeper is one who has “face-to-face contact with large numbers of community members as part of their usual routine” (Burnette et al., 2015). LGBTQ refugees and asylees may interact with various gatekeepers, beginning in their country of origin and throughout their resettlement journey. Having their LGBTQ identities and experiences validated by these trusted gatekeepers may serve as one way to protect against suicidality, as this provides empathy and understanding.

However, there is little empirical evidence in the literature that has focused on gatekeeper intervention and prevention with LGBTQ refugees and asylum seekers specifically or the forced migrant population in general, with a notable exception being the work of Colucci and colleagues (2018). They published guidelines for gatekeeper suicide intervention and prevention (suicide first-aid) for immigrants and refugees. This study was conducted using Delphi methodology with 44 experts, practitioners and individuals with related lived experiences. Ultimately, 80 guidelines were developed to support and intervene with immigrants and refugees experiencing suicidality (Colucci et al., 2018).

One guideline in particular relates directly to the concepts discussed in this theoretical framework. It states that, “if the first aider has to call the police, they should explain the person is from immigrant or refugee background and may have distrust towards police” (Colucci et al., 2018, p. 10). This recommendation aligns with the discussions in this theoretical framework surrounding experiences of stigma and discrimination in formal settings, particularly throughout the asylum journey. Likewise, it is strongly recommended that culturally responsive gatekeeper suicide prevention training be provided for humanitarian workers and other direct practitioners working with LGBTQ refugees and asylees.

Additionally, Alessi and Kahn (2017) developed a practice framework for clinical practice and mental health services for LGBTQ asylum seekers. The overall goal of this framework was to cultivate resiliency in LGBTQ asylum seekers in order to better cope with challenges of resettlement, which include managing experiences related to minority stress in the host country. The three core components of Alessi and Kahn’s LGBTQ-affirmative framework are: establishing safety and stability in treatment and in the environment, developing skills for managing the asylum claims process and providing strategies for dealing with the challenges of resettlement.

If LGBTQ refugees or asylum seekers have experienced stigma and discrimination through negative encounters with formal helpers during their journey, they may then experience difficulty developing future relationships and trusting bonds with practitioners. Likewise, establishing safety and stability is one crucial way that practitioners can mitigate against exacerbating pre-existing trauma and potentially reduce suicide risk. Practitioners can do this by helping LGBTQ refugees and asylum seekers gain access to essential resources (food, shelter, clothing, someone to call in an urgent situation) and cope with minority stress in the host country. Strategic intervention for dealing and coping with the asylum claims process and broader resettlement challenges can directly assist LGBTQ refugees or asylum seekers in cultivating resilience, strength and trust. Further, suicide risk assessment can readily be integrated into this existing framework.

There are practice implications for gatekeepers who work directly in communities and with families to develop support and inclusion for LGBTQ individuals. Since having at least one supportive relationship may reduce the risk of suicide attempt by 40% (The Trevor Project, 2019), a critical first step for frontline practitioners is to address the chosen family and community systems as social supports in targeted interventions. A summary of practice implications is detailed in [Table 1].{Table 1}

 Conclusion



This review of the literature offers a preliminary theoretical framework for understanding factors contributing to suicide risk, as well as those that may protect against this risk, in LGBTQ refugees and asylum seekers from a lifespan perspective. The novel contribution of this study is that it examines individual areas of inquiry (e.g. suicidality in LGBTQ individuals who are not forced migrants, childhood adversity, premigration victimisation, minority stress, queer migration) and integrates them to create a holistic understanding of the complexities that emerge to precipitate suicide risk and protective factors among this population. This literature review has yielded both a theoretical framework for understanding this problem as well as practice implications from the literature for enhanced service provision.

Recommendations include further exploration into the unique experiences of suicidality with LGBTQ refugees and asylum seekers. This includes examining the meaning of suicidality across contexts, cultures and religions, and how this may intersect with the way sexual and gender nonconformity is constructed in these settings. As there is minimal evidence in the literature, further exploratory studies should be conducted to elicit narratives from these individuals themselves. Intervention research can only be truly beneficial to this population when their voices and experiences are heard as well as when they also have a contributing voice to the nature and direction of research and intervention.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

1The acronym LGBTQ is used in this article instead of LGBTIQI to reflect the original research conducted for the development of this theoretical framework, which included articles related to lesbian, gay, bisexual, transgender, and queer/questioning individual’s lives and experiences.

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