Anonymity and representation

BackgroundSeveral reviews have found that psychological trauma affects access to health care services, including mental health care, in the general population. People from refugee and asylum seeker backgrounds are more likely to have a mental illness than the general population, and experience a broad range of barriers and facilitators to service access. However, to date there has been no comprehensive consideration of the potential effect of psychological trauma on access to primary health care within this population.MethodsThis paper provides a mixed-methods systematic review of literature which included any consideration of the relationship between psychological trauma and access to primary health care. A systematic search of Medline, PsychInfo, Scopus, Web of Science, Embase, CINAHL and Cochrane Library was conducted. Study eligibility criteria were empirical, peer-reviewed studies that considered the relationship between psychological trauma and access to, or use of, primary healthcare in resettlement countries for refugees (including asylum seekers). Papers were required to be written in English and published between 1998 and August 2019. Quality was assessed using the Multi-Methods Appraisal Tool. The search identified a total of 14 eligible studies (11 quantitative and 3 qualitative) which had explored this relationship in refugee and asylum seeker populations.ResultsOverall, synthesis of findings indicated variable results with respect to the impact of psychological trauma on service access. Specifically, the review found that while rates of psychological trauma were high. Key themes were that while general health care access was comparable or greater than the general population, rates of mental healthcare specifically were low. In addition, included papers identified a range of barriers to service access—particularly somatisation, stigma and healthcare provide knowledge about psychological trauma.ConclusionsWhile there is a critical need for more research in this area, the study points to several key recommendations including training of general practitioners in relation to psychological trauma, ensuring culturally responsive services, and the use of interpreters. Finally, due to the levels of somatisation found in some studies, ensuring general practitioners understand the somatic element of psychological trauma—particularly within some groups of people from refugee backgrounds—is important.

The Comprehensive Plan of Action (CPA) was adopted in response to continued refugee exodus from Vietnam and the resulting political consequences of what had become a protracted international dilemma. The approach inherent in the CPA was to address in a comprehensive manner all aspects of the problems relating to the Vietnamese Boat People (VNBP), including the causes of their flight. Unlike most other refugee situations, this required the co-operation and participation of the country of origin. Many of the features of the CPA required the participation of the United Nations High Commissioner of Refugees (UNHCR), most notably its active involvement in refugee status determination in countries which had no previous experience in this regard. The objectives of the CPA were to end the flow of non-refugees, determine on an individual basis the refugee status of all VNBPs arriving in first asylum camps, resettle refugees to third countries and return non-refugees to the country of origin. Mass information campaigns in Vietnam were used to explain the CPA and the possibility of legal departure under the Orderly Departure Programme. The main feature, on which all the other elements rested, was the Refugee Status Determination (RSD) of asylum seekers who arrived in first asylum countries after an agreed cut-off date (March 1989). Previously, Vietnamese fleeing their country were resettled under an arrangement agreed by governments participating in the 1979 Geneva Conference. The adoption of the CPA in 1989 brought an end to automatic resettlement and required that all VNBPs arriving after the cut-off date be screened to determine their individual refugee status. Many found this extremely difficult to accept, particularly the Vietnamese Boat People themselves, given the previous fifteen years' practice. It was critical to the success of the CPA that Refugee Status Determination proceedings be fair and that the special historical circumstances of the VNBPs were taken into account. The political environment in which the CPA was drafted recognized that the refugee definition contained in the 1951 UN Refugee Convention and 1967 Protocol would guide the RSD proceedings, but that account should also be taken of other international instruments relating to refugees. It was furthermore acknowledged that humanitarian consideration should be given to the particular situation of the Vietnamese, and that there be respect for maintaining family unity. Interpretation regarding the weight given to each of these factors dictated the screening process and created controversy among the various interested parties. Non-governmental organizations, in particular, felt that increased weight should be given to the humanitarian aspects of the CPA. Others, particularly resettlement countries, were concerned about a too liberal interpretation of the refugee definition and an elastic application of the principle of family unity. In addition, positive changes in Vietnam made it necessary to put increased weight on the requirement to show a well-founded fear upon return. UNHCR was given the task of monitoring the procedures and training the government officials who were to screen the asylum seekers. This paper examines the factors contributing to the RSD process, analyzes their significance and assesses the results of the RSD exercise.

Since Amnesty International's March 1993 report, ‘Japan: Inadequate Protection For Refugees And Asylum Seekers’ (also published in 5 IJRL 205), refugee status procedures in Japan have received wider attention. The present paper contains the government response to the report (Annex 1), but also aims to provide more detailed information on the decision-making process and the treatment of asylum seekers in Japan. It explains the basic provisions of the Immigration Control and Refugee Recognition Act (text attached as Annex 2), and describes a number of factors, including the experience with Indo-Chinese boat-people, as well as the determination practice of other countries, that were taken into account in drafting the legislation. In the coming years, each government will need to recognize the spirit of international solidarity and equitable burden-sharing, and to behave accordingly. To make such a realistic approach more effective, it is essential to nurture and maintain reliable and complementary relations among governments, international organizations and non-governmental organizations. The author suggests that this is not likely to be achieved through ‘alienating’ governments by insisting mat what is not legally binding be implemented by them as obligations under the Convention. Instead, discussion should focus on ways to minimize the exodus of refugees, to contain the effects as much as possible once such exodus has occurred, and to find equitable burden-sharing among international actors

Employment is a social determinant of health, providing differential access to health insurance, social networks, and other resources that influence health trajectories. Asylum seekers are a subgroup of immigrants who have fled persecution in their home countries and with both precarious immigration status and employment access while they await adjudication of their asylum claims. We explored U.S. asylum seekers' experiences at the intersections of immigration, employment, and health and wellbeing. English and Spanish-speaking asylum seekers (age >/=18 years old) were recruited predominantly from an academic medical center-based Asylum Clinic. Interviews were conducted over the phone by a bilingual research coordinator, recorded, transcribed, and analyzed thematically. We identified four themes: (1) Work as essential yet inaccessible within the asylum process, marked by waiting, limited ability to access basic necessities and health services, and people resorting to desperate methods to obtain income; (2) Underemployment, which involved suboptimal opportunities due to devaluing of experience in their home country, transportation challenges, and competing demands; (3) Workplace inequity and exploitation; and (4) Employment as a source of stability, identity, and purpose. Our study highlights the employment challenges faced by U.S. asylum seekers, which can harm their health and wellbeing. Increasing pathways to employment during the asylum adjudication process can be one mechanism for promoting health and wellbeing in this population. Further, asylum policy, and the labor regulations connected to it, must be examined through the lens of structural vulnerability.

BackgroundThe U.S. immigration system mandates that persons seeking asylum prove their persecution claim is credible and their fear of returning home is well-founded. However, this population represents a highly trauma-exposed group, with neuropsychiatric symptoms consequent to prior torture or maltreatment that may interfere with cognitive function and their ability to recall their trauma. These memory lapses may be incorrectly perceived by asylum adjudicators as indicators of dishonesty and jeopardize the person’s credibility and asylum claim. Our retrospective mixed methods study seeks to present associations between trauma and memory loss in a sample of persons seeking asylum to the U.S. and describe how memory impairments manifest in this trauma-exposed population.MethodsWe randomly selected 200 medico-legal affidavits from 1346 affidavits collected in the past 30 years, as part of the Physicians for Human Rights Asylum Network connecting clinicians with legal providers for medical and/or psychiatric affidavits of U.S. asylum seekers and persons seeking other forms of humanitarian relief (hereafter, “asylum seekers”). Data was extracted from these affidavits using a coding manual informed by the Istanbul Protocol, the global standard for torture documentation. Seven affidavits were excluded due to missing age. We used multiple logistic regression to assess the association of memory loss with neuropsychiatric diagnoses: head trauma, post-traumatic stress disorder (PTSD), and depression. We supplemented these findings with a qualitative content analysis of the affidavits documenting memory loss. Memory loss presented among the asylum seekers’ affidavits in several ways: memory gaps of the traumatic event; challenges with presenting a clear chronology of the trauma, avoidance of traumatic memories, and persistent short-term memory loss interfering with daily activity.ResultsA majority of the sample received a neuropsychiatric diagnosis: 69% (n = 132) of asylum-seekers received a diagnosis of PTSD and 55% (n = 106) of depression. Head trauma was reported among 30% (n = 58) of affidavits. Further, 68% (n = 131) reported being subject to physical violence and 20% (n = 39) were documented as being at risk of suicide. Memory loss was documented among 21% (n = 40) asylum-seekers. In adjusted models, both PTSD and depression, but not head trauma, were associated with memory loss (p<0.05).ConclusionStakeholders in the asylum process, spanning the medical, legal and immigration enforcement sectors, must be aware of the interplay of trauma and memory loss and how they might impact immigration proceedings for this vulnerable population.

BackgroundAsylum seekers are at elevated risk of self-harm, and the personal and public health costs of self-harm are high; yet the monitoring and reporting of self-harm has been limited and lacking in transparency. This study aims to evaluate the quality of self-harm incident reporting across the Australian asylum seeker population, including by processing arrangements (i.e. community-based, community detention, onshore detention, Nauru, and Manus Island).MethodsAll self-harm incidents reported across the entire Australian asylum seeker population between 1 August 2014 and 31 July 2015 were obtained via the Freedom of Information Act. We assessed the quality of self-harm incident reporting according to the World Health Organization (WHO)'s self-harm reporting guidelines.ResultsA total of 949 self-harm incident reports were assessed. Date, location (processing arrangement), and time of self-harm were routinely reported. Gender was recorded in less than two thirds (62.1%) of all incidents. Method(s) used to self-harm was reported in 81.5% of all incidents, though IDC-10 codes were not reported in any episodes. Psychological or psychiatric assessments were recorded after 4.0% of all incidents, most frequently on Manus Island (10.9%), and in Nauru (10.0%), and least frequently in community-based arrangements (1.7%) and in onshore detention (1.4%), and not at all in community detention. Ambulances were reported as attending 2.8% of all episodes. Hospital attendances were reported following 6.0% of all self-harm incidents, with attendances most commonly reported in incidents occurring in community detention (30.3%), and in community-based arrangements (19.4%). Medevac (air ambulances) were recorded as being utilised in 0.4% of all incidents (2.1% of episodes on Nauru, 1.8% on Manus Island).ConclusionsThe findings of our study indicate that the accessibility and quality of self-harm data is substandard and inconsistent with WHO self-harm reporting guidelines. Such variable reporting makes the identification of self-harm trends, the implementation of prevention strategies – including those at a policy level - and the clinical management of self-harm, extremely challenging. Improved self-harm reporting and monitoring is urgently needed for mitigating and responding to self-harm risk among asylum seekers.

The aim of this study was to give a voice to people from asylum seeker and refugee backgrounds in Australia during the COVID-19 pandemic and to explore their perspectives concerning their experiences of everyday life. The findings highlight the impacts the pandemic had on these groups, how it exacerbated existing vulnerabilities, worsened mental health, increased social isolation, affirmed a sense of abandonment, and heightened financial precarity. The study adhered to a social constructivist approach. It used a qualitative methodology guided by a narrative research approach. Semistructured in-depth interviews with thirteen participants were thematically analyzed to generate a global theme and subthemes. For people from asylum seeker and refugee backgrounds in Australia, the government-mandated lockdown measures led to increased feelings of loneliness and loss of social support networks, reduced access to public spaces, and limited engagement in face-to-face activities and opportunities for socializing and maintaining mental well-being. The pandemic intensified domestic partner violence incidents and financial stress emerged as a major concern. Participants lost or had reduced employment, and many were ineligible for government financial support. These challenges intersected with preexisting hardships which contributed to feelings of abandonment. Based on the findings, implications include the need for inclusive policies and targeted healthcare support, measures to prevent and respond to partner violence, and inclusive financial assistance schemes that address the unique needs of people from asylum seeker and refugee backgrounds in Australia. Further research is needed to inform therapeutic supports and trauma-informed services for these groups.

Asylum claimants’ experiences of crimmigration controls are shaped by gender, race, and class. This article seeks to show how intersecting identities of women seeking asylum interact with stigma. The article draws from research with 16 asylum seekers in the UK which incorporated narrative interviews, ethnography, and the use of text messaging as a diary method. The article finds that intersecting identities are impacted by crimmigration controls to develop a stigmatised identity. Despite attempts to hide their immigration status, the stigma associated with ‘being’ an asylum seeker was internalised and this became women’s dominant identity, resulting in a series of harms including social isolation.

Digital evidence is rapidly emerging as a tool for migration authorities in refugee status determination (RSD)—the procedure for determining whether a person meets the criteria for protection as a “refugee.” Its growing popularity may be seen as a response to the relative dearth of “hard” evidence in asylum procedures, where decisions often hinge exclusively on the applicant's personal narrative and assessment of her credibility. In this essay, we critically examine the growing use of digital evidence in RSD by authorities and the human rights concerns that arise from some of these practices. We then move to outline some examples of how digital evidence might also present new opportunities for scholars, practitioners, and asylum seekers themselves, helping to substantiate claims and document underlying inequities in existing RSD practices. In the process, we seek to navigate a balance between the techno-solutionism that hails digital evidence as a panacea and those a priori dismissing digitization as techno-hype and inherently problematic.

Procedural fairness in automated asylum procedures: Fundamental rights for fundamental challenges

O solicitante de refúgio se define enquanto categoria migratória a partir do processo de elegibilidade para o reconhecimento da condição de refugiado. O que, a princípio, seria necessariamente uma etapa migratória, de caráter provisório, costuma adquirir, em muitos casos, matizes de permanência, submetendo os migrantes que se encontram no trâmite do processo de elegibilidade às implicações próprias de tal categoria. O objetivo com o presente trabalho é propor, a partir da base de dados do CONARE, uma forma de se mensurar o tempo que os solicitantes de refúgio permanecem nessa condição migratória atualmente no Brasil e avaliar qualitativamente as implicações de tal cenário. Como resultados, percebe-se um aumento expressivo e contínuo no tempo de permanência na condição de solicitante de refúgio de 2014 a 2020 quando não se levam em conta os venezuelanos nos dois últimos anos, com um maior percentual de pessoas que aguardam três anos ou mais pela resposta a seu pleito. Identifica-se, como consequência, a exposição a problemas como as restrições do contato com parentes através da reunião familiar e dificuldades em fazer planos de longo prazo exequíveis em decorrência das incertezas inerentes à referida situação migratória. Propõem-se, enfim, reflexões sobre um aparente esforço de redução das solicitações pendentes, com especial atenção à realidade dos migrantes.

In March 2014 we spent a week on Christmas Island as medical consultants to the Australian Human Rights Commission (AHRC) Inquiry into the Impact of Immigration Detention on Children. The visit involved three Human Rights Commission staff as well as the authors, paediatrician Karen Zwi and child psychiatrist Sarah Mares, representing the Royal Australasian College of Physicians and the Royal Australian and New Zealand College of Psychiatrists respectively. Using interpreters, we spoke to over 40 unaccompanied children and service providers to ascertain processes and policies and to give feedback about detainees of immediate concern. We would like to honour the voices of the detainees; we have used their exact words where possible. In a separate paper, we focus on the families and children detained in immigration acilities on Christmas Island. Unaccompanied children are children under the age of 18 years who are seeking asylum from threatened or experienced danger. They arrive unaccompanied by a parent, legal guardian or adult relative over the age of 21 years. On arrival to Australia, unaccompanied children by law become the legal wards of the Department of Immigration and Border Protection (DIBP). The role of a legal guardian is commonly regarded internationally as one who ‘stands in loco parentis to the child’, which includes making decisions regarding the best interests of the child and providing for the child’s emotional and material needs. In Australia, the Minister’s role tends to be nominal without practical assistance offered to the children, which has been described as leaving them not only unaccompanied but also unrepresented. A DIPB officer is appointed locally as the children’s ‘Delegated Guardian’ as discussed below. Most unaccompanied children leave their homes as a desperate measure in search of protection, education and employ ment, and to contribute to the welfare of their family. They have often embarked on dangerous journeys, experienced war, the death of family members, persecution, violence, sexual abuse, escape from forced recruitment into armed organisations and forced domestic labour. These experiences occur during critical developmental periods, thus placing them at risk of mental health problems. Research is limited to a few cross-sectional or on-arrival studies, which have shown that around 25–50% have emotional and behavioural problems, anxiety, depression and post-traumatic stress disorder (PTSD), at higher rates than in accompanied asylum seeker children. However, consistent with other studies on refugee children, the majority of unaccompanied children score below clinical cut-offs for psychiatric disorder, thus displaying a marked resilience. The severity of psychiatric symptoms is likely to increase with more traumatic events experienced prior to forced migration, demonstrating the cumulative impact on well-being of traumatic exposure. Children exposed to adversity following migration, particularly those placed in prolonged detention, are more severely affected. Studies show increased symptoms for those exposed to rioting, fires, violence and self-harm attempts by parents or others in detention. Rapid resolution of asylum claims reduces the duration of uncertainty and associated distress for children, whereas insecure asylum status is associated with a range of psychological problems that can have long-lasting effects. Prompt access to services catering for physical and psychological health is important, as are long-term stability of residence and socially supportive environments. It is also known that PTSD symptoms are increased in lower-support living arrangements suggesting that foster family living and high support may improve outcomes.

People from refugee and asylum seeker backgrounds resettling in Australia often experience intersecting risks for poor mental and physical health. Physical activity can promote better health outcomes, however there are limited programs tailored for this population. Therefore, understanding how to support refugees and asylum seekers to engage in physical activity is crucial. This paper aims to describe how the experience-based co-design (EBCD) process was used to identify priorities for a new physical activity service for refugees and asylum seekers. Using an EBCD framework we conducted qualitative interviews and co-design workshops with service users (refugees and asylum seekers living in the community) and service providers at a community Centre in Sydney, Australia. Sixteen participants, including eight service users and eight service providers engaged in the EBCD process over 12-months. The interviews revealed common themes or ‘touchpoints’ including barriers and enablers to physical activity participation such as access, safety and competing stressors. Subsequent co-design focus groups resulted in the establishment of five fundamental priorities and actionable strategies; ensuring cultural and psychological safety, promoting accessibility, facilitating support to access basic needs, enhancing physical activity literacy and fostering social connection. Using EBCD methodology, this study used the insights and lived experiences of both service users and providers to co-design a physical activity service for refugees and asylum seekers which is safe, supportive, social and accessible. The results of the implementation and evaluation of the program are ongoing.

This chapter considers the methodological challenges and ethical implications of undertaking a qualitative study of experiences of forced labour among refugees and asylum seekers in the UK. Employment is prohibited while an asylum claim is being processed and for refused asylum seekers, which made identifying participants willing to talk about labour experiences extremely difficult, even if the work experience occurred after an individual gained leave to remain as a refugee with permission to work. This chapter discusses how access was negotiated through participant observation outreach leading to in-depth interviews with 30 individuals. The indicators of forced labour offered by the International Labour Organisation (ILO) were found to be a useful tool for engaging in colloquial discussions of severely exploitative work practices to identify purposively sampled participants without being dependent on definitions of coercion. Challenges to access resulted not only from individuals’ apprehension of speaking to researchers but also from the concerns of gatekeeping agencies nervous to talk about unauthorised employment. In this sense, the ‘doctrine of illegality’ that surrounds ‘illegal employment’ extends far beyond individual workers and workplaces. The chapter considers the question of ‘doing no harm’ in research with individuals who have complex immigration cases and practical needs, and also considers the importance of negotiating informed consent in iterative and informal ways beyond formal signed consent sheets. Discussing how anonymity operates by describing analysis to interviewees in tangible ways was an important corollary to gaining meaningful informed consent. This requires ethical approaches to extend into how data are written up and disseminated.

With 1 in 3 women affected, accounting for one billion women worldwide, Violence Against Women (VAW) constitutes one of the widest reaching human rights violations globally. Although the forms they take may vary, these abuses are not confined to a single social class, geographic region, or culture. Existing studies have yet to describe the full burden of abuse that asylum-seeking women endure throughout their lifetimes. We describe a novel coding tool that classifies types of abuse, identifies abuse perpetrators, and estimates how long and how often each abuse was experienced. The authors used this tool to describe and categorize the abuses endured by 85 cisgender, adult women seeking asylum in the United States who presented to the Weill Cornell Center for Human Rights for forensic medical evaluations from 2013 to 2017. We reviewed a total of 180 legal and forensic medical affidavits that were written in support of the applicants’ asylum claims. Using the coding tool, we identified each abuse, classified every perpetrator, and, whenever possible, estimated how long and how frequently each abuse was endured. Interpretations of the raw data contained in this article and a discussion of their significance can be found in our associated publication: “Gender-Based Violence experienced by Women Seeking Asylum in the United State: A Lifetime of Multiple Traumas Inflicted by Multiple Perpetrators” [1]. The coding instrument described herein characterizes VAW by classifying the narrative data that are included in interviews, focus groups, medical records, and the like. Our coding instrument is the first of its kind to describe all types and severities of violence endured by women, classify the perpetrators of that violence, and delineate the timeline of violence over each individual's life. We hope that this holistic approach to classifying and describing VAW will enable other research groups to examine untested or unrealized associations between victims, perpetrators, and abuses. Ultimately, obtaining more complete data will empower us to advocate more effectively and to design more comprehensive care for victims of VAW.