Okay, good afternoon, everyone. Thank you for being here on this last day of the APA. My name is Omar Fattal. I'm a psychiatrist with the Pride Clinic at Bellevue Hospital in New York, and I'm the system chief for behavioral health for NYC Health and Hospitals. But I'm here today in my capacity as a board member and a founder member of LabMash, the Lebanese Medical Association for Sexual Health, which is an organization of healthcare professionals that we founded in 2012, and our mission is to advance the health of LGBTQ people in Lebanon and the MENA region, and we've been focusing a lot on mental health and specifically conversion practices, but mental health in general. So I'm going to pass it on to Joanne to introduce herself. Hi, everyone. Yes, and thanks for coming on this last afternoon. I'm Joanne Ahola, and I'm a psychiatrist in New York City in private practice, but my other passion in psychiatry is working with asylum seekers, and I've been doing this for more than 20 years. I'm also a teacher and a trainer, the founding medical director of the Weill Cornell Center for Human Rights, which was the first medical school asylum clinic in the United States. Now there are 25 of them, approximately, based on our model. I've been working with physicians for human rights for 25 years. I've also been fortunate enough to be a co-author of the 2022 update of the Istanbul Protocol, and I work with not only asylum seekers, but with people who are victims of torture who are not seeking asylum. My special interests are LGBT persecution around the world and LGBTI asylum cases, and also appearing as an expert witness in court, and co-chair of the Gap Committee on LGBTQ issues. And now to Graham. My name is Graham Reed. I'm the director of the LGBT Rights Program at Human Rights Watch. I also teach on the side. I'm an anthropologist by training, and I teach at Yale and Columbia courses related to the current work that I do in terms of international LGBTI rights work. So we do have some slides, but we're hoping, especially that this is a small group, that this would be interactive and more of a discussion, so please feel free at any point to jump in. We're going to have three sections. Graham's going to speak first, then I'm going to speak, then Joanna's going to speak, and then we're going to have a dedicated time for questions and answers. But at any moment, feel free to jump in. And to get a sense of who's in the room, we were hoping that maybe we can go around and just have everyone just say who they are and where they're coming from, and just like one sentence about what drew you to this session today. So maybe if we start with the back and then move up to the front. Yeah. My name is Steve. They're recording, so they need to ask the questions on the mic, or they're not going to hear it. Okay. We'll remember that. Yep. Thank you. Thank you. Good to know. He said the questions at the mic, because they're recording us. Oh, okay. Interesting. Yeah. So I'm Ken Ashley, a SEAL psychiatrist in New York City. I have been for many years, I was at Bellevue, and although I did not work in the refugee clinic there, I knew very much of it and worked with a lot of people in the clinic. So it's just a topic that's interesting. And I'm Flavio Kossoi. I live in New York and work for the New York State Office of Mental Health. I'm sorry, when we had the idea, we didn't know the people had to get up. I'm sorry to make you do that. We won't do it next year. I'm Jack Drescher. I'm a psychiatrist from New York City. I write and speak on the LGBTQ health issues. And since I know all three presenters, I came to hear them speak. Yeah. Thank you. Okay. Thank you so much, everyone. So just to start and summarize the objectives for today. So as I mentioned earlier, we're going to start with Graham, who's going to highlight the precarious circumstances of LGBTQ people, specifically refugees, highlighting the mental health needs. And that's going to set the stage and the background for the following sections, which is my section where I'm going to talk about a pilot that we did, Lab Mash, in collaboration with a nonprofit in France on a project for emotional support for Afghani refugees. And then I'm going to turn it to Joanne, who's going to talk about the role of the mental health professional in helping in assessment of survivors of human rights abuses. And that's one thread throughout the talk that we're hoping to bring out in people's, how can we help, right? As a psychiatrist or as a mental health professional, how can you help with this work? So hopefully we can talk about that more in the discussion section. So Graham, I'm going to turn it to you. Thank you. Three years ago, on June the 14th, 2020, Sarah Hegazi, a 30-year-old Egyptian feminist, took her own life in exile in Canada. Three years previously, she had attended a concert by Mashrou Leila, a Lebanese band that took place in Cairo. And at the concert, she waved a rainbow flag, and that became an iconic image that was widely distributed. About a week later, Egyptian authorities detained her on charges of joining a band group aimed at interfering with the Constitution, a typically trumped-up charge. There's no express prohibition against same-sex relations in Egypt, but people are often arrested under vague debauchery laws or state security laws. Sarah spoke about being tortured by members of the Egyptian police in detention, including the use of electric shocks and being subject to solitary confinement. Police also incited other detainees to sexually assault and verbally abuse her. Sarah was released on bail after three months, but those who arbitrarily deprived her of liberty and tortured her were never held to account. And this all for waving a rainbow flag. In exile, she wrote about her alienation and isolation, her suicide attempts, and how she could not return home to mourn the passing of her mother. She wrote, a year after the Mashrou Leila concert, a year after Egypt's biggest security attack against gay people, a year after I announced my difference, yes, she said, I am gay. I have not forgotten my enemies. I have not forgotten the injustice that left black spots carved in my soul and bleeding, spots that doctors have never been able to treat. Now, Sarah's experience is not an isolated incident. Security forces arrested dozens of other concert goers, many simply on the basis of their real or perceived sexual orientation or gender identity. Now, Human Rights Watch has been documenting similar abuses in Egypt for many years. Police in Egypt have a dedicated unit that are trained to entrap people using dating apps. This is a very common practice in Egypt. It's also routine to subject detainees, gay or transgender women detainees, to forced anal examinations, a spurious pseudoscientific idea that somehow sexual intercourse is evident through these examinations. These exams amount to cruel, inhuman, and degrading treatment that can rise to the level of sexual assault and torture. Sarah Ghazi's tragic story illustrates the fact that physical safety, in this instance exile in Canada, was not sufficient in terms of giving her the support that she needed, and this is the case for so many people around the world. Human Rights Watch documents abuses around the world. We work in some 100 countries, and within Human Rights Watch is a relatively small LGBT rights program. There are about four full-time researchers, I say about because sometimes people are working on short-term contracts or are there on a more part-time basis, but generally speaking we have about four full-time dedicated researchers, and we work around the world. So being embedded within a broader human rights organization, it helps us because we have other researchers whose expertise that we can draw on, but nevertheless we're quite thinly stretched. And the approach that we take is to investigate human rights abuses that take place by interviewing people who are directly affected by those abuses, and then gathering whatever other evidence we can to support their testimonies. The reputation of Human Rights Watch rests on its accuracy and reliability, so an enormous amount of attention is paid to ensuring that what we publish is reliable and accurate. And we use that information to draw attention to these abuses with a view to bringing about legal and policy change and the change in people's lived experience. Today I'm going to talk about some of the mental health needs that arise in three different situations. One is in the country-specific context in which there was a series of arrests. The other looks specifically at the experiences of migrants and asylum seekers, and the third is a situation of crisis and conflict. So the first country situation that I wanted to talk about is in Ghana. In 2021, Ghanaian police in an area of Ghana known as Ho, assisted by security forces, raided and unlawfully arrested some 21 people who were attending a workshop basically about documenting human rights abuses against LGBT people, ironically. Everyone who was at the session, including a technician who just happened to be there fixing a piece of equipment, were detained for 22 days and then finally released on bail and charged with unlawful assembly, which is a misdemeanor, and the case was later dismissed for lack of evidence of a crime. So while there was no material consequence from the arrest, there was certainly a strong impact on individual lives. All of the people that we interviewed said that they had experienced long-term mental health problems, and five said they had severe physical health problems, including two who had to be hospitalized. Here's the extract from the testimony of a 31-year-old lesbian who lived in her partner's family home with her partner prior to the arrest. When I was in there, in prison, my whole world crashed. After the first court appearance, my mother came to tell me that my grandmother had died. When we were released on bail, another family member died. My uncle told me to come to the funeral so that he could convene a meeting to deal with my sexuality. I was scared, so I did not go to the funeral. I don't know what to do with my life now. I cannot go back to Ho. My partner has lost her child. Her family kicked us out and told her she is no longer allowed to see her daughter. My partner is living in Ho with friends. We both have no income to survive. This is very typical of a story of women and the way in which they are impacted by a loss of family support networks because of the economic dependence that many women have on their families and family networks. So to be excluded from your family in this way has enormous economic consequences as well as a psychological effect. Another lesbian from Ho who was detained described the effects on her physical and mental health. She said, I got a rib infection because of sleeping on the floor. They took me to hospital and I got treatment. My mother found out about me being one of the 22. This was highly publicized in Ghana, so a lot of public attention was paid to the 22 who were detained. I had to find my own place to live because I couldn't go home. I'm going through a lot and have a hard time sleeping and flashbacks. When I sleep, I feel like I'm in the cell again. I brought a friend to come sleep at my place so that I feel safe and don't do anything to harm myself. Now in Ghana, in the wake of these arrests, a bill was proposed and is currently still in Parliament. Amongst the many extreme measures in the bill, there is a three to five year prison sentence for holding out as LGBT. In other words, for simply claiming an identity, you could face a three to five year jail sentence. And within the bill is there's a flexible sentencing is provided to the convicted person, provided that person recants and subjects themselves to medical treatment. That is state-sanctioned conversion therapy in Ghana. Now that bill hasn't passed into law, but it has been discussed widely in the country and as is so often the case when such legislation is discussed, it amps up the level of public hostility and anti-LGBT rhetoric so that the damage is done, some damage is done, even before a bill like that is passed. The second instance that I wanted to talk about is focusing specifically on the experiences of migrants and asylum seekers. LGBT refugees and asylum seekers around the world often report trauma symptoms, these include hyper-vigilance, anxiety, avoidance, depression, suicidality, and social alienation. Human Rights Watch is currently working on a report on the experiences of LGBT asylum seekers seeking sanctuary in South Africa. Many people from around the continent come to South Africa or aspire to go to South Africa because South Africa provides legal protection on the basis of sexual orientation and gender identity, and explicitly within its Refugee Act recognizes sexual orientation and gender identity as a basis for claiming asylum in South Africa. But what we found that in addition to the trauma that many people experience in their countries of origin, and often they're very difficult journeys to get to South Africa, they also find, they also experience myriad challenges within South Africa, many of which have negatively affected their mental health. So there's a big gap between policy and actual lived experience within a South African context when it comes to the experiences of asylum seekers. And so many of the LGBT asylum seekers that we interviewed recounted feeling traumatized, depressed, hopeless, isolated, and constantly fearful. And they attributed these emotions in some instance to very practical reasons such as documentation and discriminatory attitudes from officials that they encountered. So there's this gap between an aspiration towards a better life, the hope that's held out by South Africa, and then dreams deferred, and often people finding themselves living on the economic margins, and finding it very difficult to adjust to these circumstances in South Africa. Now many of these experiences are experiences that are shared in common by many refugees and asylum seekers, but there are certainly unique aspects that LGBT people face. One of those is the absence of supportive home networks. Many people who come to South Africa are able to slot into a network of supportive people from their home country. That's not often the case with LGBT people who face hostility from people from their home country, which is part of the reason why they fled in the first place. They face particular forms of discrimination, often in the form of stereotypes that are held by officials. So people who would say, but you don't look gay. So the sort of style of presentation when people are submitting their asylum claim is seen to discount the credibility of their claims. Zoe, not a real name, a 37-year-old lesbian from Zimbabwe put it this way, home affairs, the entity with which asylum seekers need to engage in order to get asylum, home affairs does not understand the emotional trauma that people go through. Psychological trauma is not measurable and there's no tool to assess this fear, exhaustion and this pain. Sylvain, a 34-year-old gay man from Zimbabwe, emphasized the importance of documentation to a better life. The problem is papers, he said, I can't develop, I'm not developing, I'm not at all, and it's stressing me every day, so that kind of constant stress of the lack of adequate documentation that would enable him to live and work in South Africa. According to Timothy, a transgender man from Zimbabwe, he said, it really, really messes you up so bad that in front of people, you're put on a face and pretend you are okay, because if it's a service you are trying to get, then you just have to suck it up and get that service. But when you are on your own, and you go back to your space, then you start feeling the impact. Now, Timothy said that he was fortunate to have access to mental health support because of his work, but he added that others in the community may not. And here I would just use two illustrative examples, one from Uganda and one from Tanzania. Uganda has also proposed, and it's been passed by Parliament and is waiting for the presidential signature for it to pass into law, probably the most extreme anti-LGBT piece of legislation in the world, both in terms of its scope and in terms of its content. And many people have been fleeing the country or trying to flee the country before this draconian piece of legislation becomes law, and many of them have fled to South Africa. And the Ugandan bill, the Ugandan NGO authorities had also clamped down on NGOs who work with LGBTI people, including those NGOs that provide vital health services to LGBT people there. So 24 organizations were put under investigation by the NGO board, four of them have been banned so far, and the others are being subject to further scrutiny. So this also has a direct impact on the access to mental health services within Uganda. Similarly, in Tanzania, authorities there closed down health facilities that were LGBT-friendly. So those that had specific programs that were tailored for LGBT people have systematically been closed down. Now health has, in most instances, been a relatively safe place, even within a context in which there's quite a lot of public hostility and political antagonism towards LGBT people, that the health space had been one that had been carved out as somewhat safe. So these have been very disturbing developments, both in Uganda and Tanzania. And then similar to the Ghana bill, in Uganda, the bill passed by Parliament also has a provision called the Rehabilitation of Homosexuals, and there it provides for conversion therapy for convicted persons. Okay, my last illustrative example is in a situation of crisis and conflict, and the example I'm going to use is a recent one, and that is in Afghanistan. So people such as LGBT people who experience discrimination, marginalization, and criminalization, whether that's of same-sex conduct or gender expression, in peacetime can expect that their precarious situation will be exacerbated in times of conflict, so meaning that vulnerable groups are especially vulnerable in conflict situations. And for LGBT people, there are often two dimensions to this. One is invisibility, out of necessity of needing to live in secret, and the other is hostility that's directed towards them because of their identities. And this is often compounded by criminalization, the effect of the criminal law. Even in settings when the law is seldom enforced, it sends a state message that it's okay to discriminate against LGBT people. And often LGBT people face economic marginalization and a strong reliance on the informal economy, all of which add to the precarity of their situation. So Human Rights Watch and Outright, a group that works internationally on LGBTQI issues, have documented abuses based on sexual orientation and gender expression before the Taliban takeover, which included explicit criminalization of same-sex conduct, social exclusion, and instances of violence. But in the wake of the Taliban takeover, an already harsh situation became much worse, with little to no support for LGBT people, even from civil society organizations. And there are many challenges facing people who are fleeing. Not having supportive family networks, women not being able to travel alone, problems of documentation for trans people. And just looking through the report, at the subheadings of the report, the subheadings in and of themselves tell the story of the extremity of the situation that people face. The subheading of rape and sexual violence, threats from families, threats from neighbors, threats from acquaintances and sexual partners, threats through technology and social media. All of these create a situation in which people are extremely vulnerable and in which they have very few options. And in many instances, people have unusual situations that require a more holistic approach. For example, many gay men are married and have families. And interviews say they're often worried about the safety of friends and family members, including spouses, children, and partners whom they had left behind in Afghanistan. One Hamid said, I need my wife and kids to come with me because without me they won't have any shelter. He's a married father of three. Another said, I'm worried about my mother and two brothers in Afghanistan. They're all in danger. Afghans in country, and many have fled to neighboring countries where same-sex conduct is illegal, said one who was temporarily located in a neighboring country where same-sex relations are illegal, said we have to leave this place because I'm so depressed. I'm taking anti-psychotic drugs every night. If we are returned to Afghanistan, we will be killed. Several interviewees had sought mental health support as they dealt with the stress of waiting and hoping for safe passage from their current location to a country where they could settle permanently and safety. Hakim said, help us leave. Everyone knows our lives are in danger. Give us a life. The only option is to leave. If they find us, they will not give us time to speak. Please help everyone. Now, it's very seldom, actually, that Human Rights Watch encounters a situation where the only viable option is to leave the country, but Afghanistan is one of those situations. Let's say Chechnya was probably the other, the autonomous region in Russia. But for many people fleeing and getting either temporary protection or for those lucky few who find a way of getting permanent relocation to a safe third country, that's just the beginning. They still need to process much of the trauma that they've experienced prior to that moment. Thank you so much, Graham. So I'm going to talk now about a pilot that, for those who just came in, LabMASH is a Lebanese medical association for sexual health, an organization I'm part with. We, you know, you cannot hear me? Oh, yeah. So I'm going to talk next about a pilot that I have been involved in through my role with LabMASH, the Lebanese Medical Association for Sexual Health, which is an organization working on advancing the health of LGBTQ people in the MENA region, focusing on mental health. And the coincidence here is that there's definitely a connection here beyond this session, so I'm going to come back to what Graham was saying. But Joanne here, actually, from New York, connected me and LabMASH to a funder, which is Outright Action, that wanted to fund such a project, which is, you know, delivering – initially it was mental health, right, to people in Afghanistan. And we wanted to honor Sara Hijazi. And for those who just walked in, Sara Hijazi is an activist from Egypt that died by suicide in Canada just three years after she moved there, and she had been arrested and tortured in Egypt just for raising a rainbow flag at a concert. So we had been wanting to honor her memory, but also we had wanted to do something to help the mental health of LGBTQ people so people don't end up in that situation again. And it was the perfect timing, with the situation in Afghanistan being as horrible as Graham just mentioned, and as detailed in the Human Rights Watch report, we decided to do a pilot in Afghanistan and then see how that goes, and then based on that, hopefully expand. So to do that, we partnered together with Spectrum, which is a non-profit organization based in France, and the person who actually works with Spectrum is a feminist from Iran, so they're familiar with the region, they speak the language, and they had connections in Afghanistan, so it was doable. But to do that, I'm going to share with you a little bit of the thinking that went into putting something like that together, and again, hoping to maybe see if other people eventually are interested in doing this work and what kind of things you want to think about or just share some of our experience. So obviously the first question was this question about mental health versus emotional support, and this is something I actually learned from my work in New York and from all places, this idea of what is mental health and what is emotional support, and we chose those words very carefully, because mental health, we have here, oh, I'm sitting in the room, so I have to be very careful, but from a licensing perspective, from a really, legally, you cannot, you have to be licensed in a certain country, or you cannot just be going around the world delivering services, there needs to be a framework for that. But something I learned at NYC Health and Hospital, my actual job, is as a human being, there's nothing that stops you from supporting another human being, and that's emotional support, that's peer support, so any person can support any other person, and by framing it that way, I think we really got around this whole idea of, you know, liability, and setting expectations, and the people who were involved in this project, that made them feel much, much more comfortable being involved, and I'm focusing on that, because a lot of people here in the U.S. are hesitant of being involved in work like that, because they're worried, right? You know, I don't want to be sued, I don't want to get in trouble, but if we make this about human beings supporting other human beings, now obviously the difference being that these human beings who are part of this project happen to have a mental health background, right? So the skills that they bring with them, the experience is unique and different, so they have these skills, but they're not wearing the hat of a professional. So that was one major thing that we had to frame. The other one, obviously, you know, we needed the people to deliver that, right? So the biggest issue was language, so, you know, it's easy to talk about the MENA region, but it's too, you know, it's very big, and there's so many different countries and languages and cultures, it's not all the same. So focusing on Afghanistan, we needed people to speak, who speak Dari and Pashto, which are the two languages that are most commonly used there. And initially we were really, I was very skeptical, but luckily we found four mental health professionals in Virginia, and one thing that occurred to me is when, you know, when you have refugees where people leave, all kinds of people leave, including mental health professionals, right? So if there are refugees, there are refugees who are professionals as well. We tried to include people from inside Afghanistan, but it was very challenging because of the connection, it was very poor, and they could not continue with the project. So we ended up going with the four in Virginia, and they were Dari and Pashto speaking. The other thing that came up with the language is with the translation, you have to really, really trust the people you're working with. And I've seen this in Lebanon, I speak Arabic, so we've had experiences where you translate something and then on the back end when you read it, it's actually, sometimes all it takes is one word, right, being very, very, very offensive, and you don't want it there. And I'm able to catch it because I speak psychiatry and I speak Arabic and I'm able to kind of go back and forth. But when it comes to Dari or Pashto and you're translating, ultimately you just have to trust the person who's doing the translation. So that was another thing. And they have to be LGBTQ affirming. So we had to do a vetting process to make sure that the providers are actually affirming, and that was the team that worked on this. And then other things that we had to really think about are safety, and, you know, Graham mentioned some things, honestly, I mean, I know that there are themes that are common everywhere, but when it comes to, you know, places like Afghanistan and the Taliban or Egypt or Lebanon recently and other places, you really have to worry about things that you don't think about here every day, like entrapment, like literally, you know, people on social media or on dating apps, you know, entrapping you or people listening in on your calls. So you have to really, we had to really be very careful with that. So that was a big thing for us to make sure that we're not putting the people that we're trying to help in danger. And that also included the branding of the service itself, and I'm going to show you, this is the webpage that we created, and I know it's very simple on purpose, so when you look at it, obviously, it doesn't really say much, but that was on purpose, because we didn't necessarily want to, like, advertise that this is, you know, an LGBTQ portal, but we did have the logo with Sarah, actually, this is her silhouette with the rainbow flag, and that was the symbol of, and that picture became iconic, because that's the moment she raised the flag at that concert that led to her arrest. We wanted that on there to give a very small signal to people that this is a safe space, but we didn't want to put it big enough so that it doesn't endanger them. So that was a very tricky balance between, there was a lot of people who were saying, oh, you should just embed this in a general service, and that's something that we didn't want to do, because we wanted to highlight that this is actually an LGBTQ-specific affirmative service and not just part, because we wanted them to trust it. And then we also had to define what this is and what it's not. Again, this is emotional support, and it's not treatment, it's not medication management, it's not therapy, it's not long-term. The funding that we got for this was very, very, very, very small. So we had to make sure that we serve as many people as we can, so we had to limit it to four sessions per person. So we had to then say, well, what makes sense in four sessions, right? You can't do much. But we were able to focus, and I'll talk about that in a second, on the basics, and actually I'll share in a bit how the experience was with that. But also, we had to, on the front end, so here on the website, when the person goes in to request an appointment, there's actually a very small, like, not intake, but like a questionnaire where they have to answer a few questions, but also it kind of filters out, this is not an emergency. This is not, like, if you have an emergency, this is not appropriate. If you're having suicidal thoughts, that's, like, do not go forward with booking the appointment. And we asked some questions about their, like, psych history, medications, in order to evaluate, like, if someone is not appropriate for this, because it's supposed to be limited time emotional support. And then, again, to go back to the safety, and that was, to me, honestly, and to the team working on this, the biggest, biggest concern is safety. Safety of people providing this service, safety of the people receiving it, safety of, and making sure that the information is confidential. So we had to build this from scratch, and we were lucky that the person from Spectrum actually has a background in digital security, and so this whole platform was built from scratch in a very secure way, and the process to get an appointment and do the sessions was very, very secure. So you book an appointment, you get a code, you have to go back in, you have to use the code, and, you know, you have to use this specific plug-in to be able to receive the session. The reason I'm spending a lot of time talking about that is when I talk about the challenges, unfortunately, that ended up being one of the biggest challenges in delivering the service. If you think about this, I'm part of a service that we're standing up in New York, and it's a 24-7 urgent virtual care. What are we doing? Two clicks, right? Because people don't wanna do more than two clicks. If you think about it, it's just click, click, and then you wanna see someone. No one wants to go through filling out a form and getting a code and remembering the code. All these steps, and I'll show you in a minute, there are barriers. We're putting all these barriers for someone to receive the help, but unfortunately, if we don't, then we're endangering people's safety. That was the underlying essential conflict in all of this that I think ended up really restricting the use of this because of the barriers that we put in. This is the website, and then I'm gonna share with you some summary of what we ended up doing. Again, from the beginning, we knew that this was going to be small, and it's not gonna scratch the surface. We heard from Graham, obviously, there's a lot, a lot, a lot out there, but we just wanted to do a pilot to see if something like that can work and what can we learn from it, and the ideas that we would take it and then scale it up with the experience behind us, and hopefully, maybe more funding or more support from somewhere. Sorry, I forgot to also say that the last step in all of this was marketing and promoting the service. Obviously, we built all of this, we did it, we have the people ready, they were trained, but how do you promote this? We had to rely, and especially in Afghanistan, it's not that easy, so we had to rely on private, like word of mouth, through different people, networking, but also there are these mailing lists, I think maybe Graham and others are familiar with them, they're for LGBTQ organizations in the region, so we posted on there, we sent one-on-one messages with LGBTQ groups who are active in the region, and that did work, so people ended up finding out about this, but again, safety, we had to be very, very careful in how we promote this. We had 30 people initially indicating that they wanted the service by clicking on the first step, but only 13 actually ended up showing up, and I really do believe that a lot of this is because I personally struggled with this, this whole three-step thing, you have to get a code, so I feel like a lot, this is attrition, so people could not follow the process, but we could not relax the security parameters because we did not want to put people in danger, so that was one major challenge. On average, though, people did stick with, they had, the plan was four sessions, but most of them got three sessions, which was within the plan, and then the vast majority were gay men, we had only one lesbian woman, and nine were inside Afghanistan, three were in Iran, and one was already outside Afghanistan, that confirms what Graham was saying, that, you know, and we saw it with Sarah as well, just because you left, the situation does not mean that everything is okay, right, it could be, we know the trauma, and it goes with you, so language, three were Pashto-speaking, 10 Farsi, and most of them were in their 20s, and again, that, to me, could be that it just happened, or it could be a limitation because maybe people were not as comfortable with technology or being able to access this. So, I had said before that we had had a plan, but just to give you an idea of what were those sessions about, like what can you do in three sessions, I actually learned this in COVID, when we wanted to do this for our own employees in New York, we went back to the basics, and we just said, you know, trauma is trauma, right, whether it's COVID, or, I mean, obviously, different degrees, but ultimately, it goes back to the, right, trauma is stress, severe enough that it, you know, maybe breaks you down or challenges you, so then what do you do with that? You have to go back to the basics, to connecting with someone, talking, feeling like you're being listened to, but also going back to the, you know, basics, sleep hygiene, your basic coping skills, you know, having a plan, safety plan, right, thinking about things ahead of time so that when you're in the moment, you're not thinking clearly, you already have thought about a plan. So, that's what we really did, is we just focused on deep listening, on making that connection, on normalizing, talking about things, giving things words, giving things names, what's stress, what's coping, what's, you know, and so that was a summary, and I'll tell you, what ended up happening, honestly, is what people gave us as feedback, is yes, they found these things helpful. We had to be very, very sensitive to the fact that this is Afghanistan, that we're not gonna say, go to a yoga class, right, because we were, you know, thinking that that's probably not something that they can do, so that's also why we wanted to focus on everyone has a bed, ultimately, and how can you make sure you get good sleep? The biggest feedback that people gave us is what they found helpful, is to talk to someone. Like, all of this, you know, they just felt like they were so isolated, like Graham was saying, and that, to me, is not foreign to me, growing up in Lebanon, being deeply closeted, most of them married, or having these dual lives, they felt extremely isolated, extremely stuck, and they found this as an outlet to be able to talk to someone, to them, that was, in and of itself, like, very helpful, and it wasn't necessarily the actual content, or what they learned, but just having that outlet, and to me, that was my biggest message from all of this, because going into it, I was, like, really hyper, like, overthinking, like, oh, is this mental health support? But ultimately, these are human beings that just wanted to talk to other human beings, and feel supported by them. So, as expected, we saw a lot of anxiety, shame, stress, low self-esteem, trauma, but a lot of this conflict with religion, culture, like, pressure to get married, but also this, you know, terror of being outed, terror of being found, about, and it wasn't necessarily in the context of, like, the Taliban, like, it wasn't in the context, like, I don't wanna get, but it was more in the social context, like, they just don't want their family, I mean, ultimately, I'm sure it's connected, but it was much more like, they just didn't wanna, didn't want anyone to know that they were gay, and they were terrified about that, and they were very, very isolated because of that. But also, like, Graham mentioned in his presentation, there was a lot of talk about legal help, so we went in wanting to provide emotional support, and what people told us is, get me out of here, like, they were focused on, how can you help me exit? And honestly, that's another learning lesson, that sometimes, helping people can take different shapes and different forms, and sometimes, maybe that's how we can help people, honestly, is to help them exit when the situation is severe enough, but that was a very striking thing, it came up a lot. And the challenges of this, and the learning lessons, as I already mentioned, some of them, but really, I would say the biggest one was this, how do you do this work in such a, you know, oppressive and scary environment? Like, we're talking about the Taliban, literally, and, you know, how do you, on one hand, make it clear that this is LGBTQ affirming, this is welcoming, and signal to people that this is a safe space for them, but at the exact same time, not making it in a way that if they're on the website, and someone walked behind them, and they saw what they're on, that they would literally put their life in danger, so it's like, how do you balance that? How do you make the, we all know from our lives that people's attention spans getting shorter, and shorter, and shorter, people want quick, quick, quick, especially online stuff, but then we're adding all these steps to ensure security, and encryption, and all that stuff, so how do you balance those two things? So that was something that we did not have, did not have a good solution for, and then connectivity, that was definitely an issue. We were not sure going into this, again, I think the fact that everyone was in their 20s, maybe was an indication that it was easier for them, but the one thing that was striking for me, is I was talking to one of the counselors, and she said, I'm not talking about connectivity like internet connectivity, I'm talking about them literally finding a place, and a time to talk. She said that they were so terrified, and that they were so closeted, that they literally could not find a place where they can spend an hour talking to her, so that was, to me, very, also, I mean, it's not foreign in the sense that I've lived that myself, but it's just good reminder, right? Like, when we're trying to design a program, or something to just really try to understand, you know, exactly the lives of the people that we're trying to help. So, I'm gonna stop here, I'm gonna turn it to Joanne, who's gonna talk more about how we can help people, maybe once they're here, and you ask, and do you want to switch seats? Yeah, okay. Thank you. As you were speaking, Omar, I thought of Judith Herman pointing out that safety is the first step of healing. And so we see that in your program, and we also see that after people manage to get here sometimes through very dangerous journeys, I focus on the forensic part of the process of applying for asylum once people have been able to get to the United States. I'm also thinking, after Graham's talk, there was the recent publication from the Boston Medical Center about the very, very high levels of depression and PTSD in particular in the LGBTQ asylees and refugees that they see in their very large clinic. So I want to talk about things that one can do, a psychiatrist can do in our home countries once someone has found their way to where we live. Oh, so that went, uh-huh. Yes, okay. Great. Okay, good, thanks. And first of all, to the person who liked the title, No One Leaves Home Unless Home is the Mouth of a Shark. That is the first line of a very remarkable poem by Warsan Shire, who is a British Somali poet living in London, who was born in Kenya of Somali parents. The whole poem is really quite beautiful, and I thought spoke to what we were hoping to talk about today. So just a few basics. Asylum seekers and refugees have a right to protection under both international law and US law. As psychiatrists, we can play a key role in the asylum process, guided by a document called the Istanbul Protocol. And just to say, we recruit. Like Harvey Milk, we are always looking for people to join us in this work. So everyone here today, if you're not already involved with working with refugees and asylum seekers, we encourage it. It's extremely rewarding. In order to be eligible for asylum, you have to have come into the United States. So the people who are still in Afghanistan or in other countries who so very much want to leave cannot apply for asylum until they manage to cross over into the United States. And they must meet the criteria. Under international law, you need to have fled your home country and be in the country in which you're applying for asylum because you have a well-founded fear of persecution on account of one of five grounds, race, religion, nationality, membership in a particular social group, or political opinion. And so LGBTI people fall under the membership in a particular social group umbrella, which a large number of asylum seekers and some groups are easier to demonstrate than others. You also, in the United States, the laws are different in other countries. But here in the U.S., there's a one-year filing deadline. So you must file an application for asylum within one year of having stepped foot in the country. In some countries, it's as short as two weeks. Others have no deadline whatsoever. It's an onerous burden because many people do not find their way to the legal help they need to be able to meet that deadline. If it goes to court, even if an applicant is eligible and meets the definition, is meritorious applicant, immigration judges in the United States have discretion. They can decide for any reason that they do not want to grant asylum or another form of humanitarian relief. So asylum seekers are not citizens, so they're not entitled to free legal help. A small fraction of them find their way to legal help, and even a tinier fraction of that find their way to a medical or mental health evaluation. There's a lot of suspicion that applicants are faking, especially if they're claiming to be LGBT. That can be a big problem. There's a huge unmet need for asylum evaluators, especially for ones who are LGBTIQ literate. I'm always amazed at the number of people who train to do this work but do not feel comfortable and are not competent at taking on these cases. The one-year filing deadline, as I said, is very onerous. Many people will be, once they cross our borders, will be put into detention facilities or be forced to wait in Mexico, undergoing even more trauma, especially when you're LGBTIQ, you're waiting in Mexico, or you're in a detention facility. If you're lucky enough to win asylum, and if you've made it to some, hopefully, pro bono legal help, or you've been able to pay for it, and somehow you've gotten a mental health evaluation, a medical evaluation, odds are over 90% you will be granted asylum. It's about 30% if you don't have those things. So you would probably be deported. If someone is lucky enough to see one of us, it's pretty much a win. It's take on a case, save a life. There are benefits of asylum. It's sort of the brass ring of humanitarian relief. You will not be deported. If you have an immediate family that you might like to be or be able to be reunited with, often not the case with LGBT people, you have the possibility of bringing your direct relatives over. You can get work authorization. You have the possibility of seeking treatment. Many times I find the people we work with desperately need mental health treatment, but until they have the safety of knowing they're not being deported, they may put that off. They'll have a path to citizenship, permanent residence after one year, citizenship after five. And we can serve as the key expert witness in the asylum process. I didn't know this until I started this. Medical findings, our medical findings are evidence in a court of law. People who've somehow made their way here were usually not lucky enough, one, to have money to pay for this kind of help, and two, they're not bringing documents that prove that they underwent the persecution they're reporting. But when we do an evaluation and say this person's history, their symptoms, the clinical signs in the interview are consistent with the story that they tell, that is evidence in a court of law, demonstrates to the judge or to the asylum officer that this person is credible. So it very much increases the likelihood of a grant of asylum. So here it is, the UN document. The first one was in the year 2000, the update came out in 2022. The Manual on the Effect of Investigation and Documentation of Torture and Other Cruel and Human or Degrading Treatment or Punishment. Widely referred to as the Istanbul Protocol, that's where the people came up with the idea of this back in the late 1990s. And they established an international group of medical, legal, social work, humanitarian, non-profit organizations, and put together this beautiful document, it was updated in 2022. And so now it has a portion on LGBTI, well, shall we say sexual orientation and gender identity, less Western freighted term. Section, it also now has a section on children. You can get it on the UN website, just Google it, it'll be right there. The Istanbul Protocol gives us a number of roles as psychiatrists. We conduct the evaluation and write a medical legal affidavit. We document issues impacting the ability to have applied for asylum within one year if the person missed that. We can document the development over time of that person's sexual orientation, gender identity, or expression, how this might have been delayed or frozen in their country of origin where these were met with violent repression. We can explain how trauma, mental illness, stigma, can impact the ability to recall and convey what has happened to them. And this is my favorite, educating adjudicators about the sequelae of torture and other human rights abuses. Most often, judges and asylum officers deeply appreciate the work that we do. In these cases, you might be asked to prove LGBT identity. The first time someone asked me to do that in 2009, I thought the lawyer was kidding. And then I realized, no, if the case is based on this grounds, that this is why this person was persecuted, I do have to prove it. And so until now, we've had the Kinsey scale, still a gold standard in US courts. We've had the Klein sexual orientation grid from the 1970s. But nothing specific to refugees, forced migrants, asylum seekers. And so psychologist Arielle Shidlow and I created a scale to assess and document the evolution of sexual orientation and gender identity in someone's home country when they first arrived here and over time since they've arrived here. I'm happy to email it to anyone. It can be, we found, very useful in asylum cases, especially when there was a problem meeting the one-year filing deadline. So what's it like to do an interview? You already know everything you need to know before you do this. It's your usual, excellent, comprehensive psychiatric evaluation. It's usually a one-time endeavor. And sometimes you need an interpreter. It takes time to establish some trust and rapport. I think it takes about two to three hours. And I think a number of us here probably do these evaluations. Before the evaluation, you wanna speak with the attorney. Unlike treatment cases where you might like to go in sort of with an open mind and not knowing a lot in advance, if you've got a one-time interview with this person, you wanna go in knowing as much as you can in advance. Especially wanna know what are the critical legal issues in this case that prompted the legal rep to ask for your help. Medical students and residents, when trained, can assist, can take notes for you, can draft the medical legal affidavits. Tremendously helpful and will save you a lot of time. It's up to the attorney to provide you an interpreter. You can do this work remotely, we found, during COVID. And it's found to be just as effective by the research group on this at Mount Sinai. So we've done evaluations all over the world, certainly at the southern border. And it's not hard at all to get a mentor for this work or example affidavits. There's no need to reinvent the wheel. Here's one of the great shames of the United States, asylum detention, where we imprison people who've committed no crime, except to come into the United States seeking asylum, which is perfectly legal under international law. There's a mistake here, about at least 30,000 people are in detention facilities every night in the United States. Many asylum seekers, asylees are people who've gotten asylum. So many are seeking asylum. It doesn't speed up your case to be thrown into detention. Most of the detention facilities are privatized and they're profit making. If you have retirement accounts, you might very well have invested in GEO or the main two. And as you can imagine, LGBTQ detainees face multiple and disproportionate dangers in such facilities from other detainees, from staff. Often, if they're trans, they're not continued on their hormonal treatment or allowed to wear the clothing of their choice. Not given, LGBTQ people are often not given separate places in the detention facilities in which to live. We can actually do evaluations of people in detention, and we can do those remotely or in person also. And it's very rewarding to do those cases. So refugees expelled to Mexico being forced to wait, there are the most targeted people at the border. Human Rights Watch and other groups have documented thousands of murders, rapes, kidnappings, robberies. And very recently, Title 42 disappeared, but we've got Title 8 back. And you've seen the people still waiting at the southern border. Now that they have to apply on an app, and there are only a thousand spots a day that come up, technical problems with the app. And if you're rejected at the border, you can't even try again for another five years. So there will be people living near the border in Mexico for a long time to come, and right in the face of danger. Just one example, M is a real person, sorry. She was 30, from Honduras, identifies as a lesbian really since childhood, and has been persecuted for her gender non-conforming behavior ever since. She has a young daughter at the time who was six, who was born as a result of a so-called corrective rape of often suffered by lesbians, by a local gang leader. She and her daughter reached the US, but were forced to return to wait in Mexico under the Migrant Protection Protocol, so-called, forced to wait in Mexico in Title 42. The two of them suffered robbery, attempted kidnapping, extortion, and sexual molestation. I did a remote evaluation with her south of the border. We started on WhatsApp with the video, but the video compromised the audio, so we switched to audio only. I had an interpreter in Massachusetts. I was huddled around my cell phone with several med students, and she was in Mexico, and we wrote that up. Her court case was heard in December of 2019 in Texas, and asylum was granted. Now she lives in the United States, on the eastern end of Long Island. So, if you're interested how to get involved, Center for an Asylum Training, all of the 25 medical school clinics offer them, usually twice a year, but now you can do them virtually from anywhere. AsylumMedTraining.org is the website. It's a state-of-the-art asylum training put together by a consortium of medical schools and asylum clinics around the country. There are networks of asylum clinicians, offer your professional expertise in other ways that we've been talking about. And until LGBTI rights are respected around the world, asylum and mental health support are lifelines for those facing or fleeing persecution. Thank you. Thank you. Thank you, Joanne. So, I think we have around 15 minutes for questions, or comments, or feedback. That was great. Thank you. Omar, what would it take for a public hospital system like Delton Hospitals to create space in the ambulatory program for there to be dedicated asylum assessments? I mean, it'll take funding, but do you see that as something that could happen, or I guess partnership with the licensing authorities also? Yeah. But assuming that everything can get lined up, because politically it would be aligned with what New York is saying. Is this something that is feasible or desirable, given? Yeah, I mean, honestly, yes. I think what it would take is information. I think a lot of people are, and again, I don't want to generalize by any means, but I think a lot of people don't understand this work, and they worry. And as physicians, we're always worried about our license, and sometimes you don't want to be involved in something to get you in trouble. So I think that talking to them, I think, and explaining to them what the process is, what their role, I think would be very helpful. So that's one, and that's something, honestly, I would love to talk about and pursue, but I think the second one, Flavio, is from you guys, from like Omage, because right now there's just so many steps and so many restrictions. Because I've tried to do it for things like, not the same, but similar, like the letter for the gender affirming. And I can do it like this, right? And I would love to do it, and I have people in my clinic who want to do it at the Pride Clinic, but just all the different regulations that Omage puts on us, the intake, and the registry, there's a lot of different things. And again, maybe some of it is real, some of it might be misperceived, like misunderstood, but what I get is, we can't do this because we're not allowed to do these things because you have to register, you have to have a treatment plan, you have to have a, and I'm like, I don't want to do a treatment plan, I just want to give them a letter, I just want to see them, do a one hour assessment, and I can give them a letter. That could literally change their life, but I'm not able to do that currently, it's just, and like I said, it could be misunderstanding of the Omage regs for the clinics, but if we can come up with a fast track for, I'm sorry to mix those, but they're kind of connected for letters, or for things like that, or for asylum evaluations, we would, I would love to do it. No one has ever been, no one's ever brought a lawsuit. And oftentimes hospitals and residency programs are afraid of the liability of doing this kind of work, but it's never been a problem. It's either successful and people are grateful and love you, or it fails and people are deported and may be killed. It's pretty simple, and they're not citizens who would bring a lawsuit, right? But oftentimes medical schools are braver than hospitals and residency programs, I find. How are things in Belgium and Finland? Could you come up to the mic? That would be great. Okay. Well, in Belgium, you do get, indeed, also asylum for being an LGBT refugee from another, yeah, from a country where there's persecution. But usually the procedure is very long, so I don't know if there are any deadlines for application. But you often see the procedures take three, four years, which is, of course, horrible because, yeah, people are being put on hold for like three, four years where they can do nothing. They cannot start, yeah, learning the language. And I also saw things, if you know, we are a bilingual country. So people learning Dutch getting sent to the French part, and vice versa. So, yeah, it's not ideal, yes. Yeah, I don't know much about the process. I don't know that it is long. I actually, I've been asked a couple of times to provide something about somebody's mental health situation, but I don't actually know if doctors often assess those things. Or if it's just like interviews by other people about what their situation is. Kittos. So I, in my work with intimate partner violence, I've seen a lot of cases where people are applying for asylum and we've had to stress one aspect of violence or another. I was just wondering what your experience has been with those kinds of cases. And when there isn't state sponsored violence, let's say police or gang related violence, is it harder to make a case where it's just, if it's a couple or if it's just family origin, is that harder to advocate for people? Or you find that all violence is sort of treated with the legitimacy that it could happen again if they get deported. It can especially happen, and I think something like corrective rape of lesbians. Any LGBTI asylum seeker could have suffered a violence at the hands of a partner or a family member. So it varies some from case to case, but certainly that can be included in the history and in your evaluation. I was very interested about your project for the Afghan refugees. I was wondering if similar things or resources exist for, like, Arab refugees who are maybe in, like, Syria or also the people who came to Europe, because usually the problems continue. People find it difficult to connect with the LGBTQI community. Maybe they come with a family where actually the whole issue stays about staying in the closet. I see my patients, I sometimes find it quite difficult how to work with it, and I was wondering if something exists or something similar exists. Yeah, I mean, I'm not aware of any, but that was the vision, that was the idea, to start and do, like, a pilot and see. And I honestly think that, you know, with COVID changed everything with telehealth and just being able to just, you know, I was talking to Joanne about someone who's been working for three years. I mean, I've been seeing patients for the last three years, I haven't seen one of them in person. It's all telehealth. I feel like it's really changed the way we think about help and receiving help and giving help that I think now, and as Graham mentioned in his part, that a lot of this is not restricted to geography. Like, you could be in your own country, you could be in a different neighboring, you could move to another, right? And ultimately, it's just tele makes sense, right? Using technology, that's what I'm trying to say, because whether it's the people who are counselors or the people who need it, they could be anywhere at this moment, and they would need it, like you said. So I think the idea is there, it's just that, you know, the support and the funding and the, right? That's always a question. Okay, thank you. Yeah. I have a question about the medical schools, I'm Ken Campos here, and in San Diego there is a medical school, but I'm not closely involved with them at all. Are you aware, Joanne, off the top of your head if they have an asylum clinic given the proximity to the border, it's 70 miles from the medical school to Tijuana? I'm not sure about the medical school per se, but there are people in San Diego very active in asylum work, and in fact were some of the main people involved in putting together the virtual training, and there are groups like Survivors of Torture and people working at the border so close to you, so definitely. I can give you a name if you'd like afterwards. Thank you everyone so much for being here.

mental health support

asylum evaluations

LGBTQ individuals

refugee

persecution

safety

trauma

legal processes

pilot program

Istanbul Protocol

medical evaluations