4.1. LGBTIQ Asylum-Seekers’ Health in Berlin—No Happy Ending, but a Silver Lining
The aim of this study was to provide preliminary evidence on the health and healthcare utilization of LGBTIQ asylum-seekers in Berlin. The Berlin authorities recognized the special needs of this group, inter alia, by establishing a separate accommodation center for them. However, scarce evidence on healthcare needs among LGBTIQ asylum-seekers sets limits on further evidence-informed policies. Following an intersectionality approach, we assumed that LGBTIQ asylum-seekers face increased health risks due to intersecting determinants of health, including migration- and gender-related marginalization.
Indeed, our results point to a high burden of chronic and mental illness among asylum-seekers from the LGBTIQ shelter, both in comparison to asylum-seekers from other shelters, and when comparing our unadjusted averages to representative information on the German population. Among the German population, 25.3% rate their subjective health as “fair/bad/very bad”; 36.9% report a chronic illness [53
]. The prevalence of depression and anxiety is 10.1% and 15.3%, respectively [54
]. Even when considering that LGBTIQ persons in the German population may present with worse health outcomes, the prevalence rates for chronic and mental illness in our sample of LGBTIQ asylum-seekers (62% and 70%, respectively) still exceed the above estimates by far. Our findings thus support the hypothesis that the health of LGBTIQ asylum-seekers is under excess strain, as migration- and gender-related stressors and risks compound each other.
At the same time, our results indicate that asylum-seekers from the LGBTIQ shelter utilize healthcare more frequently than asylum-seekers from other shelters, across all types of health services examined. As a matter of fact, their ambulatory healthcare utilization lies close to the respective rate reported for the German population (87%, [55
]). Residence in the LGBTIQ shelter is associated with significantly higher odds of obtaining ambulatory and mental health services. Asylum-seekers with mental health needs who live in the LGBTIQ shelter are significantly more likely to use psychotherapy or psychiatric healthcare than asylum-seekers with mental health needs from other shelters.
One possible explanation is that the LGBTIQ shelter offers a relatively wide range of social services. The shelter’s close collaboration with a sensitized GP may be particularly helpful in supporting access to care, as the literature indicates that primary caregivers can play an important role in facilitating asylum-seekers’ successful navigation of the healthcare system [8
]. Hence, our results indicate that tailored health and support services yield some success in facilitating needs-based health service utilization.
However, our study also shows high rates of emergency room utilization and ambulatory care-sensitive (ACS) hospitalizations among the LGBTIQ group, irrespective of their use of ambulatory and mental healthcare. By way of comparison, average emergency room utilization in OECD countries is estimated at 31% [58
], and the prevalence of ACS hospitalizations at 20–27% [44
]. Together with that, our results on foregone doctor’s visits and out-of-pocket payments for prescribed medicines suggest that access barriers to healthcare persist, despite the support offered in the LGBTIQ shelter.
Hence, alternative explanations for these healthcare utilization patterns are that a) those asylum-seekers who find their way to ambulatory and mental health services are also more likely to find their way to emergency and hospital-based care; and/or b) that particularly complex health needs among LGBTIQ asylum-seekers exceed the capacities of the ambulatory healthcare provided. Alongside other factors, these unmet needs may contribute to frequent emergency room visits and hospitalizations, on top of ambulatory and mental healthcare utilization. These alternative explanations do not diminish the importance of tailored health and support services. Rather, they indicate that further research is needed to understand particular health needs and healthcare-seeking among LGBTIQ asylum-seekers, and thus enable the fine-tuning of these services. In line with the existing literature on LGBTIQ health [22
] and asylum-seeker health [6
], the areas of mental and chronic healthcare merit special attention.
In conclusion, our preliminary results indicate that the special health and social support services offered by the LGBTIQ shelter facilitate more adequate healthcare utilization, to some extent. The adjustment, strengthening, and extension of similar social and health services to all accommodation centers, akin to the “Bremen model” [8
], should be considered in order to contribute to comprehensive improvements in healthcare provision for all asylum-seekers.
Our findings further indicate that, beyond healthcare, asylum-seekers’ social conditions are not conducive of good health. The respondents in our study rate their quality of life as poor, as compared to European adults generally (3.68) and to people with depression (2.84) [45
]. Many respondents experience loneliness, and most consider themselves at the bottom of the social ladder. Assessments are even lower for asylum-seekers from the LGBTIQ shelter, despite relatively extensive support structures. Such stressors have been shown to fundamentally impact physical and mental health [61
]. The relevance of “minority stress” for the health of LGBTIQ populations has been documented [62
], alongside the beneficial potential of social support and inclusion [31
]. Hence, our study indicates that, beyond the positive measures that were taken by Berlin’s authorities, further improvements of the social determinants of asylum-seekers’ health are warranted. To enable systemic positive change, federal legal frameworks need to be adjusted toward equal social rights and inclusion of asylum-seekers.
Given the limited scope of our study, the findings reported here have preliminary character. Our study identified LGBTIQ asylum-seekers and refugees through a proxy, namely, their accommodation in the LGBTIQ shelter. Collinearity between LGBTIQ identity and between residence in the LGBTIQ shelter entails that effects related to openly identifying as a LGBTIQ asylum-seeker and effects related to the shelter’s extended medical and social services cannot be disentangled. In addition, we cannot rule out that the group described here as “asylum-seekers from other shelters” includes LGBTIQ individuals, who did not disclose themselves as such by describing their gender as “other”. Data collection relied on respondents’ recollection; this may induce recall bias. More detailed health measures would have allowed for more nuanced insights into the respondents’ health needs; for example, a differentiation of chronic conditions and the inclusion of stress in the mental health screening instrument (as in the DASS-21 scale). The small sample size for the LGBTIQ group limited our options for statistical analysis.
The limitations of our study could be overcome if sexual identity and orientation were accounted for in future health research and monitoring. At the same time, this would contribute to the visibility and inclusion of LGBTIQ-specific issues in migrant health research. Further research is needed to understand the intersecting determinants of LGBTIQ asylum-seekers’ health and healthcare access, including migration-related, racialized, gender-based, and other forms of discrimination. Ideally, such research should involve community representatives as partners in the investigation of problems and in the development and implementation of solutions.