A Multi-Methodological Exploration of Persecution Experiences and Related Injuries of Sexually Minoritized Asylum Seekers and Refugees in Nairobi, Kenya

: Introduction: Sexually minoritized men in the East, Horn, and Central Africa continue to ﬂee from their countries, because of actual or feared persecution, to neighboring Kenya to seek protection and safety. However, there is limited research on their experiences and needs. Therefore, this study aimed to describe the persecution experiences of gay and bisexual asylum seekers and refugees in the Nairobi Metropolitan Area. Methods: We adapted McAdam’s Life-Story Interview (LSI) to develop a semi-structured interview guide. We used the interview guide to conduct one-time anonymous in-depth interviews with 19 gay and bisexual men recruited by purposive sampling. The study also included a photovoice component and written reﬂections. We transcribed the interviews verbatim, uploaded them to NVivo 12 plus, and analyzed the data using Braun and Clarke’s six-step thematic analysis framework. Results: The mean age of the participants was 26, with the largest age group being 18–24 (n = 9, 47%). We found six major themes: (1) The Anti-Homosexuality Act, (2) death punishment, (3) physical abuse, (4) sexual violence, (5) discrimination, and (6) injuries. Conclusions: Continued multi-layered discrimination across borders may have adverse physical health outcomes for gay and bisexual asylum seekers and refugees in the Nairobi Metropolitan Area. Further collaborative strategies may help to understand and develop culturally sensitive interventions to improve their health and well-being.


Introduction
Most East, Horn, and Central African countries criminalize same-sex practices [1]. The punishment varies from death in Sudan and Somalia to imprisonment between three and fifteen years in Kenya, Burundi, South Sudan, Ethiopia, and Eritrea [2]. Rwanda and the Democratic Republic of Congo (DRC) do not criminalize same-sex practices. However, as in other African countries, their legal codes are guided mainly by Christian and Islamic principles that outlaw and encourage harsh punishment for same-sex behavior [3]. For example, the Ugandan parliament passed the Anti-Homosexuality Act (AHA) in 2014.
Similarly known as the "Kill the gays bill", the bill proposed the death penalty for same-sex practices. However, the legislators amended the punishment to life imprisonment and passed the bill into law [4]. The president annulled the bill shortly after its passage. Nonetheless, the bill worsened the persecution of MSM Ugandans. As a result, there was Sexes 2022, 3 547 an estimated tenfold increase in those seeking asylum because of sexual orientation or gender identity (SOGI)-based persecution in Nairobi, Kenya [5].
The data on sexually minoritized asylum seekers and refugees are minimal. However, a few studies have documented refugees' experiences and asylees in relocation countries, for example, the U.K. [6], the U.S. and Canada [7], and Australia [8]. Evidence from these studies indicates that an inadequate cultural and contextual understanding of diverse sexually minoritized populations led to institutionalized oppression and further discrimination in the asylum-seeking process [9,10]. Additionally, sexually minoritized refugees and asylum seekers also had a pronounced risk of physical abuse by other refugees, host communities, family members, and state agents. Previous studies indicate that African sexually minoritized groups experienced many forms of violence [11,12]. For example, 40% of respondents in a survey of 608 MSM in Kampala reported experiencing violence because of their same-sex behavior [13]. The findings were consistent with our study, which also found evidence of heightened mental distress caused by immigration stressors and post-traumatic experiences that continued to adversely affect the mental health of gay and bisexual asylum seekers and refugees in Nairobi [14]. However, there is limited evidence of the persecution experiences and the impact on the physical health of gay and bisexual asylees and refugees in Kenya.
This study aimed to describe the persecution experiences of gay and bisexual asylum seekers and refugees in the Nairobi Metropolitan Area. Understanding the experiences and their influence on health outcomes is essential for designing and delivering culturally sensitive interventions, particularly for areas with minimal programs and interventions in various migration life courses, whether while fleeing persecution or in the host country [15].

Study Design
This analysis was part of our broader qualitative study conducted in 2020. The study assessed the intersectional identities, persecution experiences, and health needs of sexually minoritized asylum seekers and refugees in Nairobi, Kenya [16].

Sampling and Recruitment
We used purposive sampling to recruit participants for the study. Purposive sampling assumes that each participant will provide in-depth information to meet the study objectives. Other researchers have also successfully used this technique for SGM asylum seekers and refugees [17]. We found it appropriate to reach our participants because they were a hard-to-reach and vulnerable population [18]. We recruited participants from local MSM asylee and refugee-led organizations in the Nairobi metropolitan area. The organizations used their listservs, WhatsApp groups, and community events to advertise the study. The study's inclusion criteria were (a) asylum seekers or refugees; (b) at least 18 years old; (c) MSM, including gay, bisexual, and other non-identifying MSM; (d) the ability to communicate in Swahili or English; (e) the ability to provide informed consent; and (f) residents of the Nairobi metropolitan area. Formative assessments and meetings with community partners found that most asylum seekers and refugees could communicate in English or Swahili (Swahili is widely spoken in various East, Horn, and Central African countries, including Kenya, Uganda, Tanzania, Rwanda, Burundi, Somali, and the Democratic Republic of Congo).

Participants
The sample consisted of 19 MSM asylees (n = 1) and refugees (n = 18) living in the Nairobi metropolitan area in 2020. The participants were between the ages of 18 and 41 (M = 26). They originated from Uganda (n = 15), Sudan (n = 2), DRC (n = 1), and Somalia (n = 1). Their level of education was none (n = 1, 5%), primary school (n = 3, 16%), high school (n = 9, 47%), and college or higher (n = 6, 47%). All participants (n = 19) fled their countries of origin because of actual or feared persecution based on their sexual orientation Sexes 2022, 3 548 and sought protection in Kenya. The participants from Sudan and DRC first ran and tried to settle in Uganda. However, they continued to experience further persecution and narrowly escaped after physical attacks and eventually moved to Kenya, where they sought asylum.

Data Collection
The study team also conducted one-on-one recruitment based on information provided by the participants. First, the researchers approached potential participants one-on-one and briefly explained the study's purpose. Then, if participants consented, they were screened using an interviewer-administered survey administered on Qualtrics. For security, all study interactions were in participants' residences or secure and private locations if the participants preferred an alternative location. After eligibility screening and oral consent, the study team interviewer administered the demographic sheet using Qualtrics, accessed on a laptop. The demographic sheet included age, sex assigned at birth, gender identity, sexual orientation (or sexual behavior), nationality, education, and years in Kenya. Finally, using a semi-structured interview guide, the research team conducted one-time anonymous in-depth interviews in English (n = 17) and Swahili (n = 2).
We adapted McAdam's Life Interview (LSI) to develop the semi-structured interview guide for the study [19]. LSI has various sections outlined as book chapters. Our study concentrated on the key scenes in the life story, challenges, and reflection. The life story's critical scenes focused on, for example, what made participants leave their country, their experiences as they traveled, and their reason for choosing Kenya in particular. Example questions included the following: Please tell me about what eventually made you decide to leave your country, would you please tell me about what caused you to flee to Kenya instead of the other places, and tell me a little about your experience of seeking asylum in Kenya.
We conducted a pilot study to assess, remove, and edit some questions for clarity and ease of interview transition. However, the interviewer explained the study to the participants and encouraged them to share their stories as they felt comfortable. The interviewer took notes and then asked follow-up questions for clarification or further details of their statements. Therefore, the participants could share their own stories and oversee their narratives. We recorded all the interviews with two recorders. One recorder ensured data safety in case the equipment malfunctioned. All the interviews were anonymous and lasted between 32.32 and 115.24 min (an average of 80 min).
We also asked participants if they wanted to participate in the photovoice component of the project. We followed the procedures adapted from Michigan State University's Photovoice training manual [20]. First, we gave participants Vivitar 7.1 Megapixel Digital cameras to take pictures for a week. They then met with researchers to share ten pictures with personal reflections that included (1) the reason for taking and sharing the photo, (2) the importance of understanding the picture, and (3) what the photo shows about their community. We provided rainbow masks to protect participants' privacy due to the threats of further persecution. Next, the participants met the research team and shared ten photos they wished to share. The research team downloaded the pictures and labeled each reflection sheet with the picture numbers.
The study team debriefed every day to discuss the project's progress. However, recruitment stopped after the 19th interview because the study team found the discussions repetitive. We, therefore, agreed that we had reached "saturation", a point where there was no new or relevant information from the data collection [21,22]. Each participant received 1000 KES (~$9) compensation.
We obtained ethical approval for the study from the University of Texas School of Public Health Institutional Review Board (IRB): HSC-SPH-19-1090. The study was also approved by the University of Minnesota IRB Number 00000-8209. Because the study was anonymous, we did not return the transcripts to the participants for review. We also ensured we reviewed the transcripts and removed any identifiable information to protect participants' and their loved ones' privacy. The P.I. and an independent consultant transcribed the interview audio files verbatim to Microsoft Word. They are both fluent in English and Swahili and translated the Swahili transcripts into English. They then reviewed the translation for accuracy by checking the transcript and repeatedly listening to the audio recording. The P.I. then uploaded the transcripts to NVivo 12 Plus software for analysis.

Data Analysis
We used the six-step thematic analysis framework [23] to conduct a parallel analysis of the texts from the interviews, photographs, and reflection sheets. In step 1 (familiarization), we reviewed the transcripts to understand specific phrases, colloquial or regional terminologies, and general data. The review enabled a contextual understanding of the data. In step 2 (coding), we highlighted some of the main ideas from the data. We highlighted the text and then coded it to new nodes. If a new idea emerged during the process, we determined whether to merge it into any identified nodes or create and name a new node. We wrote notes for specific keywords that arose. After the first review of the transcripts, we used the query function to search for words, merge them into the existing nodes, or create new ones as needed. In step 3 (generating initial themes), we reviewed the codes to identify patterns. We then created the initial themes based on existing codes. In step 4 (reviewing themes), we analyzed the themes to find similarities and differences. We then refined the themes by merging similar ones and created subthemes where needed. Then, in step 5 (defining and naming the themes), we manually downloaded the themes and created a codebook in Excel. The Excel worksheet included quotes and when or when not to use them. Finally, in step 6 (write up), we used the codebook to draft this paper, describing the persecution experiences and injuries of MSM asylum seekers and refugees in the Nairobi metropolitan area.
The researchers analyzed the photos based on the participants' reflection sheets outlining the photo's meaning, importance, and what the picture showed. They then compared similar themes and subthemes found in the interviews. Finally, to reach a consensus, the researchers discussed the common photos and perspectives from the participant's reflections and chose the images presented in this analysis.
Trustworthiness is critical in ensuring the quality of qualitative studies. Therefore, we used multiple methods to establish trustworthiness and increase the rigor of our research [24]. To ensure confirmability, we used triangulation of sources. Triangulation of sources is the cross-verification of data collection methods. Triangulation is a beneficial method for understanding and confirming phenomenological similarities or differences, thus increasing the validity of qualitative studies. We reviewed the field notes, written documents, e.g., procedural manuals, and debriefing minutes to safeguard against biases and monitor consistency with the study protocol to increase the study's validity [25].
Credibility measures the extent to which the findings are accurate or authentic. We ensured the study's credibility by collaborating with local community organizations and having a highly culturally aware research team sensitive to participants' lived realities and highly trained in conducting the analysis [26]. Lastly, transferability is the extent to which other researchers can replicate the study in different populations in similar contexts and settings. To ensure transferability, we clearly defined our study population and setting. We also used data saturation after debriefing and agreeing that we were not obtaining any added information. Thus, there was no need for further data collection [27].

Results
We identified six major themes: (1) The Anti Homosexuality Act (AHA), (2) death punishment, (3) physical abuse, (4) sexual violence, (5) discrimination, and (6) injuries. Although the discrimination experiences were not specific to a geographical locus, e.g., original home, during migration, large cities in countries of origin, refugee camps, or in Nairobi, we indicate where the persecution experiences happened. We used quotes from the interviews and a few selected photos from the photovoice part to illustrate the themes.

Anti-Homosexuality Act
This theme is linked to one of the interview questions, "Please tell me about what eventually made you decide to leave your country." The question sought to understand the adverse pre-immigration experiences that triggered participants to flee and seek protection in Kenya. Five out of the fifteen Ugandan participants described the AHA as a significant contributing factor to the increased persecution of sexual minorities in Uganda, resulting in many fleeing to Kenya for protection. Even though the president later nullified the bill, its notoriety already had a far-reaching impact that adversely affected gay and bisexual men: " . . . I think the bill [Anti-Homosexuality Act] was already signed. So, it was trending everywhere. It was the talk of the church and the mosque in the testimony and something some people used in campaigns. So, this bill, however much it was nullified later, it had already harmed people. Because some people had in their minds that gay people are supposed to be killed".

(Participant 17, 24 years)
One ground for granting asylum is establishing a well-founded fear of persecution, which may include vulnerability to persecution if one relocates to another part of the country. For example, several participants described being physically attacked and ostracized by their family or community members upon finding out about their same-sex behavior. Some escaped near-death experiences and relocated to other parts of Uganda in the hope that they would rebuild their lives in the new locations. However, AHA had created a public discourse that led to a harsher environment for sexual minorities. They, therefore, continued to face further ostracism and violence, finally forcing them to flee to Kenya for safety, as participant 5 (26 years) described: " . . . Let us say one of the things that led to my fleeing the country was their signing of the bill. It led the communities to be more homophobic towards us. They [unknown community members] would randomly kill gay people if they found us on the streets. We were taken to be like chickens to be killed anyhow [without regard for life]. After signing the bill, we tried to live in hiding. However, strangers beat my partner and friend. I managed to escape . . . but that is the last time I remember seeing my partner and my friend." Even though the president nullified the AHA, the participants described its role in significantly increasing moralist groups and religious fundamentalism that resulted in a hostile environment for SGM Ugandans and others supporting them, including their families, friends, and service providers.

Death Punishment
Many communities in Horn, East, and Central Africa have cultural and religious norms that outlaw and heavily punish same-sex behavior, in extreme cases by death. For example, one participant described his experience in his country of origin: "I had to run from home. I knew they were coming and what would happen to me. Because where I come from, death is the only punishment when they know you are gay or belong to any LGBT group! If not peeling your skin off . . . and what was to be done to me to punish me, and when they punish me, it was to be death. The government was aware of that and gave powers to kill whoever is gay or lesbian or any queer person."

(Participant 12, 22 years old)
Participants' photovoice pictures also uncovered the theme of death or murder of sexually minoritized asylum seekers and refugees in Nairobi. For example, Figure 1 shows a trench in one of the participants' neighborhoods where participant 3 (26 years old) described that they had found the body of a gay refugee in 2019. The image constantly reminded the participant of the dangers they faced in Kenya. While we could not verify if Sexes 2022, 3 551 the murder were because of sexual orientation, the picture nevertheless underscores the continued violence gay and bisexual asylum seekers face in their host communities. be death. The government was aware of that and gave powers to kill whoever is gay or lesbian or any queer person." (Participant 12, 22 years old) Participants' photovoice pictures also uncovered the theme of death or murder of sexually minoritized asylum seekers and refugees in Nairobi. For example, Figure 1 shows a trench in one of the participants' neighborhoods where participant 3 (26 years old) described that they had found the body of a gay refugee in 2019. The image constantly reminded the participant of the dangers they faced in Kenya. While we could not verify if the murder were because of sexual orientation, the picture nevertheless underscores the continued violence gay and bisexual asylum seekers face in their host communities. Additionally, while some participants were not physically hurt, they were traumatized and feared for their lives because they witnessed extreme sexual-orientation-related physical abuse or death. For example, participant 7 (22 years old) described his experience seeing the murder of a gay man by a mob in his country of origin: "When I used to see [ gay] people being killed for expressing their orientation, expressing themselves who they are, their truth of who they are. Someone because of love is crucified or even killed, do not even know, like a snake. Because after a snake is killed, it is thrown in the bush, and no one cares. That is how someone was killed or when they found out he is gay." The stories highlight the lack of protection and disregard for extreme violence, including the murder of gay and bisexual men with impunity. As a result of the intensified fear of violence, many continue fleeing their countries of origin, sometimes forced to go through similar persecution experiences in more than one country, including in Kenya, where they sought protection. However, many stories are left unknown, as only those who manage to escape can tell their stories.

Physical Violence
All participants described experiencing physical violence that included kicking, beating, stoning, and slapping. Those who had lived in the Kakuma refugee camp described hostile conditions and verbal and constant physical attacks from other refugees and their communities. Because of the continuous onslaught, some participants fled from the camps, as participant 19 (18 years old) shared: Additionally, while some participants were not physically hurt, they were traumatized and feared for their lives because they witnessed extreme sexual-orientation-related physical abuse or death. For example, participant 7 (22 years old) described his experience seeing the murder of a gay man by a mob in his country of origin: "When I used to see [gay] people being killed for expressing their orientation, expressing themselves who they are, their truth of who they are. Someone because of love is crucified or even killed, do not even know, like a snake. Because after a snake is killed, it is thrown in the bush, and no one cares. That is how someone was killed or when they found out he is gay." The stories highlight the lack of protection and disregard for extreme violence, including the murder of gay and bisexual men with impunity. As a result of the intensified fear of violence, many continue fleeing their countries of origin, sometimes forced to go through similar persecution experiences in more than one country, including in Kenya, where they sought protection. However, many stories are left unknown, as only those who manage to escape can tell their stories.

Physical Violence
All participants described experiencing physical violence that included kicking, beating, stoning, and slapping. Those who had lived in the Kakuma refugee camp described hostile conditions and verbal and constant physical attacks from other refugees and their communities. Because of the continuous onslaught, some participants fled from the camps, as participant 19 (18 years old) shared: "I lived in the camp for like for one year and something. There [Kakuma], we were harassed, and people were abusing us, that we are LGBTI [Lesbian, Gay, Bisexual, Transgender, and Intersex]. At times even they were like, they wanted just to kill us. So, I decided to leave and come to Nairobi. So UNHCR agreed to transfer my data to Nairobi." In Nairobi, the participants lived in shared safe houses on the city's outskirts. Figure 2 is an example of one of the single-roomed safehouses in a low-income neighborhood.  Figure 3 is a three-bedroomed home shared by fifteen or more at any time. Participant 10, 23 (years old), outlined the benefits of shared living in the interviews: "We love this place because it has brought us together. We have different nationalities, and we live as one person, as a family. However, the house is always congested, and we must sleep in double-deckers" (Figure 4). "I lived in the camp for like for one year and something. There [Kakuma], we were harassed, and people were abusing us, that we are LGBTI [Lesbian, Gay, Bisexual, Transgender, and Intersex]. At times even they were like, they wanted just to kill us. So, I decided to leave and come to Nairobi. So UNHCR agreed to transfer my data to Nairobi." In Nairobi, the participants lived in shared safe houses on the city's outskirts. Figure  2 is an example of one of the single-roomed safehouses in a low-income neighborhood. Figure 3 is a three-bedroomed home shared by fifteen or more at any time. Participant 10, 23 (years old), outlined the benefits of shared living in the interviews: "We love this place because it has brought us together. We have different nationalities, and we live as one person, as a family. However, the house is always congested, and we must sleep in double-deckers" (Figure 4).   Figure 3. A community house that houses many refugees. The house is always full and congested. Figure 3. A community house that houses many refugees. The house is always full and congested.  While many participants expected protection from the police, some reported experiencing constant harassment and abuse. For example, participant 3, 26 (years old) shared the photo shown in Figure 5 to highlight the link between criminalization, constant police abuse, and the arbitrary arrest and harassment of gay and bisexual asylum seekers and refugees in his neighborhood in the outskirts of Nairobi. Police harassment was also a prominent theme that emerged from the interview data. Although some of the reported cases were in their countries of origin, most of the experiences described were in Kenya. Some participants, therefore, feared seeking help from police officers, as Participant 1 (26 years old) explained: While many participants expected protection from the police, some reported experiencing constant harassment and abuse. For example, participant 3, 26 (years old) shared the photo shown in Figure 5 to highlight the link between criminalization, constant police abuse, and the arbitrary arrest and harassment of gay and bisexual asylum seekers and refugees in his neighborhood in the outskirts of Nairobi. Police harassment was also a prominent theme that emerged from the interview data. Although some of the reported cases were in their countries of origin, most of the experiences described were in Kenya. Some participants, therefore, feared seeking help from police officers, as Participant 1 (26 years old) explained:  Furthermore, the safehouses were supposed to provide protection and safety. However, they were not immune to police harassment and abuse: "…Sometime back, the police came to our house… They wanted to know why we were more than five or six people in the same house. We were arrested and stayed at Kikuyu police station for four days as they were doing their investigations. Until the United Nations High Commission for refugees learned that we were in cells, they were the ones who came and bailed us out, and then we were brought back home." Participant 6 (41 years old).
Criminalizing same-sex practices has continued to create multiple pathways for enacted stigma. The laws within the East African region continue to shape norms and attitudes that increase unfair and disproportionate harassment and violence against SGM, "I went to the police. What happened there, heeeeeei! I told the police officer what had happened. They told me, hmm, I left Uganda to do those things [samegender attraction] here [Kenya]. You people, you are the ones destroying our children here in Nairobi. Every police officer came to see me and abused me. I was ashamed. I said I would never go back to where I will report anything to the police concerning this. I felt terrible!" Furthermore, the safehouses were supposed to provide protection and safety. However, they were not immune to police harassment and abuse: " . . . Sometime back, the police came to our house . . . They wanted to know why we were more than five or six people in the same house. We were arrested and stayed at Kikuyu police station for four days as they were doing their investigations. Until the United Nations High Commission for refugees learned that we were in cells, they were the ones who came and bailed us out, and then we were brought back home." Participant 6 (41 years old) Criminalizing same-sex practices has continued to create multiple pathways for enacted stigma. The laws within the East African region continue to shape norms and attitudes that increase unfair and disproportionate harassment and violence against SGM, including gay and bisexual asylum seekers in Nairobi. There were also further disparities, particularly for those identified as Ugandans, who were quickly targeted and harassed by Kenyan police officers with impunity. Some participants, therefore, feared being attacked even when at their homes, underscoring the need for further collaborative efforts with various partners and local SGM organizations to ensure the safety of SGM asylum seekers and refugees.

Sexual Violence
Participants reported experiencing sexual violence during various phases of their immigration life course. The most frequently reported sexual violence by participants was rape by multiple perpetrators, single events or over periods, in different places, e.g., prisons and/or work for sex workers. For example, one participant described how, after seeing his partner killed, he escaped from his family home for fear of also being killed. Sadly, while fleeing, he ended up in a soldier's camp on route to the country's border, where armed soldiers raped him multiple times: "So, the man raped me! Raped me! I will never forget when I think of these things in my life. It has become so difficult to understand . . . The man raped me for the first time. He raped me when he was alone. And then from that day, he told me that thing we had done was gonna be continuous, and I should not go anywhere outside the tent . . . Others also started raping me. They started coming out like three people or two who were drunk, and they raped me-all of them. I was there from when I was 14 years [old] until 15 years [old]. I spent one good year passing through those things there, yet I was looking for a way to take myself out of the country."

(Participant 8, 21 years old)
Participants also reported experiencing sexual violence while incarcerated. For example, participant 6 (41 years old) described how he was threatened, intimidated, and raped by a group of imprisoned people upon finding out from the correctional officers that he is gay at a prison near Kakuma Refugee Camp: "At first, I did not know why they were calling me there, and because I was new, I did not know anything about being in prison... two guys entered the room with me. They were four; one remained on the door. I entered with two. Then we found another one inside. When I entered, he grabbed my hand. Another one grabbed my legs. Then they pushed me to the floor. Then, one guy came on me then said, I need to have sex with you, and I was like, no. They then said, we already know you are gay; we will kill you. That is what he mentioned. And then he started, of course, raping me, and I felt so bad. It was a terrible experience for me. Furthermore, when the second one came, he released as he was trying to penetrate me, then the rest of the two said no-no for us; we will not do that, let him go." These discussions highlight the complex interconnection between sexual violence and policies. Furthermore, these contribute to further vulnerability and marginalization of MSM refugees and asylum seekers at various entities. Therefore, some may fear reporting experiencing sexual violence and continuing to suffer from the consequences of violence over extended periods. On the other hand, some refugee-led organizations recognized many cases of sexual violence and partnered with local stakeholders to conduct workshops to raise awareness and equip sexually minoritized asylum seekers and refugees with skills to prevent and report sexual violence (See Figure 6). me. They were four; one remained on the door. I entered with two. Then we found another one inside. When I entered, he grabbed my hand. Another one grabbed my legs. Then they pushed me to the floor. Then, one guy came on me then said, I need to have sex with you, and I was like, no. They then said, we already know you are gay; we will kill you. That is what he mentioned. And then he started, of course, raping me, and I felt so bad. It was a terrible experience for me. Furthermore, when the second one came, he released as he was trying to penetrate me, then the rest of the two said no-no for us; we will not do that, let him go." These discussions highlight the complex interconnection between sexual violence and policies. Furthermore, these contribute to further vulnerability and marginalization of MSM refugees and asylum seekers at various entities. Therefore, some may fear reporting experiencing sexual violence and continuing to suffer from the consequences of violence over extended periods. On the other hand, some refugee-led organizations recognized many cases of sexual violence and partnered with local stakeholders to conduct workshops to raise awareness and equip sexually minoritized asylum seekers and refugees with skills to prevent and report sexual violence (See Figure 6).

Discrimination
Most participants described experiencing employment discrimination while in Kenya. The discrimination practices varied from pervasive stigma against non-Kenyan I.D.s stereotyping to ostracizing Ugandans, particularly as sexual minorities. For example, Participant 5, 26 (years old), took the picture in Figure 7 of his partner, who had returned home from work, and was depressed because of his ongoing discrimination at work.

Discrimination
Most participants described experiencing employment discrimination while in Kenya. The discrimination practices varied from pervasive stigma against non-Kenyan I.D.s stereotyping to ostracizing Ugandans, particularly as sexual minorities. For example, Participant 5, 26 (years old), took the picture in Figure 7 of his partner, who had returned home from work, and was depressed because of his ongoing discrimination at work. Another participant described working for a few months without pay or having frequent salary days. Then, when he reported this to the police, he was further ostracized and questioned about his permission to work in Kenya: "…He did not pay me the right amount. He used to delay and all that. So, after three months of working without payment, I went to the police to report… So, the police were like, do you have a work permit? I said no, but we had agreed. I had a copy of what we had agreed on, and we agreed he would pay me this, and he said he was OK with that. How do you say it is OK with it? Like whom gives Another participant described working for a few months without pay or having frequent salary days. Then, when he reported this to the police, he was further ostracized and questioned about his permission to work in Kenya: Sexes 2022, 3 556 " . . . He did not pay me the right amount. He used to delay and all that. So, after three months of working without payment, I went to the police to report . . . So, the police were like, do you have a work permit? I said no, but we had agreed. I had a copy of what we had agreed on, and we agreed he would pay me this, and he said he was OK with that. How do you say it is OK with it? Like whom gives you, who gave you the right to work? You are a refugee; you are not supposed to work. That was a bummer! They did not give me my money, and the police did nothing about it." (Participant 16, 24 years) Another participant gave an example of his partner to highlight the exploitation and underpayment of asylum seekers and refugees in Kenya by their employers: "Like my partner, you will get a job in Westlands [a neighborhood in Nairobi]. You know there is a minimum wage where you are supposed to earn a wage. Where you are supposed to earn five hundred, they will be delighted and willing to take you to earn two hundred Kenya shillings daily. Desperate or not desperate, you have no choice. While your colleagues earn five hundred, you earn two hundred shillings, working twice as hard as those. This amounts to exploitation, so eventually, people are run down." (Participant 2, 35 years) Employment for asylum seekers and refugees in Kenya is complicated. Participants' stories highlight the existing substantive employment discrimination MSM refugees and asylum seekers experience in Nairobi. Therefore, actual (or fear of) employment discrimination affected participants' ability to meet their basic needs and general well-being.

Injuries
Many participants reported injuries resulting from the physical and sexual violence they experienced in their countries of origin while fleeing persecution and in Kenya. In addition, participants shared conspicuously visible and hidden scars, revealing histories of traumatic injuries sustained from physical violence because of their sexual orientation. For example, Participant 12, 22 (years old), described taking the picture in Figure 8 "Because it reminded me of that day that I was attacked and stabbed with a knife." The picture corroborates the participant's interview, where he described being attacked and sustaining an arm injury that led to excessive blood loss that left him unconscious.

Injuries
Many participants reported injuries resulting from the physical and sexual violence they experienced in their countries of origin while fleeing persecution and in Kenya. In addition, participants shared conspicuously visible and hidden scars, revealing histories of traumatic injuries sustained from physical violence because of their sexual orientation. For example, Participant 12, 22 (years old), described taking the picture in Figure 8 "Because it reminded me of that day that I was attacked and stabbed with a knife." The picture corroborates the participant's interview, where he described being attacked and sustaining an arm injury that led to excessive blood loss that left him unconscious. Another participant shared the picture in Figure 8 to show the daily struggles and realities of their experience in their community, e.g., assault and robbery. He also emphasized the need for "more assistance to refugee-led initiatives to provide safe houses and sustain them to keep our people safe." Because of the frequent physical attacks and injuries, some community leaders and Another participant shared the picture in Figure 8 to show the daily struggles and realities of their experience in their community, e.g., assault and robbery. He also emphasized the need for "more assistance to refugee-led initiatives to provide safe houses and sustain them to keep our people safe." Because of the frequent physical attacks and injuries, some community leaders and gatekeeper participants visited survivors of physical violence. For example, Figure 9 shows one of those visits where a gay refugee sustained a head injury after a homophobic attack. Notably, some participants shared photos that corroborated their histories of injuries shared in the interviews. For example, Participant 7, 22 (years old), described sustaining a groin injury from a mob attack at a public park in Kenya: "I was in one of the parks. It is called Mama Ngina. Just knowing your nationality, someone boxed [beat] me hard. The way I was kicked injured my private parts [groin]. I had to have surgery. I later wrote UNHCR asking for medication. They said I should buy the medicine because I am in an urban area. I explained to them that I did not even have money to cater for my medication... even to buy painkillers, to go to government hospital sometime, they ask for I.D., once you fluke, you get the painkillers, which are not enough." For his photovoice and reflection, the participant, the picture in Figure 10, showed his facial injuries the day the mob attacked him at the park.  Notably, some participants shared photos that corroborated their histories of injuries shared in the interviews. For example, Participant 7, 22 (years old), described sustaining a groin injury from a mob attack at a public park in Kenya: "I was in one of the parks. It is called Mama Ngina. Just knowing your nationality, someone boxed [beat] me hard. The way I was kicked injured my private parts [groin]. I had to have surgery. I later wrote UNHCR asking for medication. They said I should buy the medicine because I am in an urban area. I explained to them that I did not even have money to cater for my medication . . . even to buy painkillers, to go to government hospital sometime, they ask for I.D., once you fluke, you get the painkillers, which are not enough." For his photovoice and reflection, the participant, the picture in Figure 10, showed his facial injuries the day the mob attacked him at the park.
Even though some participants accessed emergency care for their injuries, the medical treatment was not comprehensive. Some, therefore, continued to live with long-term consequences from the injuries, of which the extent of damage to their physical health remained unknown without adequate medical evaluation: "About twelve people saw my boyfriend and me kissing and hit me with a stone on my head. Later, the police took us to the hospital. So, they stitched the wound, and all this part [left front] of my head is a bit paralyzed from that time till now. Whenever I touch it, I do not feel anything around the scar. It also reminds me that I was with my boyfriend and beaten because of being gay. Sometimes I try to forget everything, but this scar reminds me of what happened. I feel so bad. I feel bad because there was a possibility that it could have affected my brain, and I could have died. I am also terrified because I feel like the next thing that will happen to me is that I will be dead! So, I am always scared of that." (Participant 6, 41 years) parts [groin]. I had to have surgery. I later wrote UNHCR asking for medication. They said I should buy the medicine because I am in an urban area. I explained to them that I did not even have money to cater for my medication... even to buy painkillers, to go to government hospital sometime, they ask for I.D., once you fluke, you get the painkillers, which are not enough." For his photovoice and reflection, the participant, the picture in Figure 10, showed his facial injuries the day the mob attacked him at the park.  These stories highlight the traumatic injuries experienced by MSM asylum seekers and refugees in Nairobi. Although some community members followed up and supplied first aid to the injured members, their narratives and pictures describe the reality of physical violence and the resulting injuries that MSM asylum seekers and refugees face in Nairobi (See Figure 9). The stories also underscore some social determinants of refugee health and how issues, e.g., poverty, may affect MSM asylum seekers' and refugees' access to services required to diagnose and manage their injuries. Finally, they also highlight the need for more assistance for refugee-led initiatives to provide safe houses and sustain them to keep our people safe (Participant 2, 35 years).

Discussion
Structural and individual factors intersected with adverse pathways adversely affecting gay and bisexual asylum seekers and refugees. Most ended up in their neighboring countries, with the majority seeking humanitarian protection in Kenya [28]. However, most of the East and Horn of African countries have criminalized same-sex practices. Even when not illegal, cultural and religious fundamentalists continued to promote policies fueling further discrimination and abuse of MSM in general, resulting in many fleeing out of fear for their lives and safety [29].
Other studies have indicated the impact of the AHA on MSM health [30,31]. The participants described the bill's significance in increased violence, eventually forcing them to flee persecution. Based on these histories, the sexually minoritized asylum seekers' or refugees' situation included fleeing from one persecution to the same or worse [32][33][34][35]. For example, while participants sought protection in Kenya, the Kenyan penal code outlaws same-sex acts, punishable by up to 14 years in prison [36]. However, most reports and studies suggest rare implementation. The laws justified the discrimination, abuse, and violence against MSM asylum seekers and refugees.
Sharma used the concept of layered discrimination in organizational management to describe individuals with characteristics of minority status concurrently across several status or identity dimensions [37]. Sharma argued that people with layered minority status ("extreme minority risk") were more likely to be discriminated against in almost all settings [37]. Sharma's concept differs from intersectionality, which assesses the intersection of individual statuses such as MSM, asylum seekers, and refugees [38]. In our study, MSM faced multiple-layered discrimination. Multi-layered discrimination in our analysis refers to social structures, geographical sites, and authorities, culminating in the persecution of MSM asylum seekers and refugees. The discrimination transcended individuals and systems, e.g., family, community, authorities, geographical sites, country changes, and the intersectional loci of persecution. However, the discrimination was not specific to a geographical location. For example, there was no refuge for the refugee: Gay discrimination and physical violence were reported without exception by all our respondents, even those who lived in safe houses. Some studies with non-refugee MSM in Kenya have indicated frequent physical and emotional abuse of MSM [39]. That was consistent with our research, which found no safe status: Not being gay, not being a refugee, xenophobia regarding country of origin, and no secure employment without exploitation or discrimination.

Physical Violence
Concurrent with previous reports and studies, our study participants reported arbitrary arrests and physical violence by the police [40]. In general, regardless of their immigration status, MSM Kenyans were likely to experience police violence. However, the situation was worse for asylum seekers and refugees. In some instances, the same perpetrators of violence assaulted the MSM refugees and asylum seekers leading to their escape to Kenya. Some participants were thus further attacked by the same people and others while at the camps. These stories are consistent with other reports highlighting the constant physical violence and threats to MSM refugees' lives in Kakuma Camp. The UNHCR recognized the security threats and relocated some MSM to Nairobi in 2017 [41]. However, most UNHCR staff were local individuals. Their religious and cultural norms were consistent with the general Kenyan society. Thus, they were likely to further discriminate against MSM asylum seekers and refugees.

Sexual Violence
Ample evidence exists regarding sexual violence and its short-and long-term impact on physical health [42,43]. However, little evidence exists of male sexual violence. Nevertheless, some studies have reported that various cultural values, attitudes, social norms, and policies continue to shroud, stereotype, and shame men who experience sexual assault [44,45]. Several studies have reported MSM's disproportionate burden of childhood sexual abuse. These studies describe various factors, for example, non-explicit or vague definitions of abuse, that may lead to underreporting and recognition of the abuse [46]. Sexual violence also featured prominently in participants' histories of persecution. One participant described being gang-raped for over a year when they were fourteen. Some studies have linked multiple forms of victimization, e.g., childhood sexual abuse of MSM and other SGM youth, to substance-use problems [47]. Because our study only included adult MSM at the time of the interview, the plight of sexually minoritized asylum seekers and refugees under 18 is unknown.
The experiences of sexual violence, including rape, while incarcerated may adversely affect the health of sexually minoritized asylum seekers and refugees. For example, unprotected anal intercourse is one of the highest risks of HIV transmission because of the increased risk of tearing rectal tissues [48]. In addition, although the UNHCR provides healthcare in collaboration with various local partners, some of the services are not culturally sensitive to the needs of sexual minorities. Those raped, therefore, had increased susceptibility to HIV [49]. Furthermore, some participants accessed HIV prevention, care, and treatment from grassroots MSM-led organizations, e.g., Ishtar-MSM and Health Options for Young Men on HIV/AIDS/STI (HOYMAS). However, these organizations did not have adequate capacity and resources to address the specific needs of asylum seekers and refugees. Thus, refugee-led or grassroots organizations must take leadership in establishing partnerships for practical and sustainable culturally sensitive healthcare.

Discrimination
Regardless of their socio-economic background, all participants fled to Kenya without documentation showing their qualifications. Like other refugees, most depended on wellwishers' transportation, food, and accommodation while fleeing persecution [50]. However, Sexes 2022, 3 560 unlike general refugees who had social support, MSM were forced into the lowest statuses across geographical sites, social structures, and systems. For example, those identified as Ugandans questioned their grounds for seeking humanitarian protection in Kenya, while Uganda was a "peaceful" country. They were thus further ostracized, physically abused, or denied employment and other essential services [51,52]. Other challenges included the language barrier. Some participants could not communicate in Swahili, Kenya's national language, resulting in further discrimination and exploitation by some employers. Some researchers have previously reported the language barrier as a significant social determinant of asylum seekers' and refugees' health.

Injuries
Previous research studies have highlighted the complex pathways through which discrimination can lead to poor physical health outcomes [53][54][55]. Our analysis uncovered various injuries and health issues resulting from persecution at different points in MSM refugees' and asylum seekers' migration life courses. The intersections of an asylee, poor, and (often) Ugandan nationality created unique, indivisible experiences. The experiences resulted in specific risk factors and various injuries that adversely affect the health and wellbeing of MSM asylum seekers and refugees. For example, some sustained head injuries and fractures and described functional limitations in their daily activities. Other studies have also suggested that MSM asylum seekers and refugees lacked support and adequate access to culturally sensitive healthcare and other required services [56,57]. The local SGM-led organizations and clinics mainly provided HIV/STD prevention and care and thus did not have the proper capacity to provide other necessary health services. Nevertheless, there was potential for partnerships with organizations, e.g., the Hebrew Immigrant Aid Society (HIAS) of Kenya, to recognize SGM refugees and provide mental healthcare. The SGM refugee organizations, therefore, need support and partnerships to ensure adequate access to the required healthcare services, including prophylactic treatment and pain management.
Although we could not meet with participants to verify and prioritize their most essential needs, the photovoice provided visual evidence that enriched and corroborated, and thus confirmed, the interview data. Additionally, the photovoice empowered and enabled a comprehensive understanding of the lived experiences through the participant's views, thus empowering them and increasing their ownership [58]. Furthermore, our analysis of the photovoice and interview data mostly revealed similarities between persecution and injuries. Nonetheless, our previous study of more stigmatized issues, e.g., sexual health, found some differences. For example, one participant who had indicated being HIVnegative disclosed his HIV-positive status in the photovoice component of the study [59]. Our study is thus consistent with other studies that have asserted the advantages of both methods in strengthening the results while also acknowledging the subject variability that may lead to similarities and differences [60,61].

Limitations and Strengths
The study had a few limitations. First, we conducted the study during the onset of the COVID-19 pandemic. Therefore, we could not meet participants as anticipated to let them prioritize the most meaningful pictures. Additionally, although some participants had been to the Kakuma refugee camp, there were various structural and individual differences between those living in the refugee camps and the urban areas. For example, most urban refugees living in shared or rented housing in Nairobi still have access to the Nairobi metropolis services. Third, the interviews were also only with participants who managed to escape. The fate of those who did not manage to flee is unknown. Finally, while the research team collaborated with various local refugee organizations, the study participants were conveniently selected. Thus, further research is needed to understand asylum-seekers and refugees' needs in the East and Horn of Africa.
Despite the limitations, the study had some strengths. First, the study team included shared research expertise, lived experience of SOGI-based persecution, and knowledge of specific regional cultural differences. Thus, the team ensured culturally sensitive data collection and accuracy of the interviews' transcription and translation, making our data transferable to understand other sexually and gender-minoritized asylum seekers and refugees in Kenya.

Conclusions
Our study is one of the first to explore the persecution histories and injuries of male sexually minoritized asylum seekers and refugees in Kenya, thus contributing to the literature on this vulnerable population. Additionally, our muti-methodological approach highlights and confirms the various social determinants of health that lead to multi-layered discrimination, abuse, and injuries of gay and bisexual asylum seekers and refugees. Therefore, our study provides valuable preliminary data that can inform further exploration and understanding of the specific impacts of violence on sexually and gender-minoritized asylum seekers and refugees in Nairobi. It is also a valuable resource for policies and developing collaborative, culturally sensitive strategies to reduce adverse physical health outcomes for MSM refugees in Kenya. Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.

Data Availability Statement:
The data presented in this study are available on request from the corresponding author. The data are not publicly available to protect the privacy of study participants.