By Celeste Bilbao-Joseph

Transgender individuals suffer from high levels of discrimination, oppression and social isolation, associated with poor mental and sexual health. Social exclusion also leads to low levels of education, high unemployment and poverty.

The experience of Trans Latinas in Canada is further complicated by their histories as migrants. They are affected by transphobia and neo-colonial racialization throughout their lives – in their communities of origin, during the migration process itself, and upon arrival in Canada. Leaving behind contexts of radical exclusion, Trans Latinas hope to find basic rights in Canada but continue to experience exclusion based on their gender, ethnicity, lived trauma, and migratory status. This radical socio-economic exclusion has a powerful dehumanizing effect.

The complex experiences of trans immigrants require an approach that emphasizes and addresses the intersectional nature of the challenges and systems of oppression brought on by their gender and migrant identities. Recognizing these needs, in 2018, we developed a partnership between researchers at GloMHI, the University of Toronto, the Centre for Spanish Speaking People, and members of the Toronto Trans Latina community to launch the 'Trans Latinas Overcoming Barriers' (TLRB) project.

The project comprised 12 biweekly workshops – with sessions on self-care, social integration, and economic inclusion – and 6 monthly peer-led Self-Care/Peer/Advocacy (SPA) sessions, to:

1. Reduce public, community, and self-stigmatization: creating a supportive environment for the social integration of transgender women;
   
2. Increase social capital: providing opportunities for transgender women to expand their social networks and strengthen existing peer support groups;
   
3. Enhance employability: increasing their knowledge and skills to help them find meaningful and trans-friendly work;
   
4. Improve overall well-being and access to health services: identifying and connecting individuals to trans-inclusive healthcare services and promoting well-being best practices; and,
   
5. Promote best practices for migrant trans women: disseminating best practices for working with trans communities, particularly immigrant trans women.
   

Year 2 of the project launched in 2019. Peer leaders coordinated and facilitated Trans SPA sessions with the support of an Advisory Committee formed by part of the research team from Year 1. We expanded the target population to all Trans folks (not gender-specific), focusing on all racialized community members (not just Latinxs) who are often also immigrants. It is important to highlight that our TLRB project was born purely from the needs of the community – a community that was treated as invisible and felt underserved and unloved.

Joining in our shared humanity, our academic team and trans community partners created this intervention with the goal of challenging the inequities and social injustices that the migrant trans community suffers. We aimed to decrease these inequities by co-creating a unique place in the world and a unique moment in time where trans migrants could thrive, be fulfilled and happy.

By focusing on needs identified by our trans community partners, we strongly believe that the tools, knowledge, and skills created in the TLRB project can help remove some of the systemic obstacles trans individuals face and may empower participants to continue this work themselves.

It is our hope that this model can be modified to different cultures or settings across Canada, Latin America, and beyond, in order to continue our mission of working as partners with the trans community and contributing to its social and economic inclusion, aiming at achieving our common goal, social justice.

Celeste Bilbao-Joseph
Mental Health Clinician
Center for the Spanish Speaking Peoples (CSSP)
Toronto, Ontario, Canada

By Professor David Scott FitzGerald
 
Most refugees do not have a legal way of reaching safety in the rich democracies of the Global North. There is no legal line where they can register and wait as their number advances. Obtaining a resettlement slot is like winning the lottery. The only realistic way to reach the Global North is to reach its territory and then ask for asylum.
 
The core of the asylum regime is the principle of non-refoulement that prohibits governments from sending refugees back to their persecutors. Governments attempt to evade this legal obligation, to which they have explicitly agreed, by manipulating territoriality. A remote control strategy of “extra-territorialization” pushes border control functions hundreds or even thousands of kilometers beyond the state’s territory. An architecture of repulsion based on cages, domes, buffers, moats, and barbicans keeps out asylum seekers and other migrants. Australia, Canada, the United States, and the European Union have converging policies of remote control to keep asylum seekers away from their territories.
 
Simultaneously, these states restrict access to asylum and other rights enjoyed by virtue of presence on a state’s territory, by making micro-distinctions down to the meter at the border line in a process of “hyper-territorialization.” “Refuge Beyond Reach: How Rich Democracies Repel Asylum Seekers” (Oxford University Press, 2019) analyzes different forms of remote control, going back to the their 1930s origins, explains how they work together as a system of control, and establishes the conditions that enable or constrain them in practice. It argues that foreign policy issue linkages and transnational advocacy networks promoting a humanitarian norm that is less susceptible to the legal manipulation of territoriality constrains remote controls more than the law itself. The degree of constraint varies widely by the technique of remote control.
 
Psychologists have shown that people are more likely to mobilize around saving the lives of identifiable individuals in close proximity. Remote control policies by design or effect thwart that humanitarian impulse. Like nation-states, medical institutions can evade their obligations by repelling those in need from entering shared spaces. Sociologist Alejandro Portes describes how U.S. hospitals often deliberately create obstacles between sick people seeking health care and the doctors who have taken the Hippocratic Oath to render aid. Only patients with the resources and insurance to get past a hospital’s clerical gatekeepers and physical barriers surrounding the examination room can put themselves in a space where the doctor’s norm to render aid is activated. This “Hippocratic bubble” is created by the same logic of controlling space that puts up barriers to keep out asylum seekers. Ironically, the healing temple where Hippocrates founded modern medicine stands on the Greek island of Kos across the water from the beach where three-year-old Kurdish Syrian refugee Alan Kurdi’s body washed up in 2015. The world’s collective failure to shelter refugees from the Syrian civil war produced its most visible icon of despair when a toddler died at the edge of the Hippocratic bubble.
 
David Scott FitzGerald, PhD
Professor, Department of Sociology
Gildred Chair in U.S.-Mexican Relations
Co-Director, Center for Comparative Immigration Studies
UC San Diego, CA, USA

By Professor Warren Dodd and Ms Amy Kipp

Honduras is a Central American country with a population of 9 million, with approximately 40 percent of people living in rural areas. In recent years, however, migration to urban centres and international destinations has increased. The decision to migrate is often related to the lack of security experienced by individuals and households. Security includes both “freedom from fear” and “freedom from want.” People may migrate trying to avoid threats of physical violence or seeking better opportunities for education and employment. This strategy is particularly common among educated youth.
 
To further understand this trend, we spoke with 60 students graduating from a secondary school in the rural municipality of Yorito, Honduras. During a classroom activity, participants shared their future plans. The results of this study were presented in a paper recently published in Migration and Development.
 
Almost all (97%) participants indicated that they planned to move away from Yorito, following graduation. The majority of students shared a similar motivation for wanting to migrate, namely the lack of socioeconomic opportunities in the region. For example, an 18-year old female participant saw the lack of local employment opportunities as well as limited investment in their community as creating conditions that made it difficult for educated young people to remain in the area. She explained: “Unfortunately, there are few job opportunities given that our community is very underdeveloped. As a result, there are few career options.” Some students viewed migration as an opportunity to provide economic support to their families. “I would like to leave to find new opportunities so that I no longer depend on my mother and can support her,” said a male participant.

While migration can improve personal and household security in the region, this comes at a significant societal cost. The fact that virtually all graduating students plan to migrate is alarming, as the outmigration of educated, young people has serious social and economic implications for rural communities. With most young people leaving, communities lose the social and economic leaders of tomorrow, including educators, health care professionals, agricultural workers, and small business owners, among others.
Investment in the rural areas of Central America, including investment in agriculture, technology, infrastructure, social programming, and professional capacity development, could play an important role in creating local employment opportunities for educated youth and replace outmigration as the main livelihood strategy. Instead, unfortunately, these needs and opportunities clash with renewed threats by the U.S. government to cut foreign aid to Honduras, El Salvador, and Guatemala, combined with a lack of willingness and capacity by national governments in the region to promote such investments. Thus, in the foreseeable future, there will be few opportunities for educated youth from rural areas in Central America to enhance individual and household security by remaining in their communities. The flux of migrants from the region to North America will continue and possibly increase.

Warren Dodd, PhD
Assistant Professor
School of Public Health and Health Systems
Faculty of Applied Health Sciences
University of Waterloo
Waterloo, Ontario, Canada

Amy Kipp, MA
Research Associate
School of Public Health and Health Systems
Faculty of Applied Health Sciences
University of Waterloo
Waterloo, Ontario, Canada

By Professor María del Mar Pastor Bravo

The contentious issue of Female Genital Mutilation/Cutting (FGM/C) poses unique challenges to health promotion and health care around the globe.  FGM/C is defined by the World Health Organization (WHO) as “all procedures that involve injury to the female genital organs for non-medical reasons”*. This set of traditional practices is one of the most extreme expressions of gender-based violence and a violation of women’s rights,affecting some 200 million women and girls in over forty countries on five continents. It is estimated that 500,000 women living in the European Union (EU) have been subjected to FGM/C, and that 180,000 girls and women are at risk of undergoing FGM/C every year.In Spain, approximately 17,000 women and girls have either been mutilated or are at risk of being so.Despite the large numbers of women affected, it has been documented that availability and quality of care in Spain and Europe remain a challenge. WHO has set priorities to eradicate FGM/C, encouraging researchers to document the dramatic consequences of this practice.It is expected that such knowledge will help health care providers in Western countries better understand the experience of women who suffer the consequences of FGM/Cand provide transcultural, respectful care.

The article “Living with mutilation: A qualitative study on the consequences of female genital mutilation in women's health and the healthcare system in Spain” (Midwifery, 66, 119–126) reports the results of a study based on interviews with genitally-cut migrants who had given birth in the Spanish National Healthcare System. The study objective was to better understand the perspective of these women on health care. Participants reported physical, psychological, obstetric and sexual complications that could be linked back to FGM/C. Among immediate physical consequences they described hemorrhage and intense pain, with related difficulty urinating. Long-term complications were also mentioned that could be ascribed to this practice, including recurrent urinary infections and hepatitis B. Psychological consequences identified through the interviews included fear, emotional pain, rage, frustration, anguish, sadness, depression, and post-traumatic stress disorder. Women suffered changes in their sexuality, such as fear of engaging in sexual intercourse, dyspareunia (decrease in sexual pleasure), and difficulties in reaching orgasm. They also experienced complications during pregnancy with a greater need for episiotomies, instrumental deliveries, and caesarean deliveries. Furthermore, participants reported that health care professionals did not openly address the issue of FGM/C, never discussing with them the implications of their condition at any phase of care.

The lack of acknowledgement and information-sharing regarding FGM/C does not represent adequate care for this population. As a universal, publicly funded system, the Spanish National Healthcare System, as other health care systems in the EU, should be responsive to changes in the population it serves. Given how rapidly the demographic profile of the European population is evolving, monitoring changes in population needs and establishing appropriate responses, including training of health care professionals, is essential for immigrants but important for all users.

*WHO (2018) Fact Sheet: Female Genital Mutilation. https://www.who.int/news-room/fact-sheets/detail/female-genital-mutilation

María del Mar Pastor Bravo, PhD
Associate Professor
Faculty of Nursing, University of Murcia
Murcia, Spain

By Professor Anahi Viladrich

In recent years, the United States (U.S.) has witnessed heated debates on immigrants’ rights to government-sponsored health coverage, particularly after the passage of the 2010 Patient Protection and Affordable Care Act (i.e., ACA or Health Reform; Public Law 111-152, 2010). ACA was aimed at providing accessible and affordable health care coverage to formerly uninsured populations. However, it ended up barring undocumented immigrants—about 12 million people—from any publicly subsidized health insurance. Given the American public’s heated rhetoric with respect to immigration, scholars have become increasingly interested in understanding the frames most often used by the media that argue for either the inclusion or exclusion of unauthorized immigrants in the U.S.

Frame analysis, a well-known conceptual tool among political theorists has become popular in the broader social sciences in recent years given its power to deconstruct and explain media images. In this article, we define frames as conceptual packages of information summarizing a topic and imbuing it with a particular moral weight and ideological direction. For example, terms such as “illegal immigration” or “amnesty” are not neutral as they imply that unauthorized immigrants are law-breakers and perpetrators of criminal acts. Given the ubiquitous presence of the media and its role in shaping attitudes towards immigration, it is key for researchers to understand the common frames (i.e., scripts, metaphors and representations) that are publicly constructed either against or in support of immigrants’ entitlement to health services.

In our analysis of immigration in the U.S. context, a country where health care is a commodity, we found that inclusion has traditionally been supported by special circumstances. Typically, the rights of non-citizens to government-sponsored health care have been backed as a way of avoiding unintended consequences (e.g., as in the case of pregnant women bearing American children, whose lives may be at risk, or immigrants who are carriers of infectious diseases and are deemed a danger for the general U.S. population). Furthermore, public opinion has usually favored particular immigrant groups such as the innocent victim, the effortful agent, the elderly, the young, the frail, and the disabled. More recently, the U.S. media has supported highly educated immigrants, particularly those who arrived to the U.S. as children (i.e. Dreamers). These individuals are not only presumed to be industrious and talented but also “innocent,” a frame based on the assumption that they were not brought to the U.S. of their own volition.

The frames summarized above can be conflated under the figure of the “deserving” immigrant, an overarching frame that is at odds with the notion of immigrants’ entitlement to health care as a fundamental human right. While the U.S. represents a radical case, where universal health coverage represents a market-based commodity that is available either to those deemed exceptional or those with the financial means to access it, the principle of access to affordable (or free) and safe health care is being challenged in many countries. In this context, understanding how immigrants’ representations are socially constructed and disseminated through media frames is essential towards overcoming stigmatization, discrimination and exclusion of vulnerable groups across diverse nation-states and political sceneries.

Anahi Viladrich, PhD
Professor
Sociology & Anthropology, Queens College
Sociology, The Graduate Center
Community Health and Social Sciences, CUNY School of Public Health
The City University of New York (CUNY)
www.anahi-viladrich.com

By Professors Andrea Cortinois and Denise Gastaldo, Editors

With this post, the Global Migration and Health Initiative (GloMHI) launches a series of original contributions, a collection we call ‘Echoes.’ On a monthly basis, we will host original contributions by migrants, advocates, community workers, students, educators, policy makers, and applied researchers, from all over the world, who want to share ideas that contribute to an in-depth understanding of migration and its articulations with health, from multiple perspectives and disciplines.
 
GloMHI, as a group of scholars and advocates, is interested in understanding the complexity of the migration phenomenon, its global determinants, and migration as a determinant of health. Our vision is at the same time simple and trying: health for all, regardless of birthplace. The reference to the 1978 Alma Ata Declaration is transparent. We chose this vision to attract attention to one of the fundamental contradictions illuminated by migration: the one between the responsibility nation states have to protect and promote health as a fundamental human right and the way they construct their identity, on the basis of the inclusion/exclusion, belonging/being foreigner oppositions, and on the protection of borders. If governments have a responsibility for the health of their people, as the Declaration states, who will protect millions of non-citizens/denizens worldwide?
 
We try to step back and reflect on this phenomenon from a comprehensive perspective. We believe migration is one of the defining phenomena of our time, directly and closely related to some of the central existential challenges we are currently facing as a species, including climate change, environmental degradation, and resource depletion. Understanding migration, today, requires moving beyond a narrow focus on immigrant health, to recognize this phenomenon as a global one, with global causes and consequences.

Meaningfully contributing to the debate on migration, today, means challenging many of the clichés that limit our vision. Migration is not a crisis for the wealthy countries of Europe, North America, or Australasia. Migration is a crisis for the hundreds of millions of people on the move, as much as for their families, communities, and entire societies in countries of origin. Migration as a determinant of health cannot be understood purely in terms of health risks and protective factors directly related to the various phases of the migration trajectories: pre-departure; transit; short- and long-term destination situations; and return. It is essential, instead, to look at migration through an intersectionality lens, delving deeply into the complex identities of migrants, understanding their individual and collective lived experiences, reflecting on the contextual factors that shape those experiences, and exploring both the obvious and less obvious social costs of migration. Debating migration and the challenges it creates is an exercise in futility unless the historical and political economy factors at the root of this phenomenon, such as colonial rationalities, are openly and thoroughly addressed.
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We hope to contribute to this debate by giving space to the voices and showcasing the work of many who strive to understand a phenomenon that is changing our societies in profound ways and that, we believe, will only increase in size and significance, over the next decades.

Andrea A. Cortinois, PhD
Assistant Professor, Dalla Lana School of Public Health
University of Toronto
Toronto ON M5T 3M7
Canada

Denise Gastaldo, PhD
Associate Professor
Lawrence S. Bloomberg Faculty of Nursing
University of Toronto
Toronto ON M5T 1P8