Understanding Intersectional Post-Return Needs and Health Outcomes of Women and Returnees with Diverse Sexual Orientation, Gender Identity, Expression, and Sex Characteristics (SOGIESC)
Geneva – Health is a fundamental human right entitled to everyone and in its highest attainable standard it conducts to living a life in dignity. Access to integrated care is critical to good health. However, efforts to realize this right often exclude vulnerable groups including migrants, including returnees. According to the International Organization for Migration (IOM), 58 per cent of migrants in vulnerable situations who were assisted to return in 2021 had health-related challenges.
Health solutions that fail to connect with migration have a damaging effect not only on the health of individuals on the move but also on the communities with whom they interact throughout their migration journey. There is "no public health without migrant health".
To establish appropriate responses, a detailed understanding of the relationship between migration and health is essential. This includes returnee populations. A study conducted by IOM, in partnership with Samuel Hall and the African Centre for Migration and Society at the University of the Witwatersrand in South Africa, explored the links between health needs, access to care, and sustainable reintegration of returnees. Findings show that health and reintegration mutually impact each other over time – and its negative repercussions are felt more by some than others.
The study, funded by the European Union, took a life-course approach and followed a mixed-methods approach, conducting fieldwork in Brazil, Ethiopia, the Gambia, Georgia, Pakistan, and Senegal.
Most returnees come back with health problems that they did not have before
Migrants often return with health problems that have been acquired during their migration journey. This means that they, and the health systems they return to, are often unequipped to tackle their health challenges. This is especially pronounced among female returnees, forced returnees, and returnees who spent at least six months abroad. Returnees often pointed to a delayed response to their health needs when they returned and viewed deteriorating health as an irreversible loss.
This is in large part due to migrants’ exposure to harmful environments during their migration, with cumulative effects on both their physical and mental health. Changes in returnees’ health status across the migration cycle is also found to be influenced by various structural and environmental factors. It is common to notice physical health problems upon returning to their countries of origin, such as chronic pain due to violence during their journey and respiratory illnesses due to climatic conditions.
Our research showed that there are several reasons that contribute to the inaccessibility of health care services such as lack of specialists in the local area, non-coverage of services under the public health system, longer wait times, or delayed treatment due to high health costs and priority to heterosexual male members of society, poorer quality of care, and shortage or unavailability of medication.
Returnees face additional barriers to health care access, on top of those faced by the general population.
Returnees have reported being denied care more often at post-return compared to their pre-migration stage. In the face of unmet health needs, returnees reported resorting to a variety of coping strategies. Poor access to positive social determinants of health, including decent housing, nutrition, and legal protection, were also found to have negative impacts on returnees' health.
Barriers experienced by some returnees include denial of care when their health condition occurred overseas; discrimination when they are victims of trafficking; misconceived perceptions towards them in relation to sexually transmitted diseases; financial difficulties in accessing health service; lack of information and documentation to access care; as well as language barriers.
These barriers lead to returnees’ health needs being unmet, which breaks the continuity of care essential to their physical and mental health, and to their possible stigmatization.
Tackling stigmatization and triple vulnerability
Women and those with diverse SOGIESC may face far greater challenges in accessing health-care services than men upon return due to the triple stigma based on identity, gender, and migration.
In some societies, risk-taking is more acceptable among men than women; thus, female returnees who decide to migrate face more stigma and social pressure than men upon return.
For example, in the Gambia, traditional understandings of gender-related dynamics discourage women from receiving health-care services, including psychosocial support from health-care providers of the opposite sex.
Moreover, girls and women are generally labelled as accompanying family members, which restricts their access to health care in a stigmatized society. Female returnees face more difficulties in accessing health care than male returnees while in their countries of origin (pre-migration and post-return), except in patriarchal societies where they either go with their husband or father. They often depend on their husbands or families financially, which does not change during the migration journey. This makes women more vulnerable than men to the negative effects of ill health and poor reintegration.
The study reported that in Brazil, there are additional health risks faced by returnees with diverse SOGIESC, whose migration is often found to be related to sex work, leading to a higher risk of contracting sexually transmittable infections. While progress is broadly being made to improve access to sexual and reproductive health for women, girls, and people with diverse SOGIESC, larger efforts are required to include migrants.
How can we move forward?
All returnees in our study faced health needs that were unaddressed. Yet, the experience of every returnee is different and hence calls for a gender-sensitive and intersectional approach. There is an urgent need to understand the specific needs of women and people with diverse SOGIESC based on their unique migration journeys. To achieve this, a pre-return and post-return assessment can help identify existing health needs.
This helps build a continuum of care across the migration cycle. Considering the implications of how gender and identity play a huge role in determining access to equitable health care, it is important to develop an individual care plan for migrants. For example, timely testing and sharing of information should consider differences in languages and names for pharmaceuticals and procedures.
Mental health screenings upon return, facilitated by a trained person of the same gender, are also essential to providing psychosocial support to returnees, especially women who are more likely to take the burden of unpaid care work within their families.
Strengthening follow-up support for returnees who have long-term health needs would help create sustainable health outcomes and stronger reintegration processes within the migration cycle. There is also a need to align reintegration and health programming. This could be done by combining development funding that supports the public health system and reintegration.
Finally, migrant awareness should be mainstreamed into health systems policies at national, regional, and international levels. This would further require a longitudinal study with insights on how returnees’ health and reintegration outcomes, especially those from vulnerable communities, continue to interact to manifest either deteriorations or improvements over time.