Spring 2019 Journal: The Impact of Immigration Policy on Mental and Reproductive Health

March 1, 2019 bppj Health, Immigration, Race, Reproductive Justice, Social Justice 0

Photo by Janko Ferlic on Unsplash

This article is the second article featured in our Spring 2019 journal. For the complete journal, please see the “Current Issue” tab above.

By Iris Wong

Edited by: Althea Lyness-Fernandez and Annie McDonald

United States immigration policies have a profound impact on the individuals they seek to regulate, particularly on the mental and reproductive health of immigrants. This article explores this relationship, focusing on the interactions between the U.S. immigration system and those involved in it, as well as the consequences of these interactions on the mental and reproductive health of the immigrants who are embedded in it. These individuals range from children and adolescents to adults and LGBT individuals, whose mental and reproductive health are affected in distinct, yet similar ways by their interactions with the U.S. immigration system. This paper analyzes the failures of our immigration system to adequately address the mental and reproductive health needs of immigrants to the U.S., as well as identifies the ways in which the U.S. immigration system actively harms immigrants’ mental and reproductive health. Finally, this article will provide concrete policy recommendations in order to remedy the deficiencies in our immigration system that are detrimental to the mental and reproductive health of immigrants.

Introduction

Debates around immigration policies in the United States often center on national security, separating those who are “from” the U.S. and those who are not. This “us vs. them” rhetoric is myopic and hypocritical. Immigrants constitute a sizable proportion of the U.S. population. Between 1820 to 2017, 83 million immigrants obtained lawful immigrant permanent resident status [1], and about three million refugees have claimed asylum in the U.S. as of 2016 [2]. Today, immigrants make up 13.5 percent of the U.S. population, compared to 4.7 percent in 1970 [3]. As a fundamental and integral part of the United States, immigrants deserve better treatment by the government. Many migrants travel to the U.S. seeking safety and freedom. Yet current U.S. immigration policies commit state violence by putting migrants at risk of physical harm and psychological strain, then denying them access to resources when they are in government custody or after they cross the border. Worse, regardless of how young a migrant is and how briefly they interact with immigration officials, the experience has lifelong effects that permeate every part of their daily life.   

One important—though inconspicuous—effect of immigration policies is the impact on an immigrant’s reproductive and mental health. Moreover, compromising one jeopardizes the other: the World Health Organization defines reproductive health as “a state of complete physical, mental and social well-being”[4] and that “reproductive health can only be achieved when mental health is fully addressed” [5]. For undocumented immigrants in the United States, the process of migrating and encounters with U.S. government officials have significant impacts on both aspects of health. These health risks are particularly acute for asylum seekers—especially women, children, and lesbian, gay, bisexual, and transgender (LGBT) people who are fleeing from violence in their home country [6]. Refugees from the Northern Triangle of Central America, which includes Guatemala, Honduras, and El Salvador, made up 42 percent of migrants apprehended at the border in 2016 [7]. These migrants are fleeing a region where an average of nine women and/or girls were victims of gender-motivated homicides every week in 2017 [8]. In Honduras alone, 264 LGBT people have been killed since 2009 [9].

Those who successfully cross the border continue to face health risks due to acculturative stress, defined as a psychosocial strain experienced by immigrants in response to stressors they encounter from adapting to life in a new country [10]. Learning a new language, searching for a job, and reestablishing social support networks in a new community all contribute to acculturative stress. In turn, acculturative stress is associated with anxiety, depression, and suicidal thoughts [11]. Immigrants face further health risks when the U.S. government makes the barriers to accessing health insurance or preventive reproductive healthcare services impossible to cross. For communities of color and LGBT people, the racism and stigmas they face during and after their journey make them especially vulnerable to reproductive and mental health risks. To fully comprehend how immigration policies affect immigrants’ mental and reproductive health, this paper examines three policies and how they affect children, adolescents, and adults, respectively.

A note on terminology: Reproductive health does not only apply to cisgender women, but also important to cisgender men as well as transgender, intersex, nonbinary, and other gender non-conforming people. As such, inclusive terminology such as gender-neutral terms and pronouns like “they,” “them,” and “theirs” will be used as much as possible.

Family separation policies create adverse childhood experiences for young children that impact their reproductive health later in life

Children who are migrating with their families in pursuit of safety and stability are instead at risk of lifelong traumatization at the hands of U.S. government officials. In April 2018, the Trump Administration announced a “zero tolerance” policy that prosecuted everyone who illegally crossed the United States border, even if they claimed refugee asylum [12]. As a result, approximately 3,000 children who traveled with their families to the southern U.S. border between April and June were separated from their parents and turned over to shelters operated by the U.S. Health and Human Services Department’s Office of Refugee Resettlement (ORR) [13]. Of those, about 2,400 are “tender age” detainees who are under 12 years old [14]. Data from the Department of Homeland Security (DHS) showed that as of October 15, 2018, 2,363 children were discharged from ORR custody. Additionally, 125 children whose parents were deported made the difficult decision to not seek reunification with their parents in order to pursue asylum, and 120 children who have not decided to waive reunification remain in ORR custody [15]. However, these government-issued data may be underestimated, as a report from the DHS inspector general stated that “DHS struggled to provide accurate, complete, reliable data on family separations” [16]. For the children who are waiting for reunification, the median length of detention as of October 15 is 154 days—over five months—and some have been in detention for as long as a year [17]. Experts from the American Academy of Pediatrics have cited studies showing that separating immigrant children from their families and detaining them in shelters, however brief, causes psychological trauma and post-traumatic stress disorder (PTSD) [18]. Health professionals further classify traumatic experiences like these as “adverse childhood experiences” (ACEs), which cause lasting mental development and health impacts [19]. Other types of ACEs include being a victim of violence or witnessing any violence in one’s neighborhood [20], and deportation or migration [21]—upsetting events that many of these children have already experienced prior to arriving at the border. Moreover, after a child is moved into the custody of ORR, they may experience physical or verbal abuse from federal staff [22], which further degrades their likelihood of growing up as a healthy adult.

As a child experiences an increasing number of ACEs, their reproductive health deteriorates. Without adequate care and resources to process their childhood traumas, these children are more likely to engage in high-risk sexual behaviors later in life [23], contract sexually transmitted infections (STIs) [24], become pregnant during their teenage years [25], and experience unintended pregnancies as an adult [26]. Further, in a study examining the relationship between ACEs and STIs, researchers found that a child who was physically abused was 60 percent more likely to contract STIs as an adult and a child who had incarcerated family members was 100 percent more likely to contract STIs as an adult [27].

Although current measures of ACEs do not fully capture the negative impacts of parent separation due to migration [28], children’s brains cannot distinguish between different sources of toxic stress. For example, the stress of parent separation has the same impact on a child’s brain development as living with an alcoholic parent or being bullied [29]. Therefore, these stark statistics on brain development could realistically apply to immigrant children exposed to various sources of toxic stress. In fact, given the distress children may experience from migration, traditional measures of ACEs may underestimate the negative impact on immigrant children.

Regardless, Trump’s policy of separating families, prosecuting the adults, and detaining the children in a hostile environment is wreaking havoc to the future mental and reproductive health of children who have already endured so many stressful events in their young lives. The U.S. government has an opportunity to provide safety and mental health services to help children process their traumas and grow up into healthy adults. Instead, the government creates additional ACEs and increases migrant children’s suffering.

Adolescent undocumented immigrants face mental health stressors that can be alleviated by DACA, but not by much

For undocumented immigrants who successfully enter the U.S., their mental health and, by extension, reproductive health are still at risk. These health risks are especially true for adolescents who must face these challenges during a critical developmental period. While discussions of undocumented immigrants frequently focus on Latinx communities, Asian Pacific Islanders (API) are also critical members of this population. With 1.7 million API undocumented immigrants [30] and over 33 API languages spoken in the United States [31], an in-depth understanding of how immigration policies affect API adolescents’ health is also needed.

Both API and Latinx adolescent immigrants experience stress from their undocumented status. Among young adults in the API community, the acculturative stress from feelings of shame and stigma of being undocumented, compounded with the model minority myth that APIs are successful due to their self-sufficiency [32], leads to reluctance to seek community resources and a negative attitude towards mental health services [33]. Similar stressors are experienced by Latinx immigrants whose undocumented status causes them to “struggle even more for basic necessities, experience perpetual fear of deportation, and…often [be] confined to the lowest-wage jobs” [34].

The psychological concerns that an undocumented adolescent experiences directly impacts their reproductive health. When one’s mental health deteriorates, one’s judgment and decision making skills are compromised and is associated with risky sexual behavior and “heightened vulnerability to unintended pregnancy, STIs including HIV, and gender-based violence” [35]. As these adolescents delay getting primary care or ignore their health issues due to their immigration status [36], they are also less likely to seek contraception and other family planning services, which leads to increased risk of STIs and unintended pregnancies. At a time when a young person undergoes fundamental socio-emotional development, anxiety about their immigration status prevents them from seeking resources that protect their health.

The Deferred Action for Childhood Arrivals (DACA) program initiated by the Obama Administration in 2012 may have alleviated some of these stressors, but it still has shortcomings. An undocumented immigrant who is approved for DACA is protected from deportation for two years and can apply for a work permit [37]. Data from September 2017 shows that of the 690,000 DACA recipients, women make up the majority at 53 percent, and two thirds are under 25 years old [38]. Studies show that DACA recipients experience a sense of “emotional and psychological peace” that improved the mental health of API DACA recipients [39] and reduced the shame Latinx immigrants feel about being undocumented [40].  Unfortunately, while Latinx DACA recipients report increased social support, social integration, and positive sense of self, the API undocumented community remains divided as the model minority myth perpetuates stigma, shame, and silence against undocumented immigrants [41]. Notably, 70,000 former DACA recipients did not renew their benefits or had their renewal applications denied after the Trump Administration announced plans to phase out the program [42]. While that only constitutes about 9 percent of all DACA recipients, it is still unconscionable that these young adults can no longer benefit from the program.

However, as discussed in the previous section, the ACEs of migration and growing up undocumented are not easily forgotten and leave lasting health impacts [43]. While a few DACA recipients can access employer-based health benefits, the majority were not offered coverage [44]. And since DACA recipients are disqualified from obtaining healthcare through the Affordable Care Act and Medicaid [45], most remain uninsured [46]. This means that even if DACA recipients wish to seek care to address these ACEs, they still face barriers of healthcare access. Furthermore, lack of insurance and the high barriers to care mean people who are pregnant are unable to receive prenatal and postpartum care, and those with uteruses are less likely to receive cervical and breast cancer screening, HIV/AIDS testing and treatment, and family planning services [47].

U.S. Immigration and Customs Enforcement (ICE) policies endanger pregnant and LGBT people

Adult undocumented immigrants face dangerous conditions that put their mental and reproductive health at risk when they arrive at the U.S. border. In December 2017, the Trump Administration implemented a new policy that superseded the Obama Administration’s directive that “pregnant women will generally not be detained by ICE” except in “extraordinary circumstances” [48]. Under the new Trump directive, ICE no longer has explicit policy guidance to avoid detaining pregnant women. Instead, the new directive merely states that ICE staff should ensure pregnant detainees are receiving appropriate medical care, and should be transferred to another detention facility when it is determined that the current facility cannot provide that care [49]. However, reports have emerged of pregnant detainees suffering miscarriages and being shackled while in custody [50], a practice in direct contradiction to recommendations from the American College of Obstetricians and Gynecologists [51].

But concerns about the treatment of pregnant people in ICE detention centers have existed prior to Trump’s directive. Detainees described experiencing symptoms of depression and stress from confinement [52] and suffering miscarriages without adequate medical attention [53]. Many of these detainees had children with them, and some became pregnant as a result of rape prior to or during their migration to the U.S [54]. Survivors of rape are at a higher risk of mental and behavioral disorders such as depression, anxiety, PTSD, dissociative disorders, and suicide [55]. Additionally, researchers found that stereotypes exaggerating Latinas’ sexuality combined with the societal traumas from the “systemic emotional, verbal, and physical assaults by those with power and privilege against members of marginalized group” [56] mean that these pregnant detainees, most of whom are from Central America, are less likely to seek help addressing the mental effects of rape.

It is horrendous that these detainees suffer additional atrocities while they are enduring the multiple health impacts from surviving rape and being pregnant. The mistreatment of those in federal custody is tantamount to state violence against their reproductive and mental health. Without adequate medical care, nutritious meals, or pregnancy-related accommodations (such as a first floor dormitory to avoid climbing stairs [57]), pregnant detainees are at a higher risk of perinatal depression, feelings of loss and guilt after a miscarriage, and anxiety over unintended pregnancies [58] For those who have already suffered greatly prior to reaching the U.S. border, it is unconscionable that they are further attacked by the U.S. government in this way.

LGBT people are no safer in the hands of the U.S. government. A recent report found that, based on data provided by ICE for Fiscal Year 2017, LGBT people detained in ICE custody are 97 times more likely to be sexually assaulted than those who do not identify as LGBT [59]. The prevalence of sexual assault is especially concerning because many of these immigrants are seeking asylum from sexual violence or state persecution due to their sexual orientation in their home countries [60]. And like many asylum seekers, LGBT immigrants who experience traumas from gender-based violence before and during their migration are at high risk of chronic mental and behavioral disorders like depression, anxiety, and PTSD [61].

Data on sexual violence experienced by LGBT detainees, including whether they are housed with men or women in ICE facilities, is extremely limited, as ICE has not released its required annual sexual assault data for the past four years [62]. In a congressional letter from Rep. Kathleen Rice’s (D-NY) office to the DHS Secretary Kirstjen Nielsen, Rep. Rice stated that “ICE reported…that, as of December 2017, 4 of the 17 facilities in which transgender women were detained were all-male and the rest were a mix of male and female populations. ICE did not provide information about whether transgender women were housed with men or women in those facilities” [63]. Further, data on sexual victimization of LGBT people in U.S. federal and state prisons as well as local jails demonstrate a grim pattern for those in ICE facilities. The latest available report from the Bureau of Justice Statistics stated that between 2011-2012, “12.2% of prisoners and 8.5% of jail inmates reported being sexually victimized by another inmate; 5.4% of prisoners and 4.3% of jail inmates reported being victimized by staff” [64]. Because power dynamics may prevent victims from reporting incidents, especially where the perpetrator is the staff, these statistics are likely an underestimate.

ICE further traumatizes transgender detainees by denying adequate treatment, detaining transgender women with men, or placing them in solitary confinement [65], despite ICE’s own rules to “consider on a case-by-case basis whether a placement would ensure the detainee’s health and safety”[66]. Solitary confinement is not an adequate solution for LGBT people, as studies have shown that even a short period of solitary confinement can exacerbate mental health problems, and irreversible psychological damage can occur after 15 days [67]. Of the 298 transgender people detained by ICE in FY 2017, 14 were placed in involuntary solitary confinement, while 25 requested it for protection because their placement in the general population was unsafe [68]. Additionally, transgender people were detained for an average of 99 days in FY 2017, more than double the average 43.7 days all immigrants spent in ICE custody [69]. Reports of transgender detainees being denied medical services like HIV medication or hormone replacement therapy and subjected to abusive strip searches further deteriorate their human right to physical, mental and social wellness [70]. That a transgender person is forced to risk their mental health for physical protection is inhumane. That they are detained for a significantly longer time without basic care than others is cruel. That they suffer these atrocities in U.S. government facilities is nothing less than state violence.

Conclusion

U.S. immigration policies have long-lasting repercussions on a person’s reproductive and mental health. The need for policies based on the human rights of immigrants is ever more crucial because of the traumas they have already endured prior to interacting with the U.S. government. Immigrants—indeed, refugees—fleeing from violence do not deserve further abuse of their mental and reproductive health, least of all from the very institution in which they seek asylum. To that end, below are some policy recommendations to improve the reproductive and mental health of immigrants:

The U.S. Government should seek alternatives to detaining migrants

Not only should the U.S. government immediately stop separating families at the border and reunite children with their parents, but the government should also go a step further by seeking alternative methods to govern migration. A report by the International Detention Council (IDC) identified and researched the efficacy of more than 250 alternatives to immigration detention in over 60 countries, including those with high numbers of asylum seekers, refugees, and migrants, as well as those with fewer resources [71]. Defined as any law, policy, or practice where people are not detained on the basis of their migration status [72], alternative methods promote the health and wellbeing of migrants without exacerbating existing trauma. These alternative methods also reduce wrongful detention and litigation, improve compliance with immigration and case resolution processes, and increase voluntary or independent departure rates[73]. In particular, research shows that migrants are more likely to accept and comply with decisions that are not in their favor in the immigration processes if they trust that they have been through an informative, fair, and efficient process [74]. Due to these benefits and lower operation costs, alternatives also cost 80 percent less than detention [75].

Based on their research, the IDC developed the Community Assessment and Placement (CAP) model. It includes elements such as: using screening and assessment to tailor management and placement decisions; providing holistic case management focused on case resolution; ensuring fundamental rights are respected and basic needs are met; and ensuring people are well-informed and trust they have been through a fair and timely process [76]. While IDC  recognizes that complete control over all cases is unrealistic and migration cannot always be prevented, the CAP model can help identify and address the motivating factors of migration without putting migrants’ human rights at risk [77]. What’s more, this model reminds policymakers that migrants are not criminals and do not deserve to be detained or treated as such.

Local jurisdictions can expand healthcare to all its residents, regardless of immigration status

Cities like San Francisco and Washington, DC, are paving the way to ensure residents’ health are not jeopardized based on their immigration status. The Healthy San Francisco program provides access to affordable, basic, and ongoing health care services by connecting enrollees with a medical home, which then assigns enrollees to a physician to coordinate the care they need [78]. Quarterly enrollment fees are designed not to exceed five percent of family income for people with income below 500 percent of the federal poverty level (FPL). Those who earn below that threshold are not charged a fee [79]. In Washington, DC, the locally-funded DC Healthcare Alliance Program provides health insurance for anyone who is a DC resident, has a household income of up to 200 percent FPL, and is ineligible for Medicaid or Medicare [80]. While the Alliance does not cover mental/behavioral health services, it does cover preventative care (checkups, diet and nutrition) as well as prenatal care [81]. Expanding access to healthcare for all residents may demand high upfront costs from municipalities. However, when the federal government has caused irrevocable harm to immigrants and made it impossible for those people to access basic healthcare services, local authorities have the opportunity to mitigate these damages for their community.

Community organizations can bolster health in immigrant communities by building trust between them and providers

Where bureaucracy fails to remediate its harmful policies in a timely manner, community-based organizations can play a unique role in filling in those gaps, especially in healthcare. However, trust is a fundamental element in providing healthcare services. The uncertainty of DACA, as well as discriminatory practices sanctioned by the government (such as ICE raids), prevent immigrants from seeking routine prevention or primary care appointments. In a 2017 Kaiser Family Foundation survey of 100 immigrant families in five cities, families reported that fear of deportation caused them to cut back on well-child visits and prenatal care [82]. However, families who trust their provider or feel the doctor’s office is a safe space report that they continued seeking care [83]. As such, health clinics need to make extra effort to establish trust and safety with their immigrant patients. Best practices include: posting signs in multiple languages that welcome immigrants and list immigrant rights in clinic offices; training clinic staff on the legal rights of immigrant patients; establishing a relationship with an immigration lawyer who can be available if an enforcement officer enters the clinic; and educating patients that their health care information is protected by federal and state law [84]. While these practices do not address the larger societal causes of discrimination and racism against immigrants, they can prevent rumors and misinformation from increasing fear and panic within the immigrant community [85].

Iris Wong is a second-year Master of Public Policy candidate at the Goldman School of Public Policy.

Endnotes

  1. U.S. Department of Homeland Security. (2018, October 2). Table 1. Persons obtaining lawful permanent resident status: Fiscal years 1820 to 2017. Retrieved from https://www.dhs.gov/immigration-statistics/yearbook/2017/table1
  2.  U.S. Department of Homeland Security. (2018, January 8). Table 13. Refugee arrivals: Fiscal years 1820 to 2016. Retrieved from https://www.dhs.gov/immigration-statistics/yearbook/2016/table13
  3. Lopez, G.; Bialik, K.; Radford, J. (2018, November 30). Key findings about U.S. immigrants. Retrieved from Pew Research Center website: http://www.pewresearch.org/fact-tank/2018/11/30/key-findings-about-u-s-immigrants/#
  4.  World Health Organization. (2009). Mental Health Aspects of Women’s Reproductive Health: A Global Review of the Literature (p. 1). Retrieved 10 August 2018, from http://www.who.int/reproductivehealth/publications/general/9789241563567/en/.
  5. Ibid, p. ix
  6. See, e.g. Grillo, I. (2018, June 21). ‘There is no way we can turn back.’ Why thousands of refugees will keep coming to American despite Trump’s Crackdown. Time. Retrieved from http://time.com/5318718/central-american-refugees-crisis/; Mathema, S. (2018, June 1). There are (still) refugees: People continue to flee violence in Latin American countries. Retrieved from Center for American Progress website: https://www.americanprogress.org/issues/immigration/reports/2018/06/01/451474/still-refugees-people-continue-flee-violence-latin-american-countries/; Bubacz, K.; Flores, A. (2018, April 30). These people from the caravan want you–and Trump– to know why they’re coming to America. BuzzFeed News. Retrieved from https://www.buzzfeednews.com/article/katebubacz/heres-why-people-asylum-us-mexico#.xw1nrYL7r
  7. Bermeo, S. (2018, June 26). Violence drives immigration from Central America. Retrieved from Brookings Institute website: https://www.brookings.edu/blog/future-development/2018/06/26/violence-drives-immigration-from-central-america/
  8.  See note 6. (República de El Salvador Portal de Transparencia, “Homicidios Año 2016,” available at http://www.transparencia.oj.gob.sv/Filemaster/InformacionGeneral/documentacion/c-40/8142/HOMICIDIOS%20A%C3%91O%202016.pdf (last accessed May 2018); República de El Salvador Portal de Transparencia, “Homicidios Año 2017,” available at http://www.transparencia.oj.gob.sv/Filemaster/InformacionGeneral/documentacion/c-40/10796/HOMICIDIOS%20A%C3%91O%202017.pdf (last accessed May 2018).)
  9.  Moloney, A. (2017, November 27). ‘Terrorized at home’, Central America’s LGBT people to flee for their lives: report. Retrieved from Reuters website: https://www.reuters.com/article/us-latam-lgbt-rights/terrorized-at-home-central-americas-lgbt-people-to-flee-for-their-lives-report-idUSKBN1DR28O
  10.  Arbona, C., Olvera, N., Rodriguez, N., Hagan, J., Linares, A., & Wiesner, M. (2010, August) Acculturative stress among documented and undocumented Latino immigrants in the United States (p. 364). Hispanic Journal of Behavioral Science, 32(3), 362-384.
  11.  Ibid.
  12.  U.S. Department of Justice. (2018, April 6). Attorney General Announces Zero-Tolerance Policy for Criminal Illegal Entry [Press Release]. Retrieved from https://www.justice.gov/opa/pr/attorney-general-announces-zero-tolerance-policy-criminal-illegal-entry
  13.  Foran, C. (2018, July 5). HHS Now Estimates Under 3,000 Kids Separated From Parents in Government Custody. CNN. Retrieved from https://www.cnn.com/2018/07/05/politics/separated-families-border-immigrants-number-of-kids/index.html
  14.  Dickerson, C., & Fernandez, M. (2018, June 20). What’s Behind the ‘Tender Age’ Shelters Opening for Young Migrants. New York Times. Retrieved from https://www.nytimes.com/2018/06/20/us/tender-age-shelters-family-separation-immigration.html
  15.  ACLU. (n.d.) Family separation: By the numbers. Retrieved from https://www.aclu.org/issues/immigrants-rights/immigrants-rights-and-detention/family-separation
  16.  Ibid.
  17.  Ibid.
  18.  Linton, J.M. Griffin, M., & Shapiro, A.J. (2017, April). Detention of immigrant children [Policy Statement] (p. 6). Pediatrics, 139(4), 1-13.
  19.  Stevens, J.E. (2018, June 19). Those who separate immigrant children from parents might as well be beating them with truncheons [Blog post]. Retrieved from ACESTooHigh website:  https://acestoohigh.com/2018/06/19/those-who-separate-immigrant-children-from-parents-might-as-well-be-beating-them-with-truncheons/
  20.  Moore, K., Sacks, V., Bandy, T., & Murphey, D. (2014, July). Fact Sheet: Adverse Childhood Experiences and the Well-Being of Adolescents. Retrieved from Child Trends website: https://www.childtrends.org/wp-content/uploads/2014/07/Fact-sheet-adverse-childhood-experiences_FINAL.pdf
  21.  ACEs Connection Resource Center. (n.d.). ACE Surveys (Different Types Of). Retrieved from https://www.acesconnection.com/g/resource-center/blog/resource-list-extended-aces-surveys
  22.  Planas, R., & Miller, H. (2018, June 21). Migrant Children Report Physical, Verbal Abuse In At Least 3 Federal Detention Centers. Huffington Post. Retrieved from https://www.huffingtonpost.com/entry/migrant-children-abuse-detention-centers_us_5b2bc787e4b0040e2740b1b9
  23.  Hillis, S.D., Anda, R.F., Felitti, V.J., Nordenberg, D., & Marchbanks, P.A. (2000, July). Adverse childhood experiences and sexually transmitted diseases in men and women: A retrospective study. Pediatrics, 106(1), 1-6. (For example, having early, unprotected sexual activity and high number of sexual partners.)
  24.  Ibid.
  25.  Hillis, S.D., Anda, R.F., Dube, S.R., Felitti, V.J., Marchbanks, P.A., & Marks, J.S. (2004, February). The association between adverse childhood experiences and adolescent pregnancy, long-term psychosocial consequences, and fetal death. Pediatrics, 113(2), 320-327.
  26.  Dietz, P.M., Spitz, A.M., Anda, R.F., Williamson, D.F., McMahon, P.M., Santelli, J.S.,…Kendrick, J.S. (1999, October 13). Unintended pregnancy among adult women exposed to abuse or household dysfunction during their childhood. Journal of American Medical Association, 282(14), 1359-1364.
  27. See note 23, p. 3.
  28.  Flores, G., & Salazar, J. C. (2017). Immigrant Latino Children and the Limits of Questionnaires in Capturing Adverse Childhood Events. Pediatrics, 140(5), e20172842.
  29. See note 19.
  30.  Ramakrishnan, K.; Shah, S. (2017, September 8). One out of every 7 Asian immigrants is undocumented. Retrieved from AAPI Data website: http://aapidata.com/blog/asian-undoc-1in7/
  31.  Sudhinaraset, M., To, T.M., Ling, I., Melo, J., Chavarin, J. (2017, June). The influence of Deferred Action for Childhood Arrivals on undocumented Asian and Pacific Islander young adults: Through a social determinants of health lens (p. 742). Journal of Adolescent Health, 60(6), 741-746.
  32.  Ibid, p. 745. (“Model minority myth may perpetuate stigma and silence as it undermines the heterogeneity in experiences among different Asian groups. Studies among APIs find that the model minority stereotype contributes to psychological distress and negative attitudes toward mental health services”)
  33.  Ibid, pp. 744-745.
  34.  Siemons, R., Flesh-Raymond, M., Auerswald, C.L., & Brindis, C.D. (2017, June). Coming of age on the margins: Mental health and wellbeing among Latino immigrant young adults eligible for Deferred Action for Childhood Arrivals (DACA) (p. 543). Journal of Immigrant Minority Health, 19(3), 543-551.
  35.  See note 4, p. viii.
  36.  See note 31, p. 744.
  37.  U.S. Department of Homeland Security, Citizenship and Immigration Services. (n.d.). Archive DACA: Frequently Asked Questions. Retrieved from https://www.uscis.gov/archive/frequently-asked-questions
  38.  Lopez, G., & Krogstad, J.M. (2017, September 25). Key Facts About Unauthorized Immigrants Enrolled in DACA. Retrieved from the Pew Research Center website: http://www.pewresearch.org/fact-tank/2017/09/25/key-facts-about-unauthorized-immigrants-enrolled-in-daca/
  39.  See note 31, p. 744.
  40.  See note 34, p. 548.
  41.  See note 31, p. 745.
  42.  See note 38.
  43.  See note 34, p. 547.
  44. See note 34, p. 546
  45.  Wiley, D. (2014, April 11). For DACA grantees, health insurance is (only) a dream [Blog post]. Retrieved from Georgetown University Health Policy Institute, Center for Children and Families website: https://ccf.georgetown.edu/2014/04/11/for-daca-youth-health-insurance-is-only-a-dream/
  46. See note 34, p. 546.
  47.  National Latina Institute for Reproductive Health. (n.d.). Deferred Action for Childhood Arrivals (DACA) and Reproductive Justice [Factsheet]. Retrieved  from http://latinainstitute.org/sites/default/files/Deferred-Action-for-Childhood-Arrivals-and-Reproductive-Justice-NLIRH-Fact-Sheet.pdf
  48.  U.S. Department of Homeland Security, U.S. Immigration and Customs Enforcement, Office of Enforcement and Removal Operations. (2016, August 15). Identification and Monitoring of Pregnant Detainees (Directive No. 11032.2). Retrieved from https://www.ice.gov/sites/default/files/documents/Document/2016/11032.2_IdentificationMonitoringPregnantDetainees.pdf
  49.  U.S. Department of Homeland Security, U.S. Immigration and Customs Enforcement, Office of Enforcement and Removal Operations. (2017, December 14). Identification and Monitoring of Pregnant Detainees (Directive No. 11032.3). Retrieved from https://www.ice.gov/sites/default/files/documents/Document/2018/11032_3_PregnantDetaines.pdf
  50.  O’Connor, E., & Prakash, N. (2018, July 9). Pregnant Women Say They Miscarried in Immigration Detention and Didn’t Get the Care They Needed. Buzzfeed News. Retrieved from https://www.buzzfeednews.com/article/emaoconnor/pregnant-migrant-women-miscarriage-cpb-ice-detention-trump#.kxaLEDJx
  51.  The American College of Obstetricians and Gynecologists. (2011, November). Health Care for Pregnant and Postpartum Incarcerated Women and Adolescent Females [Committee opinion]. Retrieved from https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Health-Care-for-Pregnant-and-Postpartum-Incarcerated-Women-and-Adolescent-Females
  52.  American Immigration Council. (2017, September 26). Increasing Numbers of Pregnant Women Facing Harm in Detention. Retrieved  from https://americanimmigrationcouncil.org/advocacy/detained-pregnant-women
  53.  Ibid.
  54.  Ibid.
  55.  United Nations Population Fund (2008). UNFPA Emerging Issues: Mental, Sexual and Reproductive Health (p. 3). Retrieved from  https://www.unfpa.org/sites/default/files/pub-pdf/mental_rh_eng.pdf
  56.  Bryant-Davis, T., Chung, H., & Tillman, S. (2009, October). From the margins to the center: Ethnic minority women and the mental health effects of sexual assault. Trauma, Violence, & Abuse, 10(4), 330-357.
  57.  See note 52.
  58.  See note 55.
  59.  Gruberg, S. (2018, May 30). ICE’s Rejection of its Own Rules is Placing LGBT Immigrants at Severe Risk of Sexual Abuse. Retrieved from Center for American Progress website: https://www.americanprogress.org/issues/lgbt/news/2018/05/30/451294/ices-rejection-rules-placing-lgbt-immigrants-severe-risk-sexual-abuse/
  60.  See, e.g. Moreau, J. (2018, June 6). LGBTQ Migrants 97 Time More Likely to be Sexually Assaulted in Detention, Report Says. NBC News. Retrieved from https://www.nbcnews.com/feature/nbc-out/lgbtq-migrants-97-times-more-likely-be-sexually-assaulted-detention-n880101;  Del Valle, G. (2018, January 17). Asylum Seekers are Being Sexually Assaulted in U.S. Detention. The Outline. Retrieved from https://theoutline.com/post/2893/immigrants-are-being-abused-by-ice-in-us-detention-centers?zd=5&zi=c7eb367i; Gruberg, S., & West, R. (2015, June 18). Humanitarian Diplomacy. Retrieved  from Center for American Progress website: https://www.americanprogress.org/issues/lgbt/reports/2015/06/18/115370/humanitarian-diplomacy/
  61.  See note 55.
  62.  See note 59.
  63. Rice, K. M., MOC. (2018, May 30). LGBT Immigrants in ICE Detention [Letter to U.S. Secretary of Homeland Security Kirstjen Nielsen]. Retrieved from https://kathleenrice.house.gov/uploadedfiles/2018.05.30_lgbt_immigrants_in_ice_detention_letter_to_sec_nielsen.pdf
  64.  Beck, A.J.; Berzofsky, M.; Krebs, C. (2013, May). Sexual Victimization in Prisons and Jails Reported by Inmates, 2011-12 [NCJ 241399] (p. 3). Retrieved from U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics website: https://www.bjs.gov/content/pub/pdf/svpjri1112.pdf)
  65. See note 59.
  66.  DHS, 6 CFR §115.42 (2015).
  67. Physicians for Human Rights. (2013 April), Buried Alive: Solitary Confinement in the US Detention System (p. 41). Retrieved from https://s3.amazonaws.com/PHR_Reports/Solitary-Confinement-April-2013-full.pdf
  68.  See note 65.
  69.  See note 59.
  70.  Stauffer, B. (2016, March 23) “Do You See How Much I’m Suffering Here?” Abuse Against Transgender Women in US Immigration Detention. Retrieved from Human Rights Watch website: https://www.hrw.org/report/2016/03/23/do-you-see-how-much-im-suffering-here/abuse-against-transgender-women-us
  71.  International Detention Coalition. (2015) There Are Alternatives: A Handbook for Preventing Unnecessary Immigration Detention (Revised Edition) (p. 1). Retrieved  from https://idcoalition.org/wp-content/uploads/2016/01/There-Are-Alternatives-2015.pdf
  72.  Ibid,  p. 7.
  73.  Ibid, p. 9.
  74.  Ibid,  p. 15.
  75.  Ibid, p. iii.
  76.  Ibid, p. 13.
  77.  Ibid,  p. 15.
  78.  Kaiser Family Foundation, Kaiser Commission on Medicaid and the Uninsured. (2008, March). Healthy an Francisco [Fact Sheet]. Retrieved from https://www.cga.ct.gov/ph/tfs/20071001_State-Wide%20Primary%20Care%20Access%20Authority/20080514/Healthy%20San%20Francisco.pdf
  79.  Ibid.
  80.  DC Department of Health Care Finance. (n.d.) Health Care Alliance. Retrieved from  https://dhcf.dc.gov/service/health-care-alliance
  81.  Ibid.
  82.  Artiga, S.; Ubri, P. (2017, December). Living in an Immigrant Family in America: How Fear and Toxic Stress are Affecting Daily Life, Well-Being, & Health [Issue Brief (p. 14)]. Retrieved from Kaiser Family Foundation website:  http://files.kff.org/attachment/Issue-Brief-Living-in-an-Immigrant-Family-in-America
  83.  Ibid, (p.13
  84.  Kritz, F. (2018, February 22). All Are Welcome: Health Clinics Work to Allay Fears of Immigrant Patients and Their Families. Retrieved from California Health Report website: http://www.calhealthreport.org/2018/02/22/welcome-health-clinics-work-allay-fears-immigrant-patients-families/
  85.  See note 84, p. 7