Continued Trauma: A Thematic Analysis of the Asylum-Seeking Experience Under the Migrant Protection Protocols

Introduction: The Migrant Protection Protocols (MPP) required asylum seekers presenting to the U.S. southern border to wait in Mexico while seeking asylum. Currently, there is a lack of understanding of the MPP's potential harm to an already highly traumatized population. We sought to understand health impacts of this policy, including exposure to continued trauma. Methods: The University of Southern California (USC)'s Keck Human Rights Clinic analyzed de-identified legal declarations and forensic medical affidavits of 11 asylum seekers subjected to MPP. A deductive, thematic analysis was performed to understand the health impact and traumas experienced, and instances of each subtheme were counted by utilizing content analysis methodology. Results: Case analysis identified a total of 36 subthemes. Trauma subthemes included physical assault, psychological abuse, violence against family/friends, witnessed violence, sexual violence, and escalation. Perpetrator subthemes included gang, paramilitary, intimate partner, family, state, and unknown/other. Stress subthemes included despondency and social isolation. Security subthemes included reach of perpetrator, impunity of perpetrator, continued fear of persecution, fear of return, lack of safety, and reliance on strangers. Social determinants of health subthemes included tenuous housing, financial support, food insecurity, health care access, access to employment, and hazardous conditions. Psychological sequelae included anxiety, depressive, post-trauma, and suicidality; physical sequelae included dental, neurological, and dermatological sequelae. Conclusion: The MPP caused harm among these 11 cases evaluated. Harm resulted from continued trauma, worsening social determinants of health, and continued presence of fear and insecurity. The MPP may increase the risk of re-traumatization as well as detract from asylum seekers' ability to heal from pre-migration trauma.


Introduction
On January 25, 2019, The Department of Homeland Security implemented the Migrant Protection Protocols (MPP). The policy required that asylum seekers presenting to the southern border of the United States wait in Mexico during the determination of their asylum case. The policy applied to individuals who expressed fear of return to their country of origin if the individual ''ha [d] been assessed not to be more likely than not to face persecution or torture in Mexico''. 1 Exceptions to this policy included unaccompanied children, citizens or nationals of Mexico, individuals subjected to expedited removal, individuals with ''known physical or mental health issues,'' and returning legal permanent residents, among others. 1,2 Implementation of MPP deviated from previous asylum policy, which historically had allowed asylum seekers to enter into the United States for the course of their asylum proceedings. 3,4 During implementation of the MPP, 71,036 individuals were returned to Mexico, the majority of whom are seeking asylum from Honduras, Guatemala, Cuba, and El Salvador. 5 The MPP was stopped by the Biden Administration on January 20, 2021. 6 However, there is a dearth of medical literature documenting the health implications of asylum seekers' experiences while the policy was in effect.
Globally, asylum seekers experience a high degree of trauma, resulting in high rates of psychological sequelae, including major depressive disorder (MDD) and post-traumatic stress disorder (PTSD). [7][8][9][10][11][12] Rates of PTSD, MDD, and anxiety are reported to be as high as 36%, 44%, and 40%, respectively, among refugee and asylum-seeking populations. 8 These circumstances are similar for migrants in MPP from Central America, where the most common reason for flight is gang-related violence. Experiences of serious violence against family members, death threats, or threats of other violence are commonly reported. 13 Advocates and journalists have documented lack of access to food, water, shelter, and means of communication among asylum seekers subjected to the MPP, as well as instances of kidnapping, robbery, and sexual assault. [14][15][16] Reports highlight that, in practice, individuals with serious medical conditions have not been exempt from the policy, thus limiting access to appropriate medical care. 17 These reports suggest that the asylum-seeking experience under the MPP are not congruent with global standards regarding the treatment of migrants and survivors of trauma. These include the guidelines set forth by the United Nations High Commissioner for Refugees, and the Substance Abuse and Mental Health Services Administration, which defines six fundamental principles of a trauma-informed approach 18,19 This model maintains that recovery from past trauma cannot begin under situations of violence, instability, and fear. 19 We aimed at understanding the health effects of MPP, both physical and psychological, as well as the social determinants of health that impact this vulnerable population, via a focused, descriptive review of legal documents generated on behalf of asylum seekers forced to remain in Mexico.

Data sources
The University of Southern California (USC) Keck Human Rights Clinic (KHRC) is a student-run organization that connects asylum seekers and their legal representation with volunteer clinicians trained to provide forensic medical examinations. The KHRC compiled a secure Red-Cap database containing deidentified legal declarations and forensic medical affidavits of 11 asylum seekers subject to the MPP who were evaluated by KHRC clinicians. A total of 24 documents were assessed. Each paired declaration and affidavit belonging to a single client were considered a document set. Client legal declarations included a narrative description of the client's experience and reason for seeking asylum, whereas medical affidavits included the client's history as well as the physical and psychological findings and assessment of the clinician. Each of the 11 cases was identified via the clinic's clinician evaluators and was confirmed to be subject to the MPP by the date of asylum claim and location of the client at the time of the evaluation. Legal representatives of all client documents involved were consulted regarding use of deidentified client documents, inclusion of quotes and provided review of the manuscript to ensure that clients were aware and consented to use, in addition to avoid any information that could imperil ongoing cases. This study was approved by both the USC Social Behavioral IRB and the Physicians for Human Rights Ethical Review Board.

Thematic analysis
A deductive, thematic analysis of all documents was performed to understand traumas experienced by asylum seekers who were part of the MPP program. A thematic analysis methodology was selected to analyze the existing data set, as further purposive sampling could not be performed as required in a grounded theory methodology. After an initial sensitizing read of all documents, three investigators (R.F.P.L., M.C.S., T.W.S.) open coded all document sets in a line-by-line manner to generate preliminary codes of traumas, stressors, harms, and sequelae experienced by asylum seekers. We then reviewed the preliminary codes with a re-read of all documents, collapsing these into eight themes. We then iteratively refined these themes and subthemes to develop a final thematic map, including 8 themes and 36 subthemes. Each document was then coded by at least two investigators, and coding was compared. Disagreements in code application were settled by consensus. If consensus could not be achieved, the entire research team was consulted to reach a decision.
To ensure rigorous analysis and self-reflection, we employed a memoing method as codes were developed into themes, during thematic map development, and during refinement of the final thematic map. To improve trustworthiness, weekly meetings with the research team were held to discuss changes to codes. In addition, an iterative process of coding was used to develop themes and subthemes.

Content analysis
In the thematic analysis, ''stage of journey'' was a major theme relating to traumas experienced by asylum seekers. After all documents were coded using the finalized thematic map, each document set was assessed for the presence or absence of each subtheme in the premigration, during migration, and post-asylum request periods. The post-asylum request time period has specific relevance to this analysis as representing instability of the asylum-seeking experience as a direct result of being subject to the MPP. The total number of each sub-theme was calculated at each time period.

Results
The final codebook from the thematic analysis included 8 themes and 36 subthemes (Appendix Table A1). The first theme identified was stage of journey, which included three subtheme periods: pre-migration, during migration, and post-asylum request. The pre-migration period was defined to end at the time an individual fled the country of origin. The during migration period then spanned from the time of departure until presentation at the U.S. border. The post-asylum request period was then defined to begin at presentation to the border and encompassed the MPP period. In addition, seven themes described the context of the ordeals experienced in the migration process: trauma, perpetrator, stress, security, social determinants of health, psychological sequelae, and physical sequelae. In the subse-quent content analysis, the respective subthemes were mapped to each of the stages of journey (Fig. 1). Illustrative quotes for each subtheme are integrated later and listed in Table 1.

Trauma
Extensive trauma experienced in the pre-migration period provides the basis for fleeing the circumstances in the country of origin and are emblematic of the need to seek asylum. A variety of traumas was experienced and contextualized with six subthemes. Trauma persisted in the during migration and post-asylum request periods (see Fig. 1 for instances of subthemes in each period). The subtheme of psychological abuse was most common, followed by physical assault and violence against family and friends. One asylum seeker wrote: ''[T]hey beat me unconscious again. When I woke up, I was completely naked and bathed in blood. A couple of my neighbors were around me again, and they brought me to. My house. They told me they thought I was dead. I had a huge cut on my forehead, and I still have a scar from it today. I also had a bunch of marks and lashes on my back, as if they had whipped me over and over.''

Perpetrator
Perpetrator as a theme described who persecuted the asylum seeker and included subthemes of gang, paramilitary, intimate partner, family, state, and unknown/other. These perpetrator figures were pervasive in the pre-migration period but also present in the post-asylum request period.
Perpetrator is well exemplified by an asylum seeker who described: ''[The gang] beat me, and kept demanding information about where I was from, where I lived, and why I was there. They told me I was in their territory and it was going to be 'my last day'.'' ( Table 1)

Security
The security theme described factors that informed asylum seekers' assessment and perception of their own safety. Subthemes included reach of perpetrator, impunity of perpetrator, continued fear of persecution, fear of return, lack of safety, and reliance on strangers. Security subthemes identified in the pre-migration period were impunity of perpetrators, lack of safety, reach of perpetrator, and reliance on strangers. In the during migration and post-asylum request periods, all security subthemes were present, including continued fear of persecution and fear of return, which is representative of the intense feelings of insecurity among this population during their journey and while forced to remain in Mexico.
During the post-asylum request period, one asylum seeker reported: ''I received word that [they] were in Tijuana.
[He] has seen me before and knows what I look like. I am in constant fear of being seen by [them] or other gang members in Mexico and being killed.''

Stress
Stress described the psychological stressors (outside of mental illness) that created undue burdens on asylum seekers. Stress subthemes included despondency and social isolation, which were present in all periods compounding previous subthemes.
One clinician noted that their clients ''do not know anyone in Tijuana and have no one they can trust.'' Social determinants of health Six subthemes of social determinants of health also arose from the data set. Subthemes identified in the premigration period were access to employment, hazardous conditions, health care access, and food insecurity. The identification of subthemes shifted in the during  Physical assault ''They beat him with fists and feet over his entire body. He was struck in the face and his left eye. His front left incisor was avulsed. The assailants also repeatedly struck him with machetes.'' Psychological abuse ''They also said they would let their daughter live, so that they could raise her as a 'woman of the gang'.'' ''He threatened that if I said anything to my mom or if I report this to the police, he would do the same thing to my little brother.'' Violence against family/friends ''[He] also learned that his partner was raped by a narcotrafficker. He reports that the narcotrafficker raped his wife and threatened to kill her. However, he states that the narcotrafficker told his wife that she was suffering this violence in an effort to break his will to live and to 'hurt him in the worst way possible'.'' ''One day in 2018, members of [the gang] came to the firewood depot where my father worked as security guard, and demanded he give them free firewood. He refused. The gang members told him he would pay. They came back and shot him, and he died. I had to go to the morgue to identify his body. My siblings were too afraid that the gangs would identify them and target them if they went to the morgue.'' Witnessed violence ''They were beating them and taking away their cell phones with which they were recording. There were a lot of people participating, and the police had received orders to capture each person being in 'disarray.' I put it this way because they were calling it disarray, even though we were all peaceful protesters. There were no commotions nor uproars like they were calling it, but since the police started to get violent, we defended ourselves with sticks, rocks, and whatever we could find. Shortly after I gave birth to our second son, He became violent and abusive toward me. He abused me physically and sexually. He would hold me down with his body weight on top of me and choke me until I could not breathe. He also raped me many times in our bed. He was also abusive toward our two children. He would hit our oldest son and attempted to hit our youngest son. I would hold our youngest son to protect him from him, who would hit me instead. Family His attacks on me continued to become more and more violent, until I was sure that he would kill me if I continued to live with him. The worst assault in our home occurred in late 2017. He came home drunk from work. I had prepared a meal for him and was waiting at our dinner  ''My brother later filed a police report, but there was no investigation and nothing else was done.'' ''Despite providing evidence of the attack, he never heard again from the local authorities after filing this complaint.'' ''I never went to the police about the crimes and atrocities I saw around me because I knew it would not do any good and would just put me and my family in greater danger. I knew a teacher whose husband was killed by the gang. She filed a police report and they killed her.'' I was too scared to report the incident to the police. In [my country of origin], if you report problems with the gangs to police, your family will start to have problems with the gangs. My neighbor's brother was murdered, and she went to the police. migration period, to tenuous housing and financial support, but excluded food insecurity or health care access.
All social determinants subthemes were identified in the post-asylum request period, representing the most prominent period for social determinants of health subthemes (Fig. 1). Psychological sequelae and physical sequelae Finally, the presence of psychological and physical sequelae of trauma, identified as major themes, illustrate the complex health burden of these asylum seekers. Anxiety and depressive subthemes were identified in the pre-migration period. None of the subthemes were identified during migration, whereas all (anxiety, depressive, post-traumatic, and suicidality) were identified post-asylum request. This suggests an increase in psychological sequelae among these 11 cases when comparing the pre-migration period with the post-asylum request period. All 11 cases identified depressive and post-traumatic subthemes post-asylum request (Fig. 1).
One clinician described post-traumatic symptoms during the post-asylum request period, writing ''[S]he suffers from intrusive thoughts even now of these events almost every day. She has difficulty concentrating/ sleeping, she is hypervigilant, and often feels an overwhelming sense of panic.'' Physical sequelae identified in the data set included dental, dermatological, and neurological sequelae. Dermatological and neurological sequelae were identified pre-migration. In the post-asylum request period, all subthemes were present in documentation by clinicians, in which they describe scars and headaches, among other physical findings (Fig. 1).

Discussion
Globally, asylum seeker populations have experienced extensive pre-migration trauma and have been shown to have a high prevalence of PTSD and depression. [6][7][8]10,13 In documents reviewed for these 11 individuals enrolled in MPP, pre-migration trauma was similarly pervasive. Trauma described among these 11 individuals included physical, sexual, and psychological violence as well as witnessed violence and violence against family or friends. Notably, these same trauma ''They worked as live-in housekeepers but were asked to leave after a few months as relatives of the owners came to live and there was no longer any room for them.'' Health care access ''[He] does describe experiences episodes of gout while in Matamoros. He has not been able to receive proper medical care for this due to the prohibitive cost.'' Financial support ''Since the COVID-19 pandemic, their family has been unable to send money to help support them in Tijuana.'' Food insecurity ''They have had a very unstable income source and, therefore, very insecure food and housing'' ''They were often without food, sometimes for four days at a time [in the shelter].'' Psychological sequelae Anxiety ''Her guilt and feeling of hopelessness in protecting her three-year old son from the dangers in the city of Tijuana has brought her to the brink of a nervous breakdown and psychological exhaustion.'' Depressive ''She has negative thoughts and feelings, including isolation, anhedonia, sleep disturbances, decreased interest in activities, and hopelessness.'' Post traumatic ''There were many times when I thought I was going to die because of the beatings that I endured by the death squad in my town. I am traumatized by these things, and I constantly feel fear and panic at the thought or any reminder of them. And in addition to the attacks I experienced, I also witnessed horrifying things that the [paramilitary group] did to other people in my town that still haunt me to this day and give me nightmares.'' ''He also describes patterns of avoidance and hypervigilance: he rarely leaves his apartment. He is preoccupied with the notion that will be abducted by masked men, even in Tijuana. Additionally, he has difficulty concentrating and sleeping.'' Physical sequelae Dermatologic ''[He] developed an eruptive skin condition that has not responded to any antibiotic ointment or topical steroids.'' ''[He] has multiple linear scars over his bilateral knees, right arm, and right hip. There are 5 well-healed linear lacerations to the right leg, mostly around the knee, which are in various angles, both parallel and perpendicular to the axis of the leg. These are consistent with his report of assault by machetes.'' Neurologic ''She also reported consistent headaches for 3 months afterward, which she continues to occasionally have today.'' Dental ''Tooth #9 is displaced laterally, consistent with the prior avulsion injury.'' subthemes were identified in the data set in the postasylum request period. This suggests that asylum seekers enrolled in MPP have experienced additional physical and psychological trauma after requesting asylum, thus prolonging trauma exposure and exacerbating their mental health. This prolonged trauma exposure is important to understand in the context of the high proportion of these 11 individuals who screened positive for both PTSD and depression. Post-traumatic and depressive subthemes were identified in all 11 individuals included in this study. Although screening positive is not diagnostic for either condition, these results do align with the high prevalence documented in previous studies of asylum seeker populations. [6][7][8]10 Importantly, cumulative exposure to stressful or traumatic events has been associated with increased risk for or clinical worsening of both PTSD and depression. [20][21][22][23] Thus, these data suggest that MPP may lead to worsened mental health outcomes, via continued exposure to trauma among vulnerable and previously traumatized individuals.
As a result of both pre-migration trauma and compounded trauma after enrollment in MPP, asylum seekers may have experienced much from which they need to heal. To begin to heal from trauma, Substance Abuse and Mental Health Services Administration (SAMHSA's) safety principle of a trauma informed approach requires that individuals feel both ''physically and psychologically safe.'' 19 Inconsistent with this principle, documents for these 11 individuals identified security and social determinants of health as persistent ordeals in the post-asylum request period. Subthemes of tenuous housing, food insecurity, and hazardous conditions and identification of lack of safety, reach and impunity of perpetrators, and continued fear of persecution post-asylum request suggest inadequate subsistence conditions and a lack of physical and psychological safety in this period. Peer support is also a central tenant of SAMHSA's trauma-informed approach. 18 In our analysis, the subtheme of social isolation was also identified in the post-asylum request period, suggesting that lack of peer support may contribute to an environment incompatible with trauma recovery.
Similarly, guidelines for the international protection of refugees outlined by the United Nations High Commissioner for Refugees call for ''the right to a standard of living adequate for health and well-being, including food, clothing, housing and medical and necessary social services.'' Our data suggest that asylum seekers enrolled in MPP were not consistently afforded social welfare and health care as recommended by these guidelines. This, coupled with prolonged trauma exposure, requires consideration of the international human rights law principle of non-refoulement. 24 The United Nations Office of the High Commissioner states that this principle ''guarantees that no one should be returned to a country where they would face torture, cruel, inhuman or degrading treatment or punishment and other irreparable harm.'' 25 Further clarifying, ''[t]his principle applies to all migrants at all times, irrespective of migration status.'' 25 Increased cumulative trauma exposure in the context of inadequate access to basic services creates an environment incompatible with healing from prior trauma. Importantly, not only does this pose a risk to the health of the individual asylum seeker, but also to their present and future family and community through the effects of intergenerational trauma. 26,27 Limitations Our analysis is limited by the small sample size, as this population of asylum seekers is difficult to reach and understudied in the medical literature. Our dataset may be hypothesis generating for larger studies, but it also highlights critical health needs. A pre-existing dataset was used in this analysis and, therefore, only experiences documented in available declarations and affidavits were included. Thus, absence of subthemes in the available documents does not definitively represent absence of this experience in the population. Similarly, as these documents are written with the primary intent of documenting premigration factors leading to flight from country of origin and request for asylum, the traumas experienced in the ''during migration'' and post-asylum request periods may be underrepresented. To protect the safety and confidentiality of KHRC clients and prevent the possibility of tracing any information back to a single asylum seeker, all data were analyzed and presented in aggregate, which prevented any comparison between time periods for any one individual. Finally, all asylum seekers included in this study had access to legal representation for their asylum cases, and therefore both represent a small portion of the population of asylum seekers subject to MPP and a population whose attorneys determined might benefit from a medical or psychological evaluation.

Conclusions
Our thematic analysis suggests that the institution of MPP may have been harmful to the physical and psychological health of enrolled asylum seekers. Prolonged trauma exposure in the context of inadequate access to subsistence resources may increase the risk of re-traumatization and detract from one's ability to heal from cumulative trauma. Thus, this policy and others, like it, should not be utilized in the care of asylum seekers due to the impact on their health and reverberations to the larger community. Further, more work is required to understand the extent of the damage resulting from MPP, especially at the population health level, such that appropriate reparative policies may be designed to heal these prior harms and prevent similar injurious U.S. immigration policies from being employed in the future.

Implications for health equity
The MPP serve as an example of a policy with potentially detrimental health implications. This policy, in itself, should not be reinstated, nor should further policy be developed that might similarly endanger the health of vulnerable populations. To repair the damage done by this policy, the United States must consider supporting asylum seekers enrolled in this policy and enable them to safely seek asylum. We recommend that asylum seekers previously enrolled in MPP be allowed to enter and remain in the United States for the duration of their asylum proceedings, and that authorities consider how best to address medical and psychological needs exacerbated by the MPP policy. Not only might this mitigate long-term health harms for individuals enrolled in MPP but it may also prevent community health harms and propagation of intergenerational trauma. Any reference to a perpetrator of the trauma that falls outside of the previously defined perpetrator subthemes or a perpetrator who is unknown to the client.

Stress
Despondency Any reference to lack or loss of hope or loss of motivation. Any reference to the inability to continue the client's asylum claim.

Social isolation
Any reference to lack of access to community, family, friends, or other form of social support for the client's needs. Security Reach of perpetrator Any reference to fear of additional harm perpetrated by a perpetrator from the home country or associates of this perpetrator. Continued fear of persecution Any reference to fear of additional harm or trauma.

Impunity of perpetrators
Any reference to the belief or experience that perpetrators are not held accountable for, including experience reporting a crime that was not addressed by the authorities and the decision not to report based on perceived danger or presumed inaction on the part of the authorities.

Fear of return
Any reference to fear of returning to the home country, fear of individuals, organizations, or experiences in the home country. Lack of safety Any reference to feelings or experiences of being unsafe physically or psychologically. Reliance on strangers Any reference to the need for assistance from unknown others or experiences relying on unknown others. Social determinants of health Tenuous housing Any reference to instability of housing of lack of certainty with regard to housing. Hazardous conditions Any reference to living conditions that may be harmful to health or well-being, physical or psychological. Access to employment Any reference to the process of seeking employment, stability of employment, or conditions of employment. Health care access Any reference to health care access or lack thereof, experiences of seeking care, or experiences requiring care regardless of whether it was sought. Financial support Any reference to current means of financial support, including funds provided by family, friends, or community in home country or within the United States. Food insecurity Any reference to the process of feeding oneself or one's family, barriers to access, and assistance from individuals or organizations. Psychological sequelae Anxiety Any clinician reference to symptoms of anxiety. Depressive Any clinician reference to poor mood, anhedonia, a motivation, poor energy, fatigue, poor concentration, appetite change, weight change, sleep change, guilt, hopelessness, worthlessness.

Post traumatic
Any clinician reference to alterations in arousal, avoidance, negative cognitions, re-experiencing, dissociation, re-traumatization. Suicidality Any clinician reference to thoughts of death, passive death wish, plan to commit suicide, attempts. Physical sequelae Dermatological Any clinician reference to physical sequelae of trauma due to blunt injury, penetrating injury, laceration, burn, scarring, belt, or medical care. Neurological Any clinician reference to physical sequelae of trauma that is neurological (traumatic brain injury, headaches, memory or other cognitive deficits, chronic pain). Dental Any clinician reference to physical sequelae of trauma due to dental harm.

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