UNDERSTANDING FEAR OF DEPORTATION AND ITS IMPACT ON HEALTHCARE ACCESS AMONG IMMIGRANT LATINX MEN WHO HAVE SEX WITH MEN

Abstract

Purpose:

Fear of deportation and its relationship to healthcare access has been less studied among immigrant Latinx men who have sex with men (MSM), a population at risk for HIV and characterized by their multiple minority statuses. The first step is to accurately measure their fear of deportation.

Approach:

We used an exploratory sequential mixed methods design. Eligibility criteria were that research participants be ages 18–34 years; Latinx; cisgender male; having had sex with another male; residing in the District of Columbia metro area; and not a US citizen or legal permanent resident. In Study 1, we used in-depth interviews and thematic analysis. Using participants’ interview responses, we inductively generated 15 items for a fear of deportation scale. In Study 2, we used survey data to assess the scale’s psychometric properties. We conducted independent samples t-test on the associations between scale scores and barriers to healthcare access.

Findings:

For the 20 participants in Study 1, fear of deportation resulted in chronic anxiety. Participants managed their fear through vigilance, and behaviors restricting their movement and social network engagement. In Study 2, we used data from 86 mostly undocumented participants. The scale was internally consistent (α = 0.89) and had a single factor. Those with higher fear of deportation scores were significantly more likely to report avoiding healthcare because they were worried about their immigration status (p = 0.007).

Originality:

We described how fear of deportation limits healthcare access for immigrant Latinx MSM.

Research implications:

Future research should examine fear of deportation and HIV risk among immigrant Latinx MSM.

INTRODUCTION

Over the past 10 years, there has been an increase in the number of people who have been forcibly removed or deported from the United States to other countries (Amuedo-Dorantes & Arenas-Arroyo, 2019). In 2018, the Enforcement and Removal Operations (ERO) unit of the US Department of Homeland Security (DHS) removed 256,086 people who lacked permission to live/work in the United States, an increase from 2017 (US Immigration & Customs Enforcement, 2018). Heightened deportations have coincided with more funding for enforcement of federal immigration laws and a rise in anti-immigrant state legislation (Morse, Mendoza, & Mayorga, 2016; Ybarra, Sanchez, & Sanchez, 2016). In 2018, the top five countries to which people were deported were Mexico (141,045 removals), Guatemala (50,390), Honduras (28,894), El Salvador (15,455), and the Dominican Republic (1,769) (US Immigration & Customs Enforcement, 2018). Latinx (gender-neutral term for Latino/Hispanic)¹ men are the population mostoften deported (Golash-Boza & Hondagneu-Sotelo, 2013). As immigration enforcement has moved toward increased interior enforcement and collaboration with local law enforcement, racial and gender profiling has led to increased deportations of Latinx men (Golash-Boza & Hondagneu-Sotelo, 2013).

Undocumented Latinxs, those who lack legal permission to live/work in the United States, are the population most affected by mass deportation and immigration enforcement. Sociologist San Juanita García has described the ongoing threat of deportation as a social stressor for undocumented immigrants because it is a constant reminder of one’s social status and the potential of being targeted for deportation (García, 2018). The stress process model describes social stressors as conditions of threat, challenge, demand, or structural constraint that limit a person’s normal functioning (Wheaton, Young, Montazer, & Stuart-Lahman, 2013). When confronted with social stressors, individuals must cope or adapt to avoid distress. Coping is shaped by an individual’s psychosocial resources (Pearlin & Bierman, 2013). Pearlin attributes chronic stressors, such as fear of deportation, to adverse conditions in the social environment or individual societal roles. The impact of chronic stressors on health is further shaped by social and economic status, with those of less advantaged status being more vulnerable (Pearlin & Bierman, 2013).

García (2018) describes deportation threats as both chronic and anticipatory stressors that restrict undocumented Latinx movement and participation in social life. Other studies have similarly shown that the consequences of fear of deportation include decreased mobility (Szkupinski Quiroga, Medina, & Glick, 2014) and chronic stress (Arbona et al., 2010; García, 2018). To cope or adjust to deportation threats, undocumented Latinxs become vigilant, avoiding places where they will encounter police or immigration officials (García, 2018). In studies with African-Americans, the everyday anticipation of racism-related discrimination has also been conceptualized as “vigilance.” Recent work has demonstrated that this chronic stressor is associated with disparities in sleep disturbances between African-Americans and Whites (Hicken, Lee, Ailshire, Burgard, & Williams, 2013). As the stress model suggests, chronic stress associated with fear of deportation may similarly lead to worse health outcomes among Latinx immigrants.

One potential mechanism by which fear of deportation may impact health is by limiting access to and quality of healthcare services for Latinx immigrants living in the United States. Many studies have demonstrated that Latinx immigrants who fear deportation are less likely to access health services (Amuedo-Dorantes, Puttitanun, & Martinez-Donate, 2013; Berk & Schur, 2001; Hacker, Anies, Folb, & Zallman, 2015; Rhodes et al., 2015) or health insurance (Vargas, 2016), and are less able to comply with health care recommendations (Hacker, Chu, Arsenault, & Marlin, 2012), even when such services are freely available (Casey, Blewett, & Call, 2004). Latinx immigrants who fear being deported also experience higher levels of depressive symptoms and anxiety than those who do not fear being deported (Becerra, Quijano, Wagaman, Cimino, & Blanchard, 2015; Hagan, Rodriguez, Capps, & Kabiri, 2003; Maldonado, Rodriguez, Torres, Flores, & Lovato, 2013; Martinez et al., 2013).

Immigrant Latinx men who have sex with men (MSM) may be particularly vulnerable to fear of deportation because they are stigmatized by society at large on the basis of their sexual identity. The minority stress model posits individuals from stigmatized social populations experience excess stress resulting from their disadvantaged social positions (Meyer, 2003). Minority stress can include social and environmental stressors, such as interpersonal prejudice or institutional discrimination, stigma or expectations of rejection, concealment, and internalized stigma (Meyer, 2003). Stressors associated with their sexual identities, racial-ethnic idenitities and immigration statuses are all a part of a constellation of social stressors that collectively, uniquely influence the health of immigrant Latinx MSM.

For those with multiple minority statuses, such as immigrant Latinx MSM, minority stress may have an even larger impact on health (Meyer, 2003). Intersectionality is a theoretical framework that can be used to explain health disparities because of multiple minority statuses (Bowleg, 2012). Intersectionality posits that socio-structural systems (such as racism, sexism, and heterosexism) result in social categories that intersect at the individual level to produce people’s lived experiences (Bowleg, 2012). For example, Latinx transgender women confront multiple types of oppression in their experiences as a racial/ethnic, gender, and sexual minority. Using an intersectional perspective requires considering the complex or multidimensional ways these overlapping categories impact the stress experience and lead to health disparities, rather than focusing on the impact of single or dual social categories (e.g., Latinx vs White or Latinx men vs White men; Bowleg, 2012).

Prior research has adopted an intersectional perspective to address health disparities for immigrant Latinx sexual and gender minorities. Latinx gay/bisexual and transgender immigrants from Central America have described experiencing discrimination, persecution, and violence attributed to their race/ethnicity, sexual orientation, and gender, while living in the United States and in their countries of origin (Palazzolo, Yamanis, De Jesus, Maguire-Marshall, & Barker, 2016; Rhodes et al., 2013; Yamanis, Zea et al., 2018). In one study that focused on Latinx gay and transgender immigrants who were applying for immigration relief, all participants reported experiencing sexual identity discrimination and most had been victims of discriminatory violence in their countries of origin (Yamanis et al., 2018). Thus, immigrant Latinx sexual and gender minorities are particularly threatened by deportation because they know it would mean returning to violent and discriminatory conditions.

Immigrant Latinx MSM are also known to face sexual identity discrimination by family members, and thus may be more reliant on community and friend networks for social support and resilience (Gray, Mendelsohn, & Omoto, 2015; Ramirez-Valles, 2005; Yamanis, Morrissey, Bochey, Cañas, & Sol, 2020; Yamanis, Zea et al., 2018). In one study, immigrant Latinx MSM reported that in the United States, compared to their countries of origin, they enjoyed more freedom to express their sexual identity and and a stronger sense of community with other Latinx MSM (Rhodes et al., 2010). The prospect of losing such support may exacerbate fear of deportation.

Studies among immigrant Latinxs have shown that they avoid seeking health services for fear of being reported to immigration officials (Martinez et al., 2013; Rhodes et al., 2015). However, there are fewer such studies describing this specific experience among immigrant Latinx MSM. In a qualitative study among 21 immigrant Latinx MSM in the rural Southeastern US, fear of deportation because of HIV-positivity was identified as a main barrier to accessing healthcare services (Rhodes et al., 2010). Study participants did not trust health care providers to keep their information confidential, and they worried that their medical records could be used to deport them (Rhodes et al., 2010). Before January 4, 2010, having an HIV test was required for immigrants seeking a visa or entry to the United States and being HIV positive was grounds for inadmissibility (CDC, 2011). Although this policy has changed, Latinx MSM continue to report reduced access to healthcare because of mistrust toward health care providers and perceptions that providers are not sensitive to MSM (McKirnan, Du Bois, Alvy, & Jones, 2013). However, few studies have explored the role of fear of deportation in reduced access to care among immigrant Latinx MSM.

One of the potential consequences of fear of deportation among Latinx MSM is more rapid spread of HIV. According to the Centers for Disease Control and Prevention (2016), HIV diagnosis rates for Latinxs are three times the rates of non-Hispanic whites. Men accounted for 87% of new HIV infections among Latinxs in 2016, of whom, 85% were among MSM (Centers for Disease Control and Prevention, 2018). Latinx MSM were the only racial sub-group of MSM for whom annual new HIV infections increased between 2010 and 2016 (Singh, Song, Satcher Johnson, McCray, & Hall, 2017). In one study, undocumented Latinxs experienced delays in HIV diagnosis because of barriers in accessing healthcare; these barriers included fear of deportation, work restrictions, and lack of adequate translation services (Dang, Giordano, & Kim, 2012). We need more studies on the impact of fear of deportation on HIV risk among Latinx MSM.

To assess the impact of fear of deportation on HIV and other outcomes among immigrant Latinx MSM, we need to accurately measure fear of deportation. Existing measures of this construct have included one item such as “Do you worry that your friends or family members might be detained or deported due to their immigration status?” (Vargas, Sanchez, & Juárez, 2017). However, this one item does not capture how fear affects those who are not directly at risk of deportation. We know from studies that fear of deportation can affect even Latinx immigrants who hold temporary or permanent legal permission to live in the United States (Castañeda & Melo, 2014; Dreby, 2012). A more comprehensive measure of fear of deportation can thus capture those who may be affected by fear, but who are not at high risk of being deported. For example, a quantitative study from Texas compared 416 documented (those who had legal permission for temporary or permanent residency in the United States) and undocumented (those who lacked legal permission for US residency) Latinxs (66% Mexican, 34% Central American) on their seven-item measure of fear of deportation (Arbona et al., 2010). The seven items captured activities that were avoided because of fear of deportation including: (1) walk in the streets; (2) ask for help from government agencies; (3) report an infraction to the police; (4) report to the police an infraction committed against one’s person; (5) attend court if requested to do so; (6) apply for a driver’s license; and (7) wait in the street corner to get work. The study found that 32% of the documented immigrants reported avoiding at least one activity because of fear of deportation; activities they most often avoided included walking in the street, requesting help from government agencies, and applying for a driver’s license (Arbona et al., 2010). Fear of deportation among immigrants with legal permission may be in response to more restrictive immigration policies and a discriminatory social environment (Arbona et al., 2010; Menjívar, 2017). For example, Latinx immigrants who have been lawfully residing in the United States for years under Temporary Protected Status (TPS); status granted by the US DHS because of unsafe home country conditions) are now more concerned for their future. Recently, the Trump administration sought to end TPS for citizens of Nicaragua and El Salvador, the country of origin for the majority of TPS holders. While this decision is currently being held up in the courts, TPS holders are worried that they will be denied permission to remain in the United States (Svajlenka, 2019). A more comprehensive measure might capture TPS holders’ responses to fear of deportation beyond worry of an immediate deportation threat.

Furthermore, a multi-item measure is needed to fully capture the range of fear of deportation experiences among immigrant Latinx MSM. As the minority stress model suggests, those experiencing minority stress may turn to a variety of coping responses to reduce distress. This includes concealment, anticipation of rejection, and avoiding experiences of prejudice and discrimination (Meyer, 2003). Immigrant Latinx MSM may also experience fear differently from other Latinxs because of multiple stressors resulting from their intersecting social statuses. For example, they may cope by avoiding Latinx family or Latinx serving organizations to avoid sexual identity discrimination. Thus, a more comprehensive measure can capture the multitude of ways that immigrant Latinx MSM particularly experience fear of deportation.

To respond to this gap, we used an exploratory sequential mixed methods research design to develop a quantitative measure of fear of deportation for this population (Creswell, Klassen, Plano Clark, Smith, for the Office of Behavioral and Social Sciences Research, 2011). In Study 1, we used qualitative data gathered from interviews with immigrant Latinx MSM to understand the domains of fear of deportation. Specifically, we explored: (1) How do intersecting identities as Latinx and MSM, as well as their legal immigration status, affect the fear of deportation experiences of immigrant Latinx MSM? (2) How does fear of deportation affect their access to healthcare? We used the domains and quotes from the first study to develop a fear of deportation scale. Study 2 used survey data to examine the dimensionality and reliability of the developed scale and to assess the association between fear of deportation and access to healthcare among immigrant Latinx MSM.

STUDY 1: QUALITATIVE STUDY TO EXPLORE DOMAINS OF FEAR OF DEPORTATION

Method

Study Setting

The study was conducted collaboratively with La Clínica del Pueblo (La Clínica), a Federally Qualified Health Center (FQHC) that serves uninsured and underinsured Latinxs in the District of Columbia (DC) metropolitan area, including DC, northern Virginia and parts of Maryland. La Clínica offers a safe and confidential space where Latinx sexual and gender minorities can access health services, including HIV testing, navigation to social services, and support groups tailored to gay/bisexual men and transgender women. The DC metropolitan area is home to over 900,000 Latinxs, 53% of whom are foreign-born (Stepler & Lopez, 2016). Among all US metropolitan areas, the DC area has the second highest proportion of foreign-born Latinxs, after Miami-Fort Lauderdale-West Palm Beach, Florida (Stepler & Lopez, 2016). The DC area’s share of undocumented immigrants has grown recently, in contrast to a declining national rate, and in 2016 was estimated at 425,000 (Pew Research Center, 2019). DC is known as a sanctuary city for immigrants since local police do not partner with US Immigration and Customs Enforcement (ICE), unlike some police jurisdictions in Maryland and Virginia that cooperate with ICE. DC also funds the DC Alliance, a universal health insurance program, that provides insurance coverage to those who do not qualify for federal programs, including undocumented individuals (Meyer, Bovbjerg, Ormond, & Lagomarsino, 2010); Maryland and Virginia do not currently have comparable health insurance programs. DC also has the highest population proportion of sexual and gender minorities: 9.8% versus a national average of 4.5% (The Williams Institute, 2019).

The American University Institutional Review Board and the National Institute of Allergy and Infectious Diseases’ medical ethics officer reviewed and approved the protocol for both studies.

Participants

Participants were recruited by three bilingual, bicultural interviewers. Eligibility criteria for participants were as follows: (1) age between 18–34; (2) self-identify as Latino/Latinx; (3) self-identify as cisgender male; (4) have had sex with another male; (5) reside in the DC metro area; and (6) self-identify as a non-US citizen. About 20 non-US citizen Latinx MSM participated in the study.

Procedure

Data collection took place between November 2015 and February 2016. The study was advertised through the La Clínica, Facebook, and flyers. The advertisements described the study and eligibility, excluding immigration status eligibility, which was verified in person by the interviewer. Advertisements included contact information, sample interview, or survey questions, and the incentive amount ($50) participants would receive if they completed the interview. The interviewers reviewed eligibility criteria either in person or by phone, and set up an appointment with those that met the criteria and were interested in participating. Interviews were conducted in a private room at a healthcare center or a local public library. Interviewers reviewed the consent form in Spanish with each potential participant and emphasized that declining to participate would not affect receipt of services at La Clínica. Verbal informed consent was obtained without recording participants’ names. Interviews were conducted in Spanish and were digitally recorded for transcription. Interviews lasted between 60 and 90 minutes.

The interview guide was developed using a deductive approach based on previous literature on fear of deportation and health-related behaviors and minority stress theory. A community advisory board, consisting of La Clínica staff and health promoters who work with immigrant Latinx MSM, reviewed and edited the guide to ensure participant understanding. Participants were asked about their experience as a migrant, including their motivation to leave their country of origin, the possibility for return, and their experiences with immigration officials in the US participants were asked how their sexual identity impacted their interactions with immigration officials. In addition, interviewers asked several questions related to fear of deportation, including:

Have you ever been afraid of being deported? Where do you mostly feel fear of being deported? Have you ever left a job because you feared being reported to immigration authorities?

Participants were also asked about their access to healthcare, including their health insurance status, their feelings about seeking health services, and their health care providers’ attitudes toward immigrants. Finally, interviewers collected demographic characteristics such as age, country of origin, occupation, and immigration status, including whether participants were undergoing a legal process to adjust their immigration status at the time of the interview.

Data Analysis

Qualitative data were analyzed using a thematic analysis approach to identify and interpret themes from the data (Miles & Huberman, 1994). We generated codes deductively, guided by theory and prior research. Codes were grouped into 10 overarching categories (example codes for each category are provided in parentheses): (1) background of respondent (hometown; where live in DC); (2) daily life (perceptions of US; relationship status); (3) fear of deportation (avoidance behavior related to being MSM; avoidance behavior related to immigration status; anxiety because of fear of deportation; insecure places); (4) interactions with law enforcement (self-monitoring behavior); (5) migration (motivation to migrate; perception of country of origin); (6) entry and border officials (experience in detention center; border procedures); (7) family/friend support (friend network; family in the US; family’s homophobia); (8) legal process (legal status; reason does not receive legal services); (9) mental health services (perception; type); and (10) HIV-related issues (HIV/STI prevention practices; motivation for HIV testing).

During our data analysis, we inductively added a group of codes that emerged as themes, and overlaid them with other codes; these codes included: discrimination; level of openness about sexual orientation; immigration status concerns; negative feelings; and trauma. Two research assistants coded all the interviews in Spanish using Dedoose version 6.2.2. The Principal Investigator reviewed the coded transcripts for consistency across coders. During our analysis, we compared and contrasted participants’ experiences of discrimination and access to healthcare, their anxiety and fear related to deportation, and the strategies they used to manage fear. Quotes related to these key themes were translated from Spanish to English.

Results

Sample Characteristics

We describe the characteristics of the 20 qualitative study participants in Table 1. Most (90%) of the participants were undocumented. Nearly two-thirds of the undocumented participants were in the process of pursuing legal immigration relief, such as asylum status, to live in the United States. One participant had a temporary status through DACA (Deferred Action for Child Arrivals) and another participant had a temporary status through TPS; both of these temporary statuses include work authorization.

Table 1.

Characteristics of Immigrant Latinx Men Who Have Sex with Men, Who Live in the Washington, DC, Metro Area, and Participated in Qualitative Study 1 and Quantitative Study 2.

		Study 1 (N = 20)		Study 2 (N = 86)
Characteristic	Value	Percent	Number	Percent	Number
Documentation status	Undocumented	40	8	53	46
	Undocumented, but going through a legal process	50	10	40	34
	Completed a legal process, but not yet a permanent resident	10	2	7	6
Years in the United States of America	Less than five years	55	11	57	48
	More than five years	45	9	43	36
Where resides	Washington, DC	55	11	58	50
	Maryland	30	6	22	19
	Virginia	5	1	20	17
Country of origin	El Salvador	65	13	58	50
	Honduras	15	3	15	13
	Guatemala	0	0	8	7
	Mexico	10	2	7	6
	Other	10	2	12	10
Age	18–19 years	10	2	2	2
	20–29 years	55	11	68	57
	30–34 years	25	5	30	25
HIV status	Positive	25	5	19	16
Health insurance	Yes	65	13	47	40
Ever detained by US immigration	Yes	35	7	28	24

Six participants did not have health insurance; the others had access to health insurance. Most had insurance through the DC Healthcare Alliance, which provides health insurance to the undocumented. Five participants were living with HIV and had received their HIV diagnosis once in the US.

Most participants lived in DC, and a few lived in nearby suburbs in Maryland and Virginia. Many participants moved to the DC metro area to be close to family members and had not resided in other parts of the United States. Some participants had lived in other US states before moving to DC. A few participants moved to the DC area because family members in other states had rejected them because of their sexual orientation. Others moved to DC to have greater employment opportunities and to live in what they perceived as an immigrant and gay friendly city.

Migration History

A common reason for migrating was the experience of homophobic violence and discrimination in their country of origin. Many participants reported experiencing or witnessing homophobic violence in their country of origin, and worried that if they returned, they would be targeted for similar acts of violence. As one participant shared,

Going back to El Salvador is not an option. I would live with a constant feeling of not being able to go anywhere because I would be discriminated, or I would fear that at any time they can beat me.

Experiences of verbal abuse and physical assaults by family or community were also commonly reported. Five participants described their main reason for migrating was to escape a threat to their life because of being identified as homosexual. Many participants feared their lives would be in danger if forced to return their home countries. As one participant explained, “If they send me back home, I’ll just go home to die.” One participant reported that because his assailants could not find him, they killed his father and brother.

The migration journey for most participants involved crossing the Southern US border, often on foot or smuggled in trucks. In preparing to migrate, many participants felt anxiety about leaving family members behind in dangerous circumstances. While migrating, they experienced physical assaults and theft, with some participants losing important documents, such as their country of origin passports. Seven participants were detained by immigration authorities and spent time in US detention centers. Common experiences included suffering from lack of water and food, dealing with untrustworthy smugglers, and managing the risk of a discriminatory attack because of their sexual orientation.

The following themes about fear of deportation emerged from the qualitative analysis.

Intersectional Identity (Being Latinx and Gay) Exacerbated Fear of Deportation

Several participants described experiencing heightened fear of deportation because of their intersecting identities as immigrant, gay, and Latinx. One participant stated that he felt that his exposure to immigration authorities was worse because he was a Latinx immigrant who was also gay. Participants linked their fear of deportation to the violence and discrimination they experienced in their countries of origin. As one participant stated, “For the LGBT community, and especially if trans(gender), it is difficult because in our countries you can be killed for being gay.” Another participant noted:

I feel that the fear [of deportation] is greater in the LGBT community. They (the LGBT community) come alone because they don’t have anyone. They want a better life because their parents don’t accept them. If they are deported, they have to return to this place of hostility.

Fear of Deportation Affected Access to Healthcare

Participants acknowledged that their fear of deportation affected their access to healthcare in the United States. Despite the fact that 60% of participants had health insurance, many indicated that they were reluctant to engage with the US healthcare system because of their fear of being exposed to immigration authorities. They reported that some healthcare systems required identification, such as social security numbers, to receive services. As one participant stated: “If I go to a hospital and they ask me for a social [security number], I have nothing. It is better for me to stay silent…they could call immigration.” When asked about feeling comfortable going to health centers, one participant stated:

Well the truth is, I would feel a little insecure to go. I would have some fear. I think that the best thing would be to wait to see if I get sick or maybe I control it or something.

Multiple participants expressed a similar feeling, with one participant noting that, “it is something that is part of our mentality as Latinx, undocumented immigrants – that we have this fear in accessing health services because we can be deported.” In addition, a few participants acknowledged having undocumented friends who avoided HIV testing because they lacked legal identification.

Fear of Deportation Caused Chronic Anxiety

Participants described having a constant state of deportation-related anxiety. As one participant described, “When I see cars from immigration enforcement pass by me, the ones that are white cars with the blue stripe that says ‘homeland security’, I get nervous.” When asked where they experienced the most anxiety, one participant responded, “Anywhere. It comes to mind that the police can call immigration authorities, or that the immigration authorities are conducting raids, and I get afraid.” Anxiety was particularly common among participants who had not yet engaged in a legal process to adjust their immigration status.

Participants discussed several strategies they used in responding to their deportation-related anxiety. These strategies fell into two overarching domains: restricting movement and restricting engagement with social networks. Behaviors related to each domain are described below.

Restricting Movement to Relieve Deportation-related Anxiety

As a result of participants’ deportation-related anxiety, they intentionally and vigilantly restricted their movement. As one participant shared:

We don’t have the privilege to go out freely, you understand? You always live with a fear. You can’t have a life that is more familiar. You can’t get together more often with your family, or you can’t go out for fun, go out for a walk, do things, like, life is very different.

Another participant contrasted their behavior with those immigrants who are legally documented: “The case is very different for people with papers, because they can leave to go places they want or enter different places. But, someone without papers has less possibilities.”

Several participants discussed not leaving their house or going straight from home to work, and then work to home. As one participant explained,

I don’t leave my apartment much, only for important things. I don’t go out to the discos for example. This (fear of deportation) is something fundamental that you always have in your mind.

Another participant discussed how he felt confined to his local geographic area:

I would like to travel to Miami or Virginia, but I don’t do it because I’m afraid of taking a bus. Sometimes they [immigration authorities] get on the bus and check papers. I fear that they will take me and deport me.

Participants also discussed avoiding places where the police might be involved. One participant described these places:

I avoid driving. I avoid getting myself involved in problems. In bars there are problems and even if you aren’t involved, you are still at risk if they confuse you for one of them or something like that. So, I avoid it.

When hearing about police raids on the news or on Facebook, some participants altered their daily routines by not leaving home and intentionally missing work.

Restricting Engagement with Social Networks to Relieve Deportation-related Anxiety

Participants also described the impact of their fear of deportation on their social networks. As one participant shared:

With friendships, we always used to go out, but for fear [of immigration authorities] I have been distancing from them. I have fallen into a depression. I don’t know, everything is tangled with migration.

Many participants talked about avoiding being at a social event, like a party, where they thought there would be a higher risk of encountering police or immigration authorities. They also avoided drinking alcohol or going out with people who drink alcohol because of the risk involved. As one participant explained:

Sometimes when I go out with friends, they will drink in the car, but I don’t drink. We don’t have papers, so it makes me scared. So, I avoid going out to parties with friends because they can deport me.

Avoiding places where there were few Latinx people was another way to avoid being conspicuous to immigration authorities. Others vigilantly avoided places where there were many Latinxs present for fear that the immigration authorities would target those places. One participant said:

I go to X supermarket, an American place, because I know that if they are doing raids they will go to Hispanic places. But they won’t go to X supermarket.

Another participant noted that this fear of being around other Latinxs was detrimental to the sense of community usually felt by people from El Salvador. He explained:

The raids make me very sad and pained for the Salvadoran people. I have seen that during this time the people are too afraid to go out on the street. You don’t see very many Hispanics, or Latinos, like you used to years back. I have observed that many decide it is better to stay in their homes or in their apartments and not leave because they are afraid that they [ICE] will come and grab them.

Factors That Reduced the Negative Effects of Fear of Deportation

Although participants identified several factors that contributed to their fear of deportation, they also commented on ways they had been able to reduce their fear. We identified three factors that helped lessen the negative effects of participants’ fear: (1) applying to change their immigration legal status; (2) immigrant-friendly policies in their local jurisdictions; and (3) support from non-governmental organizations that had specific programming for MSM. Participants who were undergoing a legal process to change their immigration status reported a noticeable decline in deportation-related anxiety since beginning their legal proceedings. Although the outcome of their legal case was uncertain, in the meantime they received work authorization that allowed them to be “a legal ‘illegal.’” They were also able to obtain a driver’s license and access educational resources, which lowered their deportation-related anxiety. As one participant stated: “I am not afraid anymore. Now I am protected with TPS. I feel 100% safe now.” Still, those who were in a legal process were not completely immune to anxiety, as they knew their legal case could be unsuccessful. As one person stated: “Almost all of the time one has this fear here, because we are in a process of asylum and it is difficult. We are fighting.”

A few participants stated that they felt less deportation-related anxiety in Washington, DC, in comparison to Maryland and Virginia. This was in part because of the fact that in DC, the police do not collaborate with ICE. As one participant stated:

The police here can’t deport you, or rather they don’t work together with immigration authorities. A Latino here [in DC], immigrant, even if they are undocumented, has many rights. So I feel there is no fear at all.

Another participant reported:

I see that the police are closer to Hispanic people [here in DC]. The police come to talks and even come to XXX [a community-based organization serving sexual and gender minorities]. If we see a crime, we should report it, because the police will not check our papers. If we are assaulted or something happens in the street, we should call 911. 911 will not check our papers.

Some participants attributed the safety they felt in DC to the support they received from their friends, family, and the LGBTQ community in DC. They also cited DC government policies that allowed undocumented immigrants to access services. These policies include the DC Alliance, the health insurance program that covers undocumented residents.

Participants who attended non-governmental organizations serving Latinx MSM, including La Clínica, also reported lower anxiety toward accessing health care. These organizations sponsored Spanish-speaking charlas (conversation groups) for Latinx MSM, and employed LGBTQ- and Latinx-friendly service providers. charlas provided HIV prevention information, helped to reduce HIV stigma, and extended participants’ support networks. Participants described not having been tested for HIV in their countries of origin because of the lack of LGTBQ-friendly health providers and costly testing services. Thus, many participants HIV tested for the first time in the United States. The five participants who were living with HIV credited the charlas with reversing their perception that HIV is a death sentence. The positive effects of these organizations were not limited to HIV, as this participant explained:

Once you go to a clinic like La Clínica and get tested for HIV, you find out that they offer some other services. For instance, for diabetes, or if you have a health problem they can refer you to a specialist. So, you get to learn more. You are more informed and you break that first barrier of fear and feeling vulnerable.

Another participant echoed these sentiments:

Many of the Latino people don’t have health insurance so they cannot access health services. For example, many of the big clinics they won’t go to because they feel intimidated that they will ask for their social security number or insurance card. So, they avoid going to these places. So I feel like La Clínica is doing a good job because they are trying to eliminate that fear, making health services accessible.

The Development of a Scale to Assess Fear of Deportation

Given the impact of fear of deportation on health behaviors and assuming that reducing fear of deportation might improve health for this population, we sought to create a scale to capture this concept so that we could more accurately assess its impact on health. The items in the scale were generated inductively from the participants’ interviews. Using the quotes from the qualitative data, we included the behaviors often mentioned by participants. For example, our measure included items related to avoiding driving, attending parties, going places with too many Latinxs because these were mentioned by participants. We also included some items about the feelings of anxiety related to deportation (e.g., getting nervous around a police official). Based on the qualitative findings we expected to identify two scale dimensions for managing fear, restricted movement and restricted engagement with social networks.

STUDY 2: QUANTITATIVE STUDY

Method

Participants

The second study was also conducted in the DC metropolitan area, in collaboration with La Clínica and Nova Salud, a community health center serving Latinx MSM and transgender women in Northern Virginia. In total, 100 immigrant Latinx MSM completed the survey. For the analyses of fear of deportation and healthcare access, however, we include only 86 participants who were non-US citizens or non-legal permanent residents (i.e., those who were undocumented and those who had a temporary authorization, but had not yet received their green card). Recruitment and eligibility criteria were the same as for Study 1.

Procedure

The second study took place between August and November 2016. The same community advisory board that reviewed the qualitative guide provided detailed edits on the survey questions to ensure understanding by immigrant Latinx MSM living in the DC area. The surveys were completed directly by participants, in Spanish, using touchscreen tablets with Audio Computer-Assisted Self-Interview software in Spanish. As with Study 1, surveys were completed in a private room at a healthcare center or a local public library. Survey completion took between 30 and 75 minutes. Advertisement and consent procedures were the same as in Study 1.

Measures

Demographic information:

Data were collected on the age, sexual orientation (i.e., gay, bisexual, heterosexual, MSM, or other), country of origin, age upon arrival to the United States, number of years living in the United States, and immigration status of each participant.

Healthcare access:

Participants reported whether, since entering the United States, they experienced a time when they needed medical attention but did not seek it. Those who responded affirmatively were asked the extent to which each of the following barriers had been a factor in their decision to not seek care: (1) not knowing where to go; (2) not feeling safe seeking care; (3) not being out in terms of their sexual orientation; (4) being worried about their immigration status; (5) being worried about not speaking English; and (6) healthcare being too expensive. Response options were “Not at all” (1), “A little” (2), and “A lot” (3). For the present analyses, responses were dichotomized into two categories: “Not at all” (0) and “A little” or “A lot” (1).

Fear of deportation scale:

Items were taken from the Study 1 interviews and reviewed by our research team and La Clínica staff. The scale included 15 items to assess fear of deportation (see Table 2 for the items). For these items, participants were instructed to report the frequency with which they avoided or engaged in certain activities because of fear of deportation (e.g., “You avoid driving” or “You pay attention to the news about the immigration raids”), using a four-point Likert-type scale from “Frequently” (4) to “Never” (1). The mean of all items was used as an indicator of fear of deportation, with higher scores representing higher levels of fear of deportation.

Table 2.

Fear of Deportation Scale: Item Descriptives, with Higher Scores Indicating Greater Fear, Item-total Correlations, and Factor Loadings among 86 Immigrant Latinx Men Who Had Sex with Men Who Were Neither US Citizens Nor Legal Permanent Residents.

Item Because of fear of deportation, how frequently do you…	Mean	SD	Item-total Correlation	Factor Loading
(1) avoid going out a lot, for fear of encountering the police or immigration authorities (you go from your home to work and work to home)	2.71	1.09	0.66	0.71
(2) avoid driving	3.05	1.22	0.58	0.61
(3) avoid getting drunk or going out with people who get drunk	3.24	1.07	0.69	0.75
(4) avoid going out very late at night	3.06	1.08	0.73	0.80
(5) avoid calling attention to yourself	2.97	1.12	0.68	0.75
(6) avoid going to parties, going out dancing	2.86	1.07	0.65	0.72
(7) go out with people who have more time in the United States or who know the rules of this country	3.21	0.95	0.31	0.31
(8) avoid certain places for the fear of police or immigration authorities	2.91	1.12	0.63	0.63
(9) get nervous when you see a police official	2.18	1.11	0.63	0.65
(10) avoid going to places or events where there are many Latinos (Latino shops, bars, neighborhoods)	2.21	1.09	0.41	0.41
(11) avoid going to places or events where there are few Latinos	2.35	1.08	0.44	0.46
(12) avoid going out with people who can get you in trouble	3.51	0.81	0.43	0.47
(13) avoid traveling to other states in the United States	2.88	1.20	0.63	0.66
(14) avoid problems that can attract the police (for example, squabbles, driving at high speed)	3.59	0.86	0.34	0.37
(15) pay attention to the news about the immigration raids	3.47	0.84	0.56	0.59

Data Analysis

We used exploratory factor analysis (EFA) with principal axis factoring and oblique rotation to assess the dimensionality of the scale. To establish the number of factors to retain in each EFA, we used a Parallel Analysis online calculator (Patil, Singh, Mishra, & Donavan, 2017). This analysis was based on 1,000 random data matrices using the eigenvalues that corresponded to the 95th percentile of the distribution of random data eigenvalues. The last point at which the eigenvalues of the EFA were higher than those of the Parallel Analysis was used as the cut-off point to determine the number of factors to retain. Before conducting the EFA, we assessed the data’s suitability for factor analysis, using the Kaiser–Meyer–Olkin measure of sampling adequacy and Bartlett’s test of sphericity (Hair, Black, Babin, Anderson, & Tatham, 1998). To assess the internal consistency of the fear of deportation scale, we calculated Cronbach’s alpha coefficient as well as item-level correlations with the overall scale.

To assess the validity of the scale, we tested associations between fear of deportation and healthcare access among only non-permanent residents. Although our analyses were exploratory, based on both theory and previous research, we hypothesized that those with higher levels of fear of deportation would be more likely to avoid healthcare and endorse barriers to care. We used an independent samples t-test comparing fear of deportation scores among participants who reported having ever avoided needed healthcare and those who did not. We used additional independent samples t-tests to assess differences in fear of deportation for each barrier to care.

Results

Sample Characteristics

Key demographic data for the participants (n = 86) are presented in Table 1. In terms of immigration status, 53% were undocumented, 40% were undocumented but going through a legal process to change their immigration status, and 7% had completed a legal process to change their immigration status but were not yet permanent residents (they received U visas, withholding of removal, asylum or Relief Under the Convention against Torture). Similar to the qualitative participants, over half had lived in the United States for fewer than five years (57%), were 20–29 years old (68%), and were from El Salvador (58%). The quantitative sample included more participants who resided in Virginia (20%), while 58% resided in DC, and 22% resided in Maryland. Compared to qualitative participants, fewer quantitative participants had health insurance (47%), were HIV positive (19%) and had experienced being detained by the US immigration authorities (28%). Among those who responded that they had health insurance (n = 40), 68% had it through the DC Alliance program, 18% had Medicare, 10% had employer-sponsored health insurance, and 8% purchased a private insurance.

Described below are demographic characteristics for Study 2 participants for which we did not have corresponding data for Study 1 participants. When asked for their primary language for reading and speaking, 55% (n = 47) reported speaking more Spanish than English, 35% (n = 30) reported speaking only Spanish, and 10% (n = 9) reported speaking both equally. Regarding highest education level, 52% (n = 45) completed some high school or less, 23% (n = 20) graduated from high school or earned their general educational degree, and 23% (n = 21) completed some trade/vocational or higher education. In terms of sexual orientation, 77% identified as gay/homosexual (n = 66), 12% identified as bisexual (n = 10), 4% identified as a man who has sex with men (n = 4), 3% identified as “discreet or low profile” (n = 3), 2% identified as straight (n = 2), and 1 person described his sexual orientation as “normal, but sometimes I go out with transgender women.” When asked about their reasons for migrating to the United States, the top three most-endorsed reasons were “to escape violence or persecution because of me being gay” (63%, n = 54), “to live my life more openly” (54%, n = 46), and “to improve my financial situation/find work” (49%, n = 42). Finally, 41% (n = 35) of participants had ever been kicked out of or asked to leave their home because of being attracted to or having had sex with a boy or man.

Fear of Deportation Scale—Dimensionality and Reliability

Inspection of the Kaiser–Meyer–Olkin measure of sampling adequacy (0.83) and Bartlett’s test of sphericity (x² = 630.695, df = 105, p< 0.001) indicated that the data were suitable for factor analysis. Results from the EFA yielded four factors with eigenvalues larger than one, but parallel analysis supported a single factor, which explained 40.99% of the variance. Factor loadings for each item in an EFA forcing a single factor are shown in Table 2.

The fear of deportation scale showed good internal consistency (Cronbach’s alpha = 0.89), and all items were highly correlated with the scale total (see Table 2). Items most frequently endorsed included: “avoid problems that can attract the police (for example: squabbles, driving at high speed),” “avoid going out with people who can get you in trouble,” and “pay attention to the news about the immigration raids.” Least frequently endorsed items were: “get nervous when you see a police official,” “avoid going to places or events where there are many Latinos (Latino shops, bars, neighborhoods),” and “avoid going to places or events where there are few Latinos.” Considering the results of the EFA and reliability analysis, the mean of all items was used as an indicator of fear of deportation, with higher scores representing higher levels of fear of deportation.

While our analyses are focused on those who were not lawful permanent residents, we conducted one analysis including the 14 lawful permanent residents (or green card holders) in our overall study sample. As could be expected, fear of deportation was higher among participants who were not lawful permanent residents (n = 86; M = 2.95; SD = 0.66) than among those who had a permanent resident status (M = 2.41; SD = 0.63; t(98) = −2.73; p = 0.007). Among those who were not permanent residents, who are the focus of the present analyses, fear of deportation scores were not associated with age (r = 0.01, p = 0.90) or with years in the United States (r = 0.10, p = 0.34).

Associations between Fear of Deportation and Access to Healthcare

To assess the validity of our measure, we examined the association between fear of deportation and access to healthcare. Those who had ever had a time when they needed medical attention but did not seek it (n = 50; 59%) had a similar mean fear of deportation score (M = 2.95, SD = 0.61) to those that had not (n = 35, 41%, M = 2.96, SD = 0.75, t(83) = 0.02, p = 0.980). When assessing specific barriers to accessing healthcare, however, there were significant differences in fear of deportation scores among participants who endorsed some of these barriers and those who did not (Table 3). Specifically, fear of deportation scores were significantly higher among participants who avoided health care because they (1) didn’t know where to get services (t(48)=−2.63, p = 0.012); (2) didn’t feel safe (t(48) =−2.88, p = 0.006); (3) were not out as sexual minority (t(58) =−2.95, p = 0.005); and (4) were worried about their immigration status (t(48) = −2.84, p = 0.007). Fear of deportation scores did not differ among participants who endorsed language and cost as reasons for not seeking medical attention when they needed it.

Table 3.

Levels of Fear of Deportation by Barriers to Healthcare among 50 Immigrant Latinx Men Who Had Sex with Men Who Were Neither US Citizens Nor Legal Permanent Residents and Resided in the Washington, DC, Metro Area.

	Endorsed		Not Endorsed
Barrier	n	Fear of Deportation Mean (SD)	n	Fear of Deportation Mean (SD)	t(df)	p Value
Not knowing where to go	38	3.07 (0.54)	12	2.57 (0.70)	−2.63 (48)	0.012
Not feeling safe seeking care	29	3.15 (0.54)	21	2.68 (0.61)	−2.88 (48)	0.006
Not being out in terms of sexual orientation	23	3.21 (0.50)	27	2.74 (0.62)	−2.95 (48)	0.005
Being worried about immigration status	39	3.08 (0.58)	11	2.52 (0.55)	−2.84 (48)	0.007
Being worried about not speaking English	40	3.01 (0.62)	11	2.68 (0.53)	−1.61 (49)	0.114
Healthcare is too expensive	50	2.93 (0.61)	1	3.67 (n/a)	n/a	n/a

DISCUSSION

Through this mixed method study among a total of 105 mostly undocumented, non-permanent resident immigrant, Central American, Latinx MSM, we described how fear of deportation caused chronic anxiety and was associated with a reluctance to access healthcare. Using qualitative data in which participants described how they responded to their fear through vigilance, restricted movement, and limited access to their social networks, we created a measure of fear deportation. We found that fear of deportation was associated with barriers to accessing healthcare. This population’s access to healthcare is important not only for reducing HIV transmission but also for improving their overall health. Furthermore, the avoidance behaviors the participants described as a result of fear of deportation included isolation from social networks, which could negatively impact their mental health. Below, we describe several important research questions that could further clarify the relationships between fear of deportation and other health outcomes for immigrant Latinx MSM.

The rigorous process we used to develop the fear of deportation measure, with qualitative interviews informing the items we included, provides preliminary evidence of a valid measure for use with immigrant Latinx MSM. While our measure included predictable items that have been used in other measures, such as avoiding the police or immigration authorities, it also described the impact of fear of deportation on more quotidian activities, such as avoiding going out very late at night. Although we hypothesized that our scale would include two different dimensions (restricted mobility and restricted engagement with social networks), our psychometric analyses revealed only one dimension. One interpretation is that all items, including those related to social networks, captured the underlying construct of restricted mobility. For immigrant Latinx MSM, going from home to work and from work to home may have the same day-to-day meaning as restricting social engagement, such as avoiding parties. Further research is needed with larger samples of immigrant Latinx MSM to further assess the validity and generalizability of the scale.

Our study was novel because it included individuals who: (1) were undocumented; (2) held temporary residence permits; and (3) were legal permanent residents. However, further research to assess the scale’s validity should include larger samples with more participants in the latter two categories. Our results echo the research by García (2018) who describes how undocumented Latinx are vigilant about avoiding authorities because of the deportation threat. Non-permanent residents in our study reported more avoidance activities than permanent residents, which suggests that the consequences of interacting with immigration authorities may be higher for those who do not have permanent status. These results are consistent with a previous study using the same measure, which found higher avoidance among undocumented Latinx transgender women compared to those with legal status (Yamanis, Malik et al., 2018). However, it is worth noting that in both studies even the legal permanent residents reported avoidance activities because of fear of deportation. This underscores the importance of measuring fear of deportation among non-US citizens with varying types of legal status. Those who have relief from deportation, such as those with TPS, may nonetheless fear deportation because they worry that their status may change. Future research could examine how fear manifests in the lives of immigrants who reside in the United States with “liminal legality,” or uncertain or temporary legal status (Menjívar, 2006).

Fear of deportation may also change over the course of going through a legal immigration process. While our study included participants who were going through a legal process, they had not yet reached a legal conclusion, making it difficult to assess how the process affected their fears. Longitudinal studies that follow participants from start to finish of a legal immigration case could help clarify this relationship.

Our hypothesis that fear of deportation would be associated with avoiding healthcare was not supported. This may be because of the way we measured this variable, asking whether they would have accessed medical care even when they needed it. Latinx men have lower healthcare utilization rates compared to Latinx women (Livingston, Minushkin, & Cohn, 2008), and young Latinx men are less likely to access healthcare compared to young men from other racial/ethnic groups (Ortega, Rodriguez, & Vargas Bustamante, 2015). It is possible that the young Latinx men in our study who responded that they never avoided health care simply did not feel a need for medical attention. Thus, our examination of the scale’s association with barriers to accessing healthcare may be more informative.

The participants who endorsed barriers to health care, including being worried about immigration status, had higher levels of fear of deportation. These findings were supported by the findings in our qualitative interviews, in which some participants said that they would not go to the doctor even if they were sick for fear of being asked for legal documents. Together, our mixed method findings corroborate previous research demonstrating that fear of deportation is associated with less healthcare access (García, 2018; Hacker et al., 2012; Hacker et al., 2011, 2015). Furthermore, our scale was associated with barriers to accessing healthcare that were unique to immigrant Latinx MSM. Participants who endorsed barriers including not feeling safe and not being “out” regarding their sexual orientation also reported higher fear of deportation scores. We would expect, based on our qualitative findings, that those who were not open to sharing their sexual orientation might have more fear of discrimination, and, thus, more fear of returning to discriminatory environments in their countries of origin. This suggests that our scale picked up on fear of deportation experiences specific to the unique situation of immigrant Latinx MSM.

While our analyses were exploratory in nature, they provide initial support for the validity of our measure. Future research should further assess the psychometrics of the measure and its association with healthcare access in larger samples of immigrant Latinx MSM to confirm our findings. Given the recently reported national rise in HIV infections among Latinx MSM (Singh, Song, Satcher Johnson, McCray, & Hall, 2017), it is an important time to understand social and structural drivers of HIV for this population. Most of our participants were undocumented and from El Salvador, Honduras, and Guatemala. A recent study among Latinx MSM in California showed that those who originated from Central America were 2.31 times (CI: 1.41–3.79) more likely to be HIV positive than Latinx MSM from the United States, Mexico, and South America (Beymer et al., 2016). The authors suggested that health literacy, income, acculturation, and social factors may have been explanations for this finding.

However, our finding that Central Americans fear returning to discriminatory and violent countries of origin may also offer a potential explanation for higher HIV rates among this group of immigrant Latinx MSM. Our participants felt that their fear of deportation was more pronounced than other groups because they experienced persecution, including homophobic/transphobic violence, in their countries of origin. Those who fear deportation may be willing to take more risks, including engaging in sex work or having sex with risky partners, to stay in the United States. Those who are undocumented, for example, may be more likely to engage in sex work because they lack stable employment. Previous qualitative research has found that fear of deportation was a contributing factor toward immigrant Latinx transgender women remaining with abusive partners (Palazzolo et al., 2016), and intimate partner violence is a known HIV risk factor for MSM (Buller, Devries, Howard, & Bacchus, 2014). A recent study among Latinx gay and bisexual men attending a community-based clinic in Los Angeles, California demonstrated that experience of intimate partner violence was independently and significantly associated with HIV infection (aHR: 1.73; CI: 1.13–2.64) (Beymer et al., 2016). On the other hand, engaging in sex work or staying with an abusive partner may make immigrant Latinx MSM vulnerable to contact with law enforcement officials, which they avoid because of fear of deportation. Future studies among Latinx MSM should examine how risk-taking and experiences of discrimination are associated with fear of deportation to enrich our understanding of how minority stressors affect risk behaviors and HIV. These studies should also examine intimate partner violence and transactional sex as potential HIV risk factors for this population.

Compared to a previously published seven-item measure of fear of deportation (Arbona et al., 2010), our measure is more specific to immigrant Latinx sexual and gender minorities by including circumstances that may be more socially meaningful for these groups, including parties, places with many/few Latinxs, and drinking alcohol. García (2018) describes how restricted mobility affected the ability of undocumented Mexican women to freely enact their social roles, and we find a similar theme in our work. For immigrant Latinx MSM, avoiding parties where they could connect with others who share their same sexual orientation was socially isolating and resulted in worse mental health. LGBTQ Latinxs already have few places to socialize openly, and gay bars/discos/parties are some of those places. Avoiding these places thus created a barrier toward accessing their social networks, an important protective factor that fosters resilience among this population (Gray et al., 2015).

The social network and mental health consequences of fear of deportation for immigrant Latinx MSM are compounded by their intersectional identities. An intersectional perspective can demonstrate how health disparities arise from systems of oppression targeted toward people who belong to particular social categories (Bowleg, 2012). The immigrant Latinx MSM we interviewed were aware of how their intersecting social categories (including race/ethnicity, legal immigration status, and sexual orientation) made them more conspicuous and vulnerable to experiences of stigma and discrimination. Other studies among immigrant Latinx MSM and transgender women have found that such multi-faceted minority stressors resulted in unstable employment and housing, making them more vulnerable to depression, substance abuse, and HIV (Martinez et al., 2013, 2016; Palazzolo et al., 2016). For those who are HIV positive, HIV-related stigma (Logie, James, Tharao, and Loutfy (2011) adds to the layers of stigma they face.

Within the intersectionality and HIV literature, there has been insufficient attention to legal immigration status as a source of discrimination. However, there is a substantial non-HIV specific literature describing how the immigration system, including local and state policies, is historically linked to discrimination, and is a social determinant of health (Castañeda et al., 2015; Menjívar & Abrego, 2013; Ornelas, Yamanis, & Ruiz, 2020; Perreira & Pedroza, 2019). Future research could help clarify how intersectional stigma is related to HIV and other health outcomes for immigrant Latinx MSM.

Discrimination and an internalization of negative messages can result in harmful coping strategies and fewer protective behaviors, leading to poor health outcomes (Nakamura & Zea, 2010). For example, studies have highlighted the effects of immigrant-related stigma on depression (Hatzenbuehler et al., 2017; Martinez et al., 2013; Salas, Ayón, & Gurrola, 2013; Viruell-Fuentes, Miranda, & Abdulrahim, 2012). A study among immigrant Latinx transgender women (N = 38) demonstrated that being documented (vs undocumented) was inversely, significantly associated with depressive symptoms in a multivariable model (Yamanis, Malik et al., 2018). Recent studies have described the association between racial/ethnic and sexual identity discrimination in HIV outcomes for sexual and gender minorities (Logie et al., 2011; Mizuno et al., 2012; Pachankis et al., 2017). However, only one of these studies was among Latinxs and their immigration status was not reported (Mizuno et al., 2012). Among the few HIV-focused studies with immigrants, one found that structural stigma toward immigrants, measured by national policies in receiving countries, was associated with MSM migrants’ lack of sexuality disclosure during HIV testing (Pachankis et al., 2017). More research is needed on immigration-related stigma and discrimination, how it relates to fear of deportation, and the health consequences for Latinx MSM, who are at increased risk for HIV and depression.

The immigrant Latinx MSM in this study described fearing persecution in their countries of origin, which may make their fears of deportation more pronounced than those for migrants who come to the United States for economic reasons. Indeed, the notion of belonging to a persecuted group is one reason why MSM are eligible for legal asylum in the United States (U.S. CIS, 2015). Future research could explore, whether, compared to other Latinx, Latinx MSM experience an intensified threat of deportation because of their experiences of intersectional minority stress. Relatedly, a study among immigrant Latinx transgender women showed that obtaining permanent legal immigration status, such as becoming a US citizen, positively affected their mental health (Yamanis, Malik et al., 2018). In addition, permanent legal status can provide employment stability, access to health insurance and education, and legal gender identity change for transgender women (Palazzolo et al., 2016). Using an intersectional perspective that includes a focus on multiple minority statuses, including immigration status, can identify key social determinants of health that, if addressed, have the potential to alleviate health disparities.

Our research revealed several factors that lessen the harmful effects of fear of deportation, including engaging in a legal process to change their immigration status, immigrant-friendly policies, and support from LGBTQ- and Latinx-friendly non-governmental organizations. Interdisciplinary research in collaboration with immigration attorneys could explore how the process of applying for immigration relief affects fear of deportation. One study demonstrates the feasibility of immigration legal aid as a structural intervention that could reduce HIV risk for immigrant Latinx MSM (Yamanis, Zea et al., 2018). Interventions that lessen fear of deportation may have positive impacts on other health outcomes as well, and should be tested.

One limitation of our study was that it was completed in 2016, before the election of President Trump who has intensified immigration enforcement and anti-immigrant policies. In 2019, the Kaiser Family Foundation reported that one in five adults from low-income immigrant families expressed fear of enrolling in public benefit programs because it could risk their chances of getting a green card (Artiga, Garfield, & Damico, 2019). In February 2020, the DHS’s “public charge” rule went into full effect. This rule allows immigration officials to consider an individual immigrant’s access of federal health, housing, and nutrition programs as grounds for denying them immigrant status, including permanent legal residency and asylum (Kaiser Family Foundation, 2019). Thus, the associations we observed between fear of deportation and barriers to healthcare access may be more pronounced in current times. Others have described increased anxiety, even in the DC area, since the election (Roche, Vaquera, White, & Rivera, 2018). Further research on the themes described here should be conducted in the current environment.

We are also limited in the generalizability of our findings by the fact that DC is a relatively friendly area for LGBTQ immigrants. However, we included Latinx MSM from Virginia and Maryland, states with less friendly policies toward immigrants than DC. We recommend that future studies on fear of deportation compare the experiences of Latinx MSM living in diverse states representing varied environments for access to health insurance and supportive non-governmental organizations.

Furthermore, our approach was limited in that we did not conduct cognitive interviews to assess participants’ comprehension of the scale items. Cognitive interviews are structured conversations where interviewers probe participants to explain their rationale as they think through a response to a survey question (Grzywacz et al., 2009). While we did not use cognitive interviews, we did present the items to a community advisory board consisting of staff and health promoters who work with immigrant Latinx MSM. Moreover, the language we used for the items came directly from participants’ interviews. Our inductive approach to generating the items, however, may be seen as a limitation. Future research using a deductive approach could assess the extent to which these items are consistent with theory and other literature describing how fear of deportation affects immigrant Latinx MSM. A related limitation is that we did not compare our new measure to other existing measures of fear of deportation. Future studies should explore how our measure compares to other measures in the literature to assess whether they are associated and similarly predict healthcare access and barriers to healthcare.

In conclusion, we describe using mixed methods how fear of deportation limits access to healthcare for immigrant Latinx MSM, a group highly in need of HIV prevention services. We learned some lessons for clinics and programs. When programs offer safe spaces and opportunities to strengthen social cohesion among the undocumented, it can help reduce barriers to fear of deportation and enhance coping with discrimination. At a minimum, health programs should reassure their clients that they will not contact immigration authorities. Referrals to legal services are crucial for immigrant Latinx MSM to feel less deportation-related anxiety. Reducing fear of deportation will likely enhance access to healthcare for this population, and, thus help improve their uptake of HIV prevention and care practices.