TABLE 2—
Results of 23 Studies of Asylum Seekers' Exposure to Violence and Its Health Effects
| Study and Setting | Study Population | Study Design (Sample Design) | Violence Definition or Measure (Health Measure) | Female Gender, % (Age, Y, Mean; Range) | Asylum Seeker Origin | Violence Prevalence | Violence–Health Associations |
| Community | |||||||
| Ichikawa et al.,46 Japan | 55 adult asylum seekers served by legal NGOs | Cross-sectional (convenience sample) | HTQ | 3.6 (30.2; 19–50) | Afghanistan | Torture, 67.3%; combat situation,b 80.0%; murder of family/friend, 67.3% | … |
| Laban et al.,59 Netherlandsa | 294 adult asylum seekers in government registry | Cross-sectional (random sample) | HTQ | 35.4 | Iraq | Torture, 30.6% (asylum seekers within 6 mo of arrival, 24.5%; asylum seekers with > 2 y since arrival, 36.4%; crude association, P = .026) | … |
| Laban et al.,60 Netherlandsa | 294 adult asylum seekers in government registry | Cross-sectional (random sample) | HTQ (BDQ) | 35.4 | Iraq | … | Torture not a significant predictor of physical impairment or chronic physical complaints (multiple linear regressionc) |
| Mueller et al.,50 Switzerland | 40 community-dwelling asylum seekers in government registry | Case–control (random sample, age and gender matched with 40 failed asylum seekers) | HTQ | 5.0 (32.4; 18–51) | West Asia, 40.0%; Africa, 27.5%; Europe, 15.0% (countries not specified) | Torture, 47.5% (failed asylum seekers, 30.0%); murder of family/friend, 40.0% (failed asylum seekers, 32.5%) | … |
| Reception centers | |||||||
| Jakobsen et al.,47 Norway | 65 adult asylum seekers from 5 language groups | Cross-sectional (complete sample) | HTQ | 46.9 (33) | Middle East/North Africa,45.3%; Somalia, 46.9%; Balkans, 7.8%b | Rape, 12.5%; torture/witnessed torture, 67.2%; combat situation,b 71.9% | … |
| Masmas et al.,49 Denmark | 142 newly arrived asylum seekers in contact with Amnesty International | Cross-sectional (convenience sample) | IP (ICD-10) | 28.9 (32; 16–73) | WHO regions: eastern Mediterranean, 56.3%; West Pacific, 16.9%; Europe, 16.2%; Southeast Asia,14.8% | Torture, 45.1% (women, 22.0%; men, 54.5%); witnessed armed conflict, 58.5% (women, 56.1%; men, 59.4%) | Prevalence in tortured vs nontortured asylum seekers: headache, 75.0% vs 35.9%; back pain, 68.8% vs 28.2%; hearing loss/dizziness, 40.6% vs 20.5%; anxiety, 26.6% vs 3.8%; depression, 42.2% vs 10.3% |
| Goosen et al.,61 Denmark | Asylum seekers aged > 15 y, 2002–2007 (total 199 942 person-years) | Population study (data from government records of all deaths in asylum seeker centers) | … | 37.5 | UNHCR regions: Middle East/Southwest Asia, 31.1%; Central, East and Southern Europe, 26.1%; West, Central, and Southern Africa, 22.4% | Rate/100 000 person-years: suicides, 17.5 (men, 25.6; women, 4.0; age standardized RR = 7.3; 95% CI = 2.2, 23.7 ); asylum seekers vs Dutch citizens, men, RR = 2.0; 95% CI = 1.37, 2.83 ; women, RR = 0.73; 95% CI = 0.15, 2.07; hospitalized suicide attempts, 145.0 (men, 119.2; women, 188.2; RR = 0.63; 95% CI = 0.50, 0.77 ) | … |
| Immigration detention centers | |||||||
| Cohen,64 UK | All asylum seekers in prisons and removal centers | Population study (Home Office statistical bulletin asylum statistics 2005) | … | Among asylum seeker suicide victims, 5 | WHO regions: eastern Mediterranean, 29%; Africa, 13%; Europe, 12% | Suicides/100 000 among asylum seekers in reception centers and prisons, 1997–2005, 112.5; estimated self-harm risk among asylum seekers in centers, 2005–2006, 12.8% | … |
| Keller et al.48 US | 70 asylum seekers in NY, NJ, and PA | Cross-sectional (convenience sample) | HTQ | 20.0 (28; 15–52) | Africa, 77.1%; eastern Europe, 10.0%; Asia, 6.0%b | Torture, 74.3%; murder of family/friend, 58.6%; sexual assault,b 25.7% | … |
| Robjant et al.,54 UK | 67 asylum seekers in immigration removal centers and 49 community-dwelling asylum seekers | Cross-sectional (convenience samples) | PDS (HADS and IES-R) | 32.8 (32; 18–66) | 43 Source countries, not specified | Torture, 30.2%; nonsexual violent assault,b 37.9%; by known assailant, 9.5%; sexual assault,b 15.5%; by known assailant, 5.2%; childhood sexual abuse, 7.8% | Interaction between interpersonal trauma and detention duration on depression, P = .02; mean scores (SD) on measures of anxiety, 14.3 (4.5) vs 12.6 (5.5); PTSD, 71.0 (15.4) vs 63.6 (26.5) for detainees with vs without interpersonal trauma |
| Steel et al.,58 Australia | 14 adult asylum seekers from single ethnic group | Cross-sectiona (complete sample) | Study questionnaire | 64.3 (28–44) | … | Assaultsb by detention staff: physical violence, 85.7%; sexual harassment, 35.7%; violent threats, 92.9%; assaults by other detainees: sexual harassment, 42.9% | … |
| van Oostrum et al.,63 Netherlands | All asylum seekers detained in 2002–2005 (222 217 person-years) | Population-based study (data from death notifications) | … | 39.5 | Among deaths: Africa, 33%; Asia, 34%; Europe, 28%b | Rates/100 000 person-years (SMR vs Dutch citizens): suicide: men, 16.38 (SMR = 1.63; 95% CI = 1.02, 2.46); women, 3.41 (0.90; 95% CI = 0.19, 2.63); homicide: men, 3.72 (2.13; 95% CI = 0.95, 5.55); women, 3.41 (4.01; 95% CI = 0.83, 11.69) | … |
| Clinics | |||||||
| Asgary et al.,42 US | 89 asylum seekers torture victims in forensic clinic | Cross-sectional (convenience sample) | IP | 13.5 (34; 18–59) | WHO regions: Africa, 39.5%; Europe, 12.1%; Southeast Asia, 24.6% | Sexual torture: rape, 6.7%; genital shocks, 7.9%; fondling, 4.5%; genital cutting, 2.2% | … |
| Boersma,43 US | 21 asylum seekers in forensic clinic for torture documentation | Cross-sectional (convenience sample) | IP | … | … | Torture or other physical violence,b 76.2%; by known assailant, 23.8%; sexual violence,b 38.1% | … |
| Bradley and Tawfiq.,44 UK | 97 Kurdish asylum seeker torture victims in forensic clinic | Cross-sectional (convenience sample) | MFVT-UK guidelines (DSM-IV) | 3.5 (30; 16–64) | Turkey | Sexual assault, 6.2% (women, 30.0%, men, 2.4%) | Nonsignificant increase in PTSD or depression in female sexual assault victims (P = .07) |
| Edston and Olsson,45 Sweden | 63 female asylum seekers in torture clinic | Cross-sectional (convenience sample) | Clinical interview | 100.0 | Africa, 47.6%; Middle East, 23.8%; Americas, 14.3%b | Physical maltreatment,b 95.2%; torture,b 76.2%; rape/sexual abuse,b 76.2% | … |
| Eisenman et al.,22 US | 24 asylum seekers in 3 community clinics in Los Angeles, CA | Retrospective cohort (weighted cluster sample) | Clinical interview | … | Americas | Political violenced: among asylum seekers, 100%; among all immigrants, 53.9% | … |
| Eytan et al.,62 Switzerland | 319 adult asylum seekers at entry medical exam | Cross-sectional (convenience sample) | Clinical interview | 27.9 (24e; 15–63) | Kosovo | Personal violence,b 21.6%; violent death of relative, 10.0% | … |
| Neuner et al.,51 Germany | 32 asylum seekers with PTSD and PV history in mental health clinic | Pilot randomized controlled trial (convenience sample) | VCOV | 31.2 (31.4) | Turkey, 78%; Balkans, 13%; Africa, 9%b | Torture, 87.5%; violent assault by stranger, 62.1%; witnessed violence against family/friend, 90.6%; suicide plans/attempts, 40.6% | … |
| Piwowarczyk,52 US | 134 asylum seekers in refugee mental health clinic | Cross-sectional (convenience sample) | IP | 65.7 (34; 20–66) | Africa, 82%; Europe, 5%; Asia, 5%; Middle East, 4%; Americas, 4% | Torture, 84.3%; rape/attempted rape, 50.0% | Torture history associated with PTSD (AOR = 4.93; P = .03)f; crudely associated with depression (P = .037) |
| Piwowarczyk et al.,53 US | 65 asylum seekers seen in refugee mental health clinic in Boston, MA and 30 refugees as comparison group | Cross-sectional (convenience sample) | Clinical interview (food security survey) | 75.4 (33.7) | Africa, 78.5%; Europe, 10.8%; Americas, 6.1%; Middle East, 4.6% | Torture,b 86.2% (vs 56.7% of refugees; P = .002); family tortured,b 63.1% (vs 53.3% of refugees; P = .25) | Torture history associated with increased odds of postmigration hunger (AOR = 10.44; P = .032)g |
| Rogstad and Dale,55 UK | 43 asylum seekers in genitourinary clinic | Cohort (convenience sample) | Clinical interview | 48.8 (27.9; 15–56) | … | Sexual violence,b 44.2% (women, 76.2%; men, 13.6%; age- and gender-matched White British patients, 0.0%) | … |
| Sanders et al.,56 US | 58 asylum seeker torture victims in forensic clinic to document torture | Cross-sectional (convenience sample) | IP | 29.3 | Sub-Saharan Africa, 67%; southern Europe, 12%; North Africa, 10% | Any beating, 91.4%; any sexual abuse during torture, 24.1% (64.7% of women, 7.3% of men) | … |
| Silove et al.,57 Australia | 33 East Timorese asylum seekers in refugee health clinic | Cross-sectional (convenience sample, retrospective chart review) | HTQ (CIDI) | 48.4 (44; 23–67) | East Timor | Torture, 43.4%; rape/sexual violence, 26.1%; combat, 56.5%h | … |
Note. AOR = adjusted odds ratio; BDQ = Brief Disability Questionnaire; CI = confidence interval; CIDI = Composite International Diagnostic Interview; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; HADS = Hospital Anxiety and Depression Scale; HTQ = Harvard Trauma Questionnaire; ICD-10 = International Classification of Diseases, 10th Revision; IES-R = Impact of Event Scale–Revised; IP = Istanbul Protocol; MFVT-UK = Medical Foundation for Victims of Torture–UK; NGO = nongovernmental organization; PTSD = posttraumatic stress disorder; PV =physical violence ; RR = rate ratio; SMR = age-standardized mortality ratio; UNHCR = United Nations High Commissioner on Refugees; VCOV = Vivo–Checklist of Organized Violence; WHO = World Health Organization. Ellipses indicate data not available.
a
Same study reported in in 2 articles.
b
Not defined.
c
Model included age, gender, psych. diagnoses, and social difficulties.
d
Interpersonal trauma: sexual violence and nonsexual physical violence or torture; political violence: described as “many types of violence such as war, torture, forced disappearances, and extrajudicial killings.”25(p627)
e
Median.
f
Adjusted for education, employment, current medical care, and other traumatic exposures.
g
Adjusted for age, gender, education, current housing, language ability, self-reported health, employment, and work authorization.
h
Prevalence reported among 23 of 33 participants; 10 participants not asked about traumatic exposures,