Considerations for Working with LGBTQIA+ Refugees
- 1 Introduction
- 2 Terminology
- 3 Treatment of LGBTQIA+ People
- 4 Common Health Issues
- 5 Trauma Unique to Members of LGTBQIA+ Communities
- 6 Treatment Principles
- 7 Centre for Victims of Torture Experience of Working with LGBTQIA+ Community
- 8 LGBTQIA+ Refugees Stories
- 9 Summary
- 10 Resources
- 10.1 Introduction to LGBTQ+ Competency Handbook for Physical Therapy
- 10.2 Healing Pain Podcast Episode 138 - LGBT Inclusion In Physical Therapy
- 10.3 National LGBTQIA+ Health Education Center
- 10.4 American Physical Therapy Association
- 11 References
Some say that sexual orientation and gender identity are sensitive issues. I understand. Like many of my generation, I did not grow up talking about these issues. But I learned to speak out because lives are at stake, and because it is our duty under the United Nations Charter and the Universal Declaration of Human Rights to protect the rights of everyone, everywhere. UN Secretary General, Ban Ki-moon to the Human Rights Council, 7 March 2012 This quote from 2012 may reflect the feelings of many, that sexual orientation and gender identity are sensitive issues to discuss and to learn about. However, our LGTBQIA+ patients are fellow community members and are counting on us to provide optimal and respectful physiotherapy care for them. The quote below, also from Ban Ki-moon, former Secretary General of the UN, is an impassioned plea for fair treatment of all, and for preventing discrimination based on sexual orientation and gender identity. He brings up important issues, that in many societies and cultures, disapproval of LGTBQIA+ community members is very powerful, but that discrimination and mistreatment must be prevented and rejected.
As men and women of conscience, we reject discrimination in general, and in particular discrimination based on sexual orientation and gender identity. When individuals are attacked, abused or imprisoned because of their sexual orientation, we must speak out… Today, many nations have modern constitutions that guarantee essential rights and liberties. And yet, homosexuality is considered a crime in more than 70 countries. This is not right. Yes, we recognize that social attitudes run deep. Yes, social change often comes only with time. But let there be no confusion: where there is tension between cultural attitudes and universal human rights, rights must carry the day. Personal disapproval, even society’s disapproval, is no excuse to arrest, detain, imprison, harass or torture anyone, ever. UN Secretary-General Ban Ki-moon, 10 December 2010 
The United Nations Speaks Out: Combating Discrimination based on Sexual Orientation and Gender Identitywbrochure,hich is available in Russian, English, Spanish and French, explains that under Article 26 of the International Covenant on Civil and Political Rights “comprises also discrimination based on sexual orientation.” Powerful quotes from world leaders, including the Ban Ki-moon quote from 2010, are included. 
Estimates vary country by country and in many countries where being a member of the LGTBIA+ community is illegal, it is difficult to get accurate estimates of percentages of people who identify as being LGBTQIA+. In a study in the United States by Newport, 4.5% of individuals identify as being lesbian, gay, bisexual, or transgender.  Members of the LGBTQIA+ community also have higher rates of heart disease and diabetes as well. A webinar “Diabetes, Heart Disease, and LGBTQIA+ Populations” from the National LGBTQIA+ Health Education Center at the Fenway Institute, as well as an educational brochure called “Diabetes Prevention and Management for LGBTQ People”  by the same institute are excellent resources for health care professionals. Being a member of the LGTBQIA+ community is illegal in many countries, including 35 African countries and participating in private, consensual same-sex activity can carry the death penalty in eleven countries. Human Dignity Trust tracks legal issues related to LGBTQIA+ community and provides resources and legal support to defend the human rights of LGBTQIA+ people around the world. 
Some studies show that alcohol abuse rates are three times higher among members of LGTBQIA+ community members than heterosexual community members, smoke cigarettes at 63% higher rates and have elevated risk for depression, anxiety and suicide. There are also typically higher rates of illicit drug use than the general population among LGTBQIA+ individuals. 
It is important to understand appropriate terminology to use for gender identity and sexual orientation, as well as appropriate pronouns to use, especially when working with gender nonbinary and transgender clients. There are many clearly written guidelines to assist with terminology.  While even well-intentioned physiotherapists can make mistakes in how they refer to clients, it is crucial to apologise when mistakes made and to commit to continuing to grow and to learn. In addition, what is acceptable in one country or language may be offensive in another context, so it is important to learn what is acceptable in the communities in which you work.
Describes sexual attraction only, and is not directly related togender identity. The sexual orientation of transgender people should be defined by the individual. It is often described based on the lived gender; a transgender woman attracted to other women would be a lesbian, and a transgender man attracted to other men would be a gay man.
Term used to describe female-identified people attracted romantically, erotically and/or emotionally to other female identified people
Term used in some cultural settings to represent males who are attracted to males in a romantic, erotic and/or emotional sense.
A person who is physically and/or sexually attracted to more than one gender. This attraction does not have to be equally split between genders and there may be a preference for one gender over others.
An umbrella term which embraces a matrix of sexual preferences, orientations, and habits. “Queer” used to be used almost exclusively as a slur but now some members of the LGTBQIA+ community use it as a term of pride. In some countries, the term, “queer” is used commonly, but in others, it is not used.
Someone who does not experience sexual attraction, or who has a little or no interest in sexual activity.
Someone whose sex assigned at birth is difficult for a doctor to categorize as either male or female. A person whose combination of chromosomes, hormones, internal sex organs, gonads, and/or genitals differs from one of the two expected patterns.
A person’s sense of being masculine, feminine, or another gender. More and more, it is realized that gender identity and gender expression, are expressed along a continuum.
Has historically been referred to as sex assigned at birth, based on assessment of external genitalia, as well as chromosomes and gonads. In everyday language is often
Used interchangeably with gender, however there are differences, which become Important in the context of transgender people. Due to commonly being subdivided into ‘male’ and ‘female’, this category does not recognise the existence of intersex bodies.
A person whose gender identity differs from the sex that was assigned at Birth. May be abbreviated as” trans.”A transgender man is someone with a male gender identity and who was assigned female identify at birth; a transgender woman is someone with a female gender identity who was assigned male identity at birth. A non-transgender person may be referred to as cisgender (cis=same side in Latin).
The outward manner in which an individual expresses or displays their gender. This may include choices in clothing and hairstyle, speech and mannerisms. Gender identity and gender expression may differ; for example a woman (transgender or non-transgender) may have an androgynous appearance, or a man (transgender or non-transgender) may have a feminine form of self-expression.
Gender Non-Conforming (GNC)
Is an umbrella term for anyone whose gender expression does not match societal expectation (Similar term: Gender Variant)
The idea that there are only two genders – male/female or man/woman and that a person must be strictly gendered as either/or.
A gender variant person whose gender identity is neither male nor female, is between or beyond genders, or is some combination of genders. Can include a political agenda to challenge gender stereotypes and the gender binary system. (Similar term: Gender Non-Binary)
Outdated Terminology to Avoid
Transvestite or Transgendered: Instead use transgender
Homosexual; Instead use gay, lesbian or bisexual
Treatment of LGBTQIA+ People
In many countries, LGBTQIA+ individuals face intense discrimination and the threat of violence and persecution, at times even from family members. Alessie et al  describes emotional, sexual and physical abuse of children who identify as LGBTQIA++ by family, schoolmates, teachers and religious leaders in their country of origin. Oftentimes, when they would report the abuse to others, they would be further punished and victimised. At times, they would be made to go to counselling or to “conversion therapy”, which is considered to be a form of torture by the United Nations.  Those who are intersex, often endure human rights violations, starting from infancy, where in some countries their family members and physicians choose a gender for the infant or young child, obviously when the child is too young to determine their gender, as per the article with links below. 
Common Health Issues
There is a large body of research showing that LGBTQIA+ clients have increased incidence of many non-communicable diseases. Research  shows that hormone therapy for both transgender men and women may increase triglycerides and that transgender men on testosterone often have increased LDL and decreased HDL cholesterol. Transgender people appear to have an increased risk of myocardial infarction and death due to cardiovascular disease, and transgender men on hormonal therapy typically have increased systolic blood pressure and at times have elevated diastolic blood pressure.
Research shows that lesbians and bisexual females are more likely to be overweight or obese as well as to be less likely to get preventive services for cancer.  LGTB older adults are five times less likely to have accessed health and social services due to fear of mistreatment and stigmatisation. This, in term, can lead to them having undiagnosed and untreated chronic health conditions such as hypertension, diabetes and various forms of cancer. LGBT youth are 2-3 times more likely to attempt suicide that heterosexual youth.
Gay and transgender individuals have higher rates of HIV/AIDS than the general population. Refugees living in urban settings without access to adequate services and means of making money, as they are often not legally allowed to work, are at times forced into trading sex for food or money which also increases their risk of contracting HIV. Physiotherapists can be important members of the health care team in helping to educate clients about decreasing HIV transmission rates, through the following:
- Correct and Consistent Condom Use
- Anti-Retroviral Therapy
- Reducing Risky Behaviours
In addition, at times, referrals to social work and to other INGO’s or NGO’s can be crucial to help to reinforce all three recommendations above. For example, if someone does not have enough food due to lack of money or access and is not taking their anti-retroviral medications because they are not to be taken on an empty stomach and make them feel sick, it could be crucial to refer to organisations which can provide food or some money to purchase food. 
Trauma Unique to Members of LGTBQIA+ Communities
Nearly all refugees have been through many traumatic experiences and some have been tortured. Many have lost family members and friends to war or other conflict related violence. What is unique to members of the LGBTQIA+ refugee community is that many of them have been bullied, verbally and sexually abused since childhood, if they were perceived as being “different” or “too feminine” for a boy or “too masculine” for a girl, or caught performing sexual activity with someone of the same gender. 
Also, unlike other refugees, LGBTQIA+ community members are often persecuted and even killed by family members once their sexual identity is discovered. Unlike other refugees, LGBTQIA+ individuals often need to flee from countries where there is no civil war and where torture and other human rights abuses against heterosexual individuals may be uncommon. LGBTQIA+ clients can be permanently rejected by all family members, friends and by their country and community at large.  In addition, LGBTQIA+ refugees are often re-victimized once they arrive in hosting countries, which are often (80% of the time) in low and middle income countries, many of which have laws in place banning homosexuality and a great deal of persecution against them. 
Also, as will be mentioned under” the role of social work “section to follow, the financial, housing and other needs of LGBTQIA+ refugees may be even greater as a whole than the needs of other refugees, whether in urban or refugee camp settings, because of the severe homophobia and violence against LGBTQIA+ community members. Often, if an LGBTQIA+ refugee reports victimisation to the police, they may be arrested for being LGTBQIA+, and at times experience gender based violence while in prison. 
At times, LGBTQIA+ refugees don’t feel safe seeking out medical care or other services, as they do not know if the organisation will be welcoming to them and if they will feel and be safe.  A role of physiotherapists and other health care professionals is to contact different organisations and ask questions in order to get the sense of whether they are LGBTQIA+ friendly, and if there is a certain staff member at the organisation who has special sensitivity or interest in working with this population. In Nairobi, the Centre for Victims of Torture arranged a resource fair for LGBTQIA+ clients, where members from organisations providing resources for housing, education, livelihood, health care including HIV prevention and treatment and legal services were present and could meet informally with staff members, provide brochures with addresses and phone members, and help the clients to feel comfortable. The event was well attended and afterwards, many clients reported that they felt safer reaching out to the NGO’s for support as they felt that they knew that at least one staff member was supportive and welcoming to them.
While many refugees are subjected to sexual torture, likely only LGBTQIA+ clients are subjected to “corrective rape”, which is committed in an attempt to change ones sexual identity.  Types of torture experienced by LGBTQIA+ clients include electric torture to genitals, being stoned, and beaten on their genitals. 
How to Ensure Safety, Comfort and Acceptance in Groups
When possible, it is ideal to have separate physiotherapy groups for LGBTQIA+ clients if the clients have a preference for being with other LGBTQIA+ clients for their safety and comfort level. At the Center for Victims of Torture in Nairobi, which is the only program where they have specialised physiotherapy services for LGBTQIA+ clients, members of this community are typically given the choice between being in an LGBTQIA+ Specific Group or a group with others of their gender. Whenever the LGBTQIA+ client is in a non-specific group, it is crucial that the physiotherapist or other health care providers do not disclose the sexual identity of the client. Many times, non-LGBTQIA+ refugees may be quite homophobic and the LGBTQIA+ clients may not feel safe and not choose to come to physiotherapy services in this case.
Need to Work with Trauma Informed Care
It is critical that physiotherapists work with LGBTQIA+ clients in respectful and through the use of trauma informed care. This includes having choice of what positions to receive physiotherapy, door open or closed, parts of body to work on, etc. Clients should be touched only with permission. Choice should be given about whether any clothing is removed. Some clients, especially those who may be transgender, and who are in some form of transmission, may not feel comfortable exposing their bodies. Invitational language should be used, with more of a tone of suggestion and offering rather than commanding, so as to avoid re-traumatizing clients.
Specialised Needs for Transgender Clients
Transgender clients may have special needs which physiotherapists can address. For example transgender men may bind their breasts tightly by tape or bandages to minimize the appearance and size of breast tissue. At times, there can be pectoral pain from the pressure of the compression, which may reduce from the use of heat, trigger point massage and stretches.  Many transgender refugees will not have access to hormonal therapies or to surgeries for gender affirmation/gender confirmation due to funding or other access issues. Approximately 80% of refugees live in lower or middle resource countries where these procedures may not be available even for nationals of that country who have financial means. There are four possible steps which transgender people may choose to or be able to access; 
For those who have surgery to add or to remove breast tissue, there may be pain or swelling which can also respond well to exercise, massage and to other treatments. There can also be pain or swelling in the genital area, either from compression, wearing tight garments to minimize the size of the penis or from surgeries to alter and to change the genitals. Exercise, cold or other treatments can help with these concerns as well. In addition, after transgender clients have “bottom surgery” of their genitals to affirm their gender, physiotherapists have a more crucial role in neuromuscular retraining of pelvic floor muscles, teach clients to do soft tissue/scar tissue work, and to provide patient education about the management of healing tissue and health for life. 
In the United States Transgender Survey, which was conducted in 2015, 54% of respondents reported that they were verbally harassed, 24% physically assaulted and 13% sexually assaulted while in school. In addition, 30% of reported having been homeless at some point of their life, with 29% of transgender respondents reporting living in poverty, as opposed to 14% of the general population. In addition, 39% of transgender individuals reported having experienced serious psychosocial distress in the month prior to answering the survey questions, compared to only 5% of the general US population. Forty percent had a lifetime history of suicide attempt as compared to 4.6% of the general population. Fifty five percent or transgender individuals who were attempting to obtain insurance funding for gender affirming surgery were denied funding, as were 25% of those who were trying to obtain funding for hormonal therapy. The study showed that among more than 2200 transgender clients, rates of Post Traumatic Stress Disorder, Depression and Anxiety went down for those who perceived themselves to be in supportive communities and for those who had started to have gender confirmation procedures, such as the use of hormones or surgeries. 
Another crucial role for the health care team caring for transgender clients is to perform an “anatomical inventory”, which is updated on a regular basis, in order to help to direct preventative screening. The body parts on the inventory include the penis, testes, prostate, breasts, vagina, cervix, uterus and ovaries.  Examples were given of transgender men getting breast cancer which was quite advanced upon detection, as medical staff had not advised them to have screening of their remaining breast tissue and transgender women developing prostate cancer.  As physiotherapists, we can bring up these topics with our clients and encourage them to seek out referrals to needed health screenings from their physicians.
Authors of the survey recommended that all patients be screened for sexual orientation and gender identity in order to ensure more appropriate care. While patients may initially feel unsafe about answering these questions, one possible way to explain is to say “We have begun to ask patients about their sexual orientation and gender identity so that we can provide optimal, affirmative care.” As with all clients, it is important not to assume gender identity or sexual orientation. For example, rather than saying, “Mrs. Lee, what would you like to focus on in physiotherapy today?” One could say “What would you like to focus on in physiotherapy today?” Or, rather than asking, “Do you have a husband or wife whom I could teach to do these stretches/manual techniques with you?” Instead saying “Do you have a partner whom I could teach these activities to?“ 
It should be recognized that gender is increasingly described as being on a continuum, rather than just having two genders on opposite ends of this continuum. Some transgender individuals do not fully identify with male or female gender but as something different or even undefined. It is crucial to ask clients what they prefer to be called, and to simply apologize if they call the person by the wrong name or pronoun. Many transgender individuals (45%) report that they have needed to educate their medical professionals about how to work with transgender people. It is important to not make comments such as the following: “Wow! You look just like a real woman.” It is also crucial for co-workers to feel comfortable in gently correcting those whom we work with in order to help to sensitize them. For example, when hearing a colleague refer to a patient by the wrong name, one could say “My understanding is that this patient prefers to be called “Jane” and not “John.” If hearing a colleague making fun of a transgender client after they leave the clinic, one could say “those kinds of comments are hurtful to others and do not help to create a respectful work environment.”
Centre for Victims of Torture Experience of Working with LGBTQIA+ Community
Developing Group TreatmentBefore the Centre for Victims of Torture started to offer specialised services for members of the LGBTQIA+ community, all clinical staff members received training, watched videos and had discussions about the specialised needs of LGBTQIA+ community members. There were staff members who originally were not comfortable working with this population, and most staff had never learned about these specific needs before and few had worked with LGBTQIA+ community members previously.
It may be ideal to invite staff from other organisations who have expertise in working with LGBTQIA+ clients to lead the trainings and to sensitive the staff to be prepared to provide optimal physiotherapy care for LGBTQIA+ clients. The Pan-Commonwealth Human Rights, Gender & Sexual Diversity Training Toolkit  includes eight modules which are designed to sensitive colleagues and members of the public to:
- Increase participants’ knowledge of the rights and dignity of LGBTQIA+ people
- Increase participants’ understanding of the challenges faced by LGBTQIA+ people in accessing public services as a a result of homophobia, biphobia and transphobia
- Challenge participants’ existing biases and prejudices to enable better support of the community: and
- Build the participants’ capacity to plan and implement training with other public sector workers. 
Another international organization, Organization for Refuge, Asylum and Migration (ORAM), which is a subsidiary partner of Alight, is an international organisation that advocates for sexual and gender minority asylum seekers and refugees fleeing persecution and violence and provide a wide range training materials and other resources which can be very useful. 
Because working with LGBTQIA+ community members became a very important part of the counseling and physiotherapy work, especially in Nairobi, and because it is crucial that all staff members respect and can work effectively with LGBTQIA+ clients, interview questions have been added about previous experience and comfort level working with this community.
Role of Social Work
In many low or middle income countries, where between 80 and 85% of refugees live, there is a great deal of homophobia and laws formalizing discrimination.  Members of the LGBTQIA+ refugee community are often faced with eviction once their LGBTQIA+ status is discovered, so they may need urgent assistance from social work for housing, so that they do not become homeless, especially during the current global pandemic. They may also have severe financial struggles. Often, if they are involved with livelihood activities such as selling goods in the market or hawking them, and their LGBTQIA+ status is discovered, their items are destroyed or their businesses are boycotted. Social workers can refer people to NGO’s or INGO’s for financial assistance or information about other livelihood programming. In addition, social work staff can refer those victimized by the police or soldiers for legal assistance. Finally, one of the other roles of social work is to refer people for emergency medical assistance. For members of the community who are HIV+ or who have other chronic medical conditions and who are having difficult accessing affordable or free medical care, having a timely referral by social work can be the difference between life and death.
For many years, the Center for Victims of Torture program in Nairobi did not have a social worker on staff, so the physiotherapy and counselling staff formed close connections with NGO and INGO partners in the field and facilitated referrals independently.
Aftercare Group for LGBTQIA+ Refugees
After several years of leading LGBTQIA+ specific physiotherapy and counseling groups in Nairobi, the Center for Victims of Torture sought out funding and decided to create a specialised interdisciplinary aftercare group for those clients who had completed counselling and often physiotherapy, who continued to have significant issues and needs. As described above, members of the LGBTQIA+ refugee community living in Kenya struggle with issues which are unique to them, and were deemed to need additional support.  Before the COVID-19 pandemic struck Kenya, two groups of 10-14 participants each were lead three times per year, in two different geographic locations in Nairobi in order to be accessible to the most people possible.
The aftercare model was developed based on research about issues and needs of LGBTQIA+ Communities around the world. An article by Lytle et al  about the use of positive psychology, emphasises the need for those working with members of the LGBTQIA+ community to help individuals and groups to identify positive coping mechanisms and to identify and utilise individual character strengths. While physiotherapists obviously do not provide mental health services, it is still important for physiotherapists to emphasize strengths of the client when prescribing home programs, and when encouraging home adherence to pain reduction and other physiotherapy programs.
Over the course of the Aftercare Program’s six weekly sessions, the following topics are addressed:
- Introductions, assessment, and acknowledging continuous trauma in the LGBTQIA+ Community; 
- Safety and how to make choices that support safety and coping skills in the face of continuous trauma and homophobia;
- Healing from shame and victim blaming;
- Concept of a chosen family and how to mitigate family and community of origin rejection and the ambiguous loss that comes with it;
- Reconstructing identity and meaning by acknowledging the different place in identity development, internal conflicts, and working to find new meaning; and
- Navigating access to services and resources in the context of discrimination and homophobia.
An essential part of the aftercare program is the training and development of peer facilitators from the LGBTQIA+ Refugee Community who had received both counselling and physiotherapy. These individuals reach out to potential participants and explain the aftercare program, co-lead the sessions, and are available to support clients between sessions as needed. As they are members of the same persecuted community, the peer facilitators have a great deal of credibility and connection with the aftercare group members.
Counsellors, physiotherapists and a social worker are all involved in leading the groups. Physiotherapists lead portions of the sessions involving mind-body connections, breathing, grounding, sleep and pain reduction and about ways to incorporate exercise into daily routines.
At the first and last sessions, a brief assessment is completed with each participant by a counsellor, peer facilitator or physiotherapist. This includes questions which are taken from existing evaluation tools used with LGTBQIA+ clients about self-acceptance and self-esteem, social support and connectedness, identity and access to resources. A majority of clients show improvement in at least several of the sections.
Clients are invited to share examples of the negative or discriminatory actions which they have experienced in order for them to be acknowledged and processed, followed by sharing examples of their strength. The groups also brainstorm strategies for resisting brutality from the police and others, and integrating with the host community.
Participants tend to be engaged, contributing and sharing their experiences within the group, and appreciative of the opportunity to participate in the program. Each participant sets personal goals and strategises ways to develop coping mechanisms to address their individual challenges. Prior to this activity, many clients stated that they had very long-term goals, which were beyond their control and ability to influence. For example, many clients’ goals revolved around being resettled in a third country. Clients were excited to learn how to set realistic, achievable goals to improve their current lives in Nairobi and see progress and success in the short-term. Many of the participants form supportive connections with others in the groups which continue after the six sessions are over, and from these connections feel less isolated.
The following Webinar from July 23, 2020 (52), about reclaiming identity among LGBTQIA+ survivors of torture and other forms of trauma, includes presentations from the Centre for Victims of Torture Social Worker, Physiotherapist, Mental Health Clinical Advisor, Funder, and the UN Independent Expert on Protection Against Violence and Discrimination Based on Sexual Orientation and Gender Identity, includes stories about some of the beneficiaries of the Aftercare Programme.
Following are four blog posts by the Center for Victims of Torture about the Aftercare Group, which can give a more personal view of the problems facing LGTBQIA+ refugees in Nairobi.
- From Trauma to Hope: Extending Care to Refugees in Nairobi: Blog by Psychotherapist Trainer Elizabeth Mbuti Muli, October 24, 2017, about the experiences of a gay man from Uganda in both his home country and in Kenya.
- Peter's Story: Blog by Center for Victims of Torture Service Users experiences, October 20, 2017
- Aftercare - Ongoing Support for the LGBTI Refugee Community at CVT Nairobi: Blog describing the LGTBI Aftercare Program, August 24, 2018, with an emphasis on the multidisciplinary care
- Innovative New Aftercare Program Helps LGBTI Survivors in Nairobi: Blog about the LGTBI Aftercare Program after had been through many cycles of work, June 5th 2018, with description of the role of peer facilitators.
Interview with a lesbian client who now works at the Centre for Victims of Torture as a peer facilitator of her experiences accessing services. From her experience she compliments the Center for Victims of Torture for creating a safe space for this community and recommends that other organisations reach out to something that she would like other facilities dealing with LGBTQIA+ clients to emulate. LGBTQIA+ individuals feel safer when they recognise the environment as welcoming. The peer facilitator suggests using pictures that have LGTBQIA+ flags, together with words from a physiotherapist that convey acceptance and safety, which can in turn encourage clients to open up about their past history. Creating and maintaining welcoming physiotherapy spaces will promote LGBTQIA+ clients’ journey of healing.
Members of the LGBTQIA+ community also need a high level of confidentiality and assurance before they feel safe to share their histories and to be willing to be examined by physiotherapy. Many clients are living in unsafe environments where there is a lot of stigmatization. If the clients have a negative experience at medical clinics and other spaces, this may hinder them from seeking physiotherapy or other services in the future. Some clients may need reassurance that if there are security cameras in a building, that they are not there to record them, but only there to try to deter criminal activities.
The peer facilitator shared that it is important for the physiotherapist not to provide undue special attention for LGBTQIA+ clients but to treat them with the respect and kindness which they would provide to any client. She felt that special attention or any type of condescending tone may reduce their self-esteem.
Having received physiotherapy services she now feels empowered. She had had severe back pain, joint stiffness, fatigue, poor sleep and headaches. This was affecting her ADLS but now she can do a lot of work easily, which has made her develop the habit of doing exercises and this has also improved her sleep hygiene. It is for this reason that she started looking for a job when she finished receiving counselling and physiotherapy. She gained access to employment through the Center for Victims of Torture as a Peer Facilitator. This peer facilitator reports that she now feels more comfortable interacting with other, and is pleased to give back to the LGBTQIA+ Community through her work.
The LGBTQIA+ Community often has difficulty in accessing needed services especially if they live outside of Nairobi, or outside of large urban areas in other countries. Often members of the LGBTQIA+ Community have many symptoms but because of financial challenges they cannot afford to access needed services. Some organizations, such as the Center for Victims of Torture, provide free services, such as physiotherapy and counselling, while others have fees for services. Some potential clients lack the knowledge of the role of physiotherapy and how it can play an integral part of their healing process from pain and other injuries. Many community members need a lot of sensitisation about how physiotherapy services can help to decrease chronic pain and to improve mobility even if the survivors have been refugees for many years and experienced traumatic events many years ago. Some LGBTQIA+ Refugees have the awareness of the role of physiotherapy and the funding for needed payment for physiotherapy services, but they may have difficulty accessing welcoming physiotherapists. The interviewee mentioned that many LGBTQIA+ Community members fear discrimination, particularly those from the transgender, so they prefer to stay at home and not to attend physiotherapy. For all of these reasons, it is crucial that physiotherapists have adequate training, both in their initial training, and on an ongoing basis, on how to work optimally with members of the LGBTQIA+ community. 
LGBTQIA+ Refugees Stories
It is crucial that physiotherapists treat LGBTQIA+ refugees with the same dignity and respect afforded to other clients. Physiotherapists need to endeavour to create an open and accepting atmosphere when working with members of the LGBTQIA+ community so as to avoid re-stigmatisation of these clients in order to help them to heal from pain and injuries. There are recommended ways for physiotherapists and others working with LGBTQIA+ clients to feel welcome in clinic spaces. It is crucial that as with all clients, confidentiality is closely guarded and that a clients’ LGBTQIA+ status is never disclosed to others, as they may not have shared this information with others.
- Members of PTPROUD, a committee of the Health Policy and Administration Section of the American Physical Therapy Association, created a 27-page guide specifically for physiotherapists for working with LGBTQIA+ clients. The guide, is written by physiotherapists who are LGBTQIA+ community members, so have both and understanding of the specialised needs of LGBTQIA+ individuals and a lived experience in how they have been treated. The guide includes reflection questions and part of the aim is for physiotherapists to respect and not just to tolerate those who are LGTBQIA+. A survey of physiotherapists in the United States of America showed that only 15% reported respecting their LGBTQIA+ patients.
- This is a podcast featuring a transgender physiotherapist, Chris Condran, speaking about inclusion in the physiotherapy profession, which describes inclusion from both the perspective of the physiotherapist and the patient.
- The National LGBTQIA+ Health Education Center provide a wide range of free learning resources including webinars , publications , learning modules  and videos  in relation to working with LGBTQIA+ clients featuring ways to improve service delivery and care.
- LGBT Voices: Perspectives on Health Care is a 13 minute long video by the National LGBTQIA+ Health Education Center about improving medical care for LGBTQIA+ patients
American Physical Therapy Association
- To Be All of Me is a blog written by Erin Kingham, an American physiotherapy student who is a lesbian. 
- HHS Discrimination Decision Runs Counter to Profession's Values is an editorial about the need for non-discrimination when working with LGTBQIA+ patients.
Do Ask, Do Tell: Toolkit for Collecting Sexual Orientation & Gender Identity Information in Clinical Settings
- This toolkit, developed by the Fenway Institute, provides specific sexual orientation and gender identity questions that are recommended by national LGBT organizations and which have been shown to work with diverse patient populations served by community health centres in different parts of the United States. It also describes how to use the data to support clinical processes, and how to train clinical staff to interact with LGBTQIA+ patients in ways that are affirming and welcoming. Finally, the toolkit highlights other resources that health care providers can use to offer culturally and clinically competent care that reflects their LGBTQIA+ patients’ unique needs.
- Free art campaign designed to increase bathroom safety for transgender and gender nonconforming people. Provide a range of printable posters that can be used as bathroom door signs, which are gender inclusive. 
- UN Secretary-General, Ban Ki-moon. Ending violence and criminal sanctions based on gender identity or sexual orientation. United Nations Human Rights Council. 7 March 2012.
- UN Secretary-General, Ban Ki-moon. Confront prejudice, speak out against violence. United Nations Human Rights Council. 10 December 2010.
- OHCHR. The United Nations. The United Nations Speaks Out: Combatting Discrimination based on Sexual Orientation and Gender Identity. 2011. Available from:https://www.ohchr.org/Documents/Issues/Discrimination/LGBT_discrimination.pdf [Accessed 25/09/2020]
- Newport F. In U.S., estimate of LGBT population rises to 4.5 percent. Gallup. 2018. Available from:Https://news.gallup.com/poll/234863/estimate-lgbt-population-rises.aspx [Accessed 25th September 2020]
- UCSF Transgender Care. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People. Available at: https://transcare.ucsf.edu/guidelines [Accessed 25th September 2020]
- Irwing MS. Cardiovascular Health in Transgender People. Rev Endocr Metab Disord. 2018 Sep:19(3):243-251. Available from: https://doi.org/10.1007/s11154-018-9454-3 [Accessed 25th September 2020]
- National LGBT Health Education Center-A Program of the Fenway Institute. Diabetes prevention and management for LGTBQ people. June 2019:1-14. Available from: https://www.lgbthealtheducation.org [Accessed 25th September 2020]
- Human Dignity Trust. Map of Countries that Criminalise LGBT People. Available from: https://www.humandignitytrust.org/lgbt-the-law/map-of-criminalisation/ [Accessed 25th September 2020]
- Amnesty International UK. Mapping Anti-Gay Laws in Africa. Available from: https://www.amnesty.org.uk/lgbti-lgbt-gay-human-rights-law-africa-uganda-kenya-nigeria-cameroon [Accessed 25th September 2020]
- Reisner SL, Pardo ST, Gamarei KE, White Hughto JM, Pardee DJ, Deo-Maier CL. Substance use to cope with stigma in healthcare among US female-to-male transmasculine adults. LGBT Health 2015;2(4):324-332. Available from: https://doi:10.1089/lgbt.2015.0001 [Accessed 25th September 2020]
- Office of Disease Prevention and Health Promotion. Lesbian, Gay, Bisexual, and Transgender Health. 2016. Available from: https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health [Accessed 25th September 2020]
- Ard KL, Makadon HJ. Improving the health care of lesbian, gay, bisexual, and transgender (LGBT) people: Understanding and eliminating health disparities. The National LGBT Health Education Center; 2016.
- Makadon HJ, Mayer KH, Potter J, Goldhammer H. Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health 2ndEdition. 2015; American College of Physicians, Philadelphia, PA.
- TED. This Is What LGBT Life Is Like Around the World | Jenni Chang and Lisa Dazols | TED Talks. Available from: http://www.youtube.com/watch?v=ivfJJh9y1UI[last accessed 25/09/20]
- Global Citizen. LGBTQ Refugees. Available from: http://www.youtube.com/watch?v=7pCxJ80IDgw. Available from: http://www.youtube.com/watch?v=7pCxJ80IDgw[last accessed 25/09/20]
- seeprogress. What it's Like to be an LGBT Asylum Seeker. Available from: http://www.youtube.com/watch?v=pbI4D3X42sk[last accessed 30/10/17]
- Deutsch MB. Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people; 2nd Edition. 2016. Center for excellence for transgender health, department of family and community medicine, University of California, San Francisco.
- LGBTQ Terminology. UCLA Lesbian Gay Bisexual Transgender Resource Center. Available from:https://www.lgbt.ucla.edu/Resources/LGBTQ-Terminology [Accessed 13th September 2020]
- Pride in Practice. Gender Pronouns: A Provider’s Guide to Referring to Transgender Patients. Available from:https://www.prideinpractice.org/articles/transgender-pronouns-guide/ [Accessed 25th September 2020]
- It Takes Courage. Defining LGBTQ. Available from: http://www.youtube.com/watch?v=tRvFj3ugdWU[last accessed 25/09/20]
- Margalit Schindler. LGBT 101: An Introduction to the Queer Community. Available from: http://www.youtube.com/watch?v=DE7bKmOXY3w[last accessed 25/09/20]
- Alessi EJ, Kahn S, Chatterji S. “The Darkest Time in my life:” Recollections of child abuse among forced migrants persecuted because of their sexual orientation and gender identity. Child Abuse Neg 2016;51:93-105: Available from: https://doi.org.10.1016/j.chiabu.2015.10.030 [Accessed 25th September 2020]
- OHCHR. Born Free and Equal: Sexual Orientation, Gender Identity and Sex Characteristics in International Human Rights Law; Second Edition, 2019; 1-104 Available from: https://www.ohchr.org/Documents/Publications/BornFreeAndEqualLowRes.pdf [Accessed 25 September 2020]
- OHCHR. Background Note on Human Rights Violations against Intersex People. Available from:https://www.ohchr.org/Documents/Issues/Discrimination/LGBT/BackgroundNoteHumanRightsViolationsagainstIntersexPeople.pdf [Accessed 25 September 2020]
- Human Rights Campaign Foundation. Mental health and the LGTBQ community. Available form: https://suicidepreventionlifeline.org/wp-content/uploads/2017/07/LGBTQ_MentalHealth_OnePager.pdf [Accessed 25 September 2020]
- North Western Melbourne Primary Health Network. LGBTIQ People Talk About Their Experiences Accessing Health Care. Available from: http://www.youtube.com/watch?v=Q5-7t_qBw14[last accessed 25/09/20]
- Montgomery College. Care to the Trans* and Gender Non-Conforming Identified Patient. Available from: http://www.youtube.com/watch?v=NEHxlmFBRrA[last accessed 25/09/20]
- NYC Health and Hospitals. LGBT Healthcare Training Video: "To Treat Me, You Have to Know Who I Am". Available from: http://www.youtube.com/watch?v=NUhvJgxgAac[last accessed 25/09/20]
- Seelman KL, Colon-Diaz MJP, LeCroix RH, Xavier-Brier M, Kattari L. Transgender noninclusive healthcare and delaying care because of fear: Connections to general health and mental health among transgender adults. Transgender Health 2017;2(1):17-28. doi:10.1089/trgh.2016.0024
- Human Rights Campaign. “Sexual Assault and the LGBTQ Community.” Human Rights Campaign, Available form: https://www.hrc.org/resources/sexual-assault-and-the-lgbt-community [Accessed 25 September 2020]
- Dehghan R. The health impact of (sexual) torture among Afghan, Iranian and Kurdish refugees: A literature review. Torture 2018;28(3):77-81.
- Gray H, Stern M, Dolan C. Torture and sexual violence in war and conflict: The unmaking and making of subjects of violence. Rev Int Stud 2020;46(2):197-216. https://doi.org/10.1017/S0260210519000391
- de Ruiter, MA, Gamble A, Gueron LPG, Kibet JJ, O’Reilly C. Physiotherapy with survivors of torture and trauma. In Eds. Probst and Skjaerven, Physiotherapy in mental health and psychiatry: A scientific and clinical based approach 2018; Pages 206-225: Elselvier London.
- LGBT Arabs. LGBT Refugees in germany. Available from: http://www.youtube.com/watch?v=9A9f6B6r-lA[last accessed 25/09/20]
- PT Alberta. Webinar: Diversity and Inclusion in Physiotherapy Practice. Available from: http://www.youtube.com/watch?v=xeU8D9pBhgA[last accessed 25/09/20]
- Transgender Health Vol.2.1, 2017. Doi:10.109/trgh.2016.0024. Available from: www.liebertpub.com
- Hill F, Condran C, Pluss AJ, Fons L, Bell KA. Introduction to LGBTQ+ Competency. Handbook for Physical Therapy: Health for Everyone. Committee of the health promotion and policy and administration section of the APTA
- Center of Excellence for Transgender Health. Case Studies. Available form:http://transhealth.ucsf.edu/video/story_content/external_files/CASE_STUDIES_11_14_13_FINAL-1.pdf. [Accessed 13 September 2020]
- Iwamoto SJ, Defreyne J, Rothman MS, Van Schuylenbergh J, Van de Bruaene L, Motmans J, T’Sjoen G. Health considerations for transgender women and remaining unknowns: A narrative review. Ther Adv Edocrinol Metab. 2019. Available form: https://doi.org/10.1177/2042018819871166 [Accessed 25 September 2020]
- Kimelstein J. Gender as an Occupation: The Role of OT in the Transgender Community [Dissertation]. New York, Ithaca College.2019 Available from:https://digitalcommons.ithaca.edu/ic_theses/424/ [Accessed 25 September 2020]
- James SE, Herman JL, Rankins S, Kesiling M, Mottet C, Anafi M. The report of the 2015 US Transgender survey. 2016; National Center for Transgender Equality.
- PTProud. Introduction to LGBTQ+ Competency Handbook for Physical Therapy. Available form: https://cdn.ymaws.com/www.aptahpa.org/resource/resmgr/csm_2019/csm_2019_handouts/Full_Handout_LGBTQIA-doc_1_1.pdf [Accessed 25 September 2020]
- Murray G, Young M. Pan-Commonwealth Human Rights, gender and sexual diversity training toolkit. Human Dignity Trust, Equality and Justice Alliance 2019. 1-48. Available from: https://www.humandignitytrust.org/wp-content/uploads/resources/EJA_PC_Toolkit_FINAL.pdf [Accessed 25 September 2020]
- Equality and Justice Alliance. Pan-Commonwealth Human Rights, Gender & Sexual Diversity Training Toolkit. 2019. Available from: https://www.humandignitytrust.org/wp-content/uploads/resources/EJA_PC_Toolkit_FINAL.pdf [Accessed 25 September 2020]
- Organization for Refuge, Asylum and Migration (ORAM). What We Do. Available from: https://oramrefugee.org [Accessed 25 September 2020]
- UN High Commissioner for Refugees (UNHCR), Working with Lesbian, Gay, Bisexual, Transgender & Intersex Persons in Forced Displacement, 2011. Available from: http://www.refworld.org/docid/4e6073972.html [Accessed 25 September 2020]
- Born Free and Equal, Sexual orientation, gender identify and sex characteristics in international human rights law: Office of the High Commissioner. UNHCR 2nd Edition. Pages 1-104. Available from:https://www.ohchr.org/Documents/Publications/BornFreeAndEqualLowRes.pdf [Accessed 25 September 2020]
- Lytle MC, Vaughan MD, Rodriguez EM, Shmerier DL. Working with LGBT individuals: Incorporating positive psychology into training and practice. Psychol Sex Orient Gend Divers 2014;1(4):335-347. Available from:https://doi:10.1037/sgd0000064 [Accessed 25 September 2020]
- Nadal KL, Whitman CN, Davis LS, Erazo T, Davidoff KC.(2016) Microaggressions Toward Lesbian, Gay, Bisexual,Transgender, Queer, and Genderqueer People: A Review of the Literature, The Journal of Sex Research 2016;53:4-5: 488-508. Available from: https://10.1080/00224499.2016.1142495 [Accessed 25 September 2020]
- Center for Vistims of Torture. Reclaiming Identity. Available from: http://www.youtube.com/watch?v=GztkBuOtbOo[last accessed 25/09/20]
- Wood G. Is your practice LGBTQ friendly? How to create a welcoming space. April 10, 2019. 1-9. Available from: https://massagemag.com/is-your-practice-lgbtq-friendly-how [Accessed 25 September 2020]
- Tyler Oakley. A Matter of Life or Death: LGBTQ+ Refugees | Chosen Family | Part 5. Available from: http://www.youtube.com/watch?v=YbmBYIV3oJI[last accessed 25/09/20]
- Fixers UK. Seeking Asylum: My Story (LGBT woman from Zimbabwe). Available from: http://www.youtube.com/watch?v=Qz2rodintb0[last accessed 25/09/20]
- TEDx Talks. The Refugee Tree: A Queer Journey from Syria to Canada | Danny Ramadan | TEDxSFU. Available from: http://www.youtube.com/watch?v=JOwDh4l_QBU[last accessed 25/09/20]
- Unreported World. Finding sanctuary from homophobic persecution | Unreported World. Available from: http://www.youtube.com/watch?v=https://youtu.be/ouE8NnLH1_0[last accessed 25/09/20]
- Chris Condran. The Healing Pain Podcast Episode 138 - LGBT Inclusion In Physical TherapyAvailable from: https://drjoetatta.libsyn.com/2019/page/2/size/25 [Accessed 25 September 2020]
- National LGBTQIA+ Health Education Center. Learning Resources - Webinars. Available from:https://www.lgbtqiahealtheducation.org/resources/type/webinar/ [Accessed 25 September 2020]
- National LGBTQIA+ Health Education Center. Learning Resources - Publications. Available from:https://www.lgbtqiahealtheducation.org/resources/type/publication/ [Accessed 25 September 2020]
- National LGBTQIA+ Health Education Center. Learning Resources - Learning Modules. Available from:https://www.lgbtqiahealtheducation.org/resources/type/learning-module/ [Accessed 25 September 2020]
- National LGBTQIA+ Health Education Center. Learning Resources - Videos. Available from:https://www.lgbtqiahealtheducation.org/resources/type/video/ [Accessed 25 September 2020]
- Erin Kingham. American Physical Therapy Association. To Be All of Me. Available from: https://www.apta.org/article/2019/10/16/to-be-all-of-me [Accessed 25 September 2020]
- American Physical Therapy Association. HHS Discrimination Decision Runs Counter to Profession's Values; APTA is opposed to ACA rule changes that open the door for discrimination based on gender identity. Available from: https://www.apta.org/news/2020/06/16/hhs-discrimination-decision-runs-counter-to-professions-values [Accessed 25 September 2020]
- Do Ask, Do Tell; A Toolkit for Collecting Data on Sexual Orientation and Gender Identity in Clinical Settings. Available from: https://doaskdotell.org [Accessed 25 September 2020]
- Do Your Business / Mind Your Business. Available from:https://www.bathroom.support [Accessed 25 September 2020]