Iranians protest in San Francisco. (Steve Rhodes: Flickr)

California has resettled more Middle Eastern refugees over the past decade than any other state in the U.S. In Northern California, Santa Clara County is a resettlement hub for Middle Eastern refugees — more than 1,300 have moved there since 2006. The majority of these refugees are from Iran and Iraq, and many carry memories of past trauma with them.

Twenty-four year old Iraqi refugee Jasmine said she definitely brought her past memories with her to California. Jasmine (not her real name) and her family fled Iraq in 2006 after insurgents killed her father in a drive-by shooting. She said they escaped to Syria, then resettled in San Jose three years later.

“You left your home. You left the place that you belong to. Your people who loved there,” Jasmine said. “Sometimes I feel like everything for me after Iraq is different: the roads, the air, the dust. I know back home. The dust of back home. I know the air of back home.”

Jasmine said she was in survival mode in Iraq and experienced a delayed reaction to the stress of war. But when she did land in America, depression hit Jasmine hard.

“What happened will remain like a scar inside yourself. Especially like we saw a lot of stuff not normal,” Jasmine told me. “Like dead people in the street. People killed in front of your eye. I don’t believe I’m going to forget them.”

After two years in the U.S. Jasmine was diagnosed with post-traumatic stress disorder, or PTSD. Now she’s getting counseling at Centers for Survivors of Torture (CST) in San Jose. But Jasmine said most of her Iraqi peers shy away from treatment because Iraqi culture, like many others, often considers mental health problems shameful.

Jasmine said therapy has given her tools to help her avoid reliving traumatic moments — a common symptom of PTSD. She says even though she can’t forget her past, she is learning how to deal with it through various activities, like doing crafts. “Especially like when I’m over-thinking I go to crochet,” she said.

Though many Middle Eastern refugees are Iraqis who have fled war-related violence, in the past decade the largest number of Middle Eastern refugees in California are actually from Iran. More than 15,000 Iranian refugees have moved to California since 2006. Many Iranians suffer religious and political persecution. And they face many of the same social and cultural taboos about seeking mental health care as Iraqi refugees.

Azin Izadifar, a 45-year-old Iranian refugee, came to the U.S. in 2009 seeking asylum. She had been arrested for participating in secret meetings during Iran’s 1979 revolution, and spent the next three years being tortured in Iran’s notorious Evin Prison. She continued to have run-ins with the Iranian government after her release, so she eventually sought asylum in the U.S. She said even though she was in America and felt safe, life was difficult. She said her nightmares about her time in Evin Prison followed her to San Jose.

“It had become so normal for me that I couldn’t even understand that there was a problem there –- I had a sleep disorder. And it could be related to the trauma I had in prison,” said Izadifar. “Then I realize, ‘OK, that’s a sign of PTSD.’”

Izadifar eventually saw a therapist and was indeed diagnosed with PTSD. She said she sees the same PTSD symptoms in many newly arrived Iranian refugees — even among people who were never imprisoned. But most of them, she said, aren’t seeking therapy.

“There’s a tendency in our culture to underestimate that and say, ‘Okay, that was past. Now we are in a free society. We have to live our lives. We have to buy a car and get a job and just be normal.’”

Izadifar and Jasmine are not alone. Most refugees have been exposed to violence and trauma unheard of in the west. In the U.S., seeing a counselor is more widely accepted, but many in the refugee community would never think that way, said Sally Sharrock, a former therapist with Centers for Survivors of Torture. She said refugees more likely to go to first ask a family member or a physician for help.

As part of a federal refugee package, people are entitled to medical and mental health care. Sharrock’s job was to get people into counseling and to keep them coming back after their first session. She said her sessions often began with practical support. “A lot of people are really actually more interested in being able to find a job and support their family and find good housing before they’re ready for any kind of psychological supportive services or therapy.”

To keep refugees coming back, Sharrock said she avoided using terms that might be associated with a mental illness, like “depression,” or “anxiety.” She said she’s found that one term seems to work across the board — “stress.”

“Often times we find the word ‘stress’ works for people,” Sharrock said. “I may then ask them how they’ve been affected by stress, how they’ve been coping with it in their own culture up until now. And our conversation will kind of progress from there.”

Izadifar, the Iranian refugee, said the therapy at CST helped her finds tools to work through her healing process. She said she’s now writing a memoir as a form of therapy. Izadifar said it’s not hard to pull up those memories, because the wounds of trauma never fully disappear.

“The wound will always be there, but there’s a difference between a wound that has not healed –- that has not been exposed to the sun — to a wound that’s been healed and now you see a scar. It’s different. The wound will be there, but you’re not as sensitive, it’s not as painful.”

The need for mental health services among veterans has increased 35% since 2007. (Getty Images)

The Department of Veterans Affairs has announced that it will add 1,600 mental health clinicians and 300 support staff to veterans hospitals across the country to help contend with the rising demand for mental health care among returning veterans. That’s an almost 10% increase in mental health staff and is sorely needed at hospitals that can’t keep up with the requests for appointments. In some places, wait time for care is much longer than the VA’s 14 day policy, the subject of a report by the department’s inspector general to be released next week.

Northern California may be faring slightly better than the rest of the country on mental health issues. “In Northern California we have many veterans coming back. We also have a lot of staff,” said Robin Jackson, a spokeswoman for the Department of Veterans Affairs Northern California Health Care System. “We’ve tripled our mental health staff in the last 4 years. So we many be ahead of the curve,” she added. Jackson said that staff in Northern California realized that traumatic brain injury and other mental trauma would be the most common illnesses in returning Iraq and Afghanistan veterans, so they ramped up their staffing to meet the need.

Northern California VA’s are meeting the department’s 14 day timeline to see veterans in need of mental health treatment, according to Jackson. She also said they’ve been doing some innovative things to help veterans feel comfortable using the VA, and to diagnosis them early. “We do a post deployment health reassessment,” Jackson said, citing the recent return of a National Guard unit where all members were given the health assessment. “They get familiar with what we have to offer and feel comfortable to come back,” she added. Jackson says California has always been at the forefront of practices like these because of the state’s large veterans population, especially in Southern California.

Dr. Hauser expects his region to get 111 new mental health professionals. “We are working hard to fill all existing vacancies and ramp up recruiting to hire new staff and create outpatient mental health teams that enhance continuity of care,” he wrote in an email. Southern California has had a hard time filling vacancies on its mental health staff that already exist. Dr. Hauser cited high cost of living in Southern California, salary competition from private networks and overal budgetary contraints as reasons why recruiting and filling psychiatrist positions has been difficult.

The Department of Veterans Affairs as whole has come under fire for long wait times and inadequate care, problems the new staff are meant to address. ”History shows that the costs of war will continue to grow for a decade or more after the operational missions in Iraq and Afghanistan have ended,” Department Secretary Eric Shinseki said in a statement. “As more veterans return home, we must ensure that all veterans have access to quality mental health care.”

The VA treats 1.3 million veterans for mental health problems nationwide, 400,000 of whom are returning from Iraq and Afghanistan. Since 2009, the VA has increased the mental health budget by 39%, but that may not be enough. The number of veterans seeking mental health help has increased 35% since 2007. The new staff will be paid for out of the VA’s existing budget.

UCSF helped create a theater workshop for HIV-positive women suffering from PTSD and other forms of trauma. From left to right: theater participant Cassandra Steptoe, UCSF Professor Edward Machtinger & Rhodessa Jones of the theater group Cultural Odyssey. (Photo: UCSF).

Scientists know that women who have been traumatized or suffer from post-traumatic stress disorder (PTSD) are more likely to be at risk for HIV.

Now two new studies published in the journal AIDS and Behavior show that HIV-positive women suffer disproportionately high rates of trauma and PTSD. In a vicious circle, the high rates of trauma lead to increased risk of further spreading the illness.

In the first study researchers at U.C. San Francisco and Harvard Medical School looked at nearly 6,000 HIV-positive women. They found HIV-positive women were twice as likely to experience violence from their partner and five times more likely to suffer from PTSD than the national average.

In the second smaller study of 113 HIV-positive women, researchers reported that women experiencing ongoing trauma were about four times more likely both to have unsafe sex and to fail taking antiretroviral medications correctly.

That combination of skipping medication and unsafe sex leads to alarming public health consequences, says lead author Edward Machtinger, who directs UCSF’s Women’s HIV Program. He said if a woman isn’t taking HIV medications properly, she is more infectious.

“And if that person is having unprotected sex with HIV-negative partners,” Machtinger told me, “that is a situation that predisposes further transmission more than any other. The conclusion that we come to is that trauma fuels all aspects of the HIV epidemic among women.”

Machtinger said the key to curbing this epidemic is to address the trauma, not just the illness. “Our hope is that screening for trauma and intervening for trauma becomes a required aspect of the care for all women with HIV, along with blood tests and HIV medication adherence.”

Machtinger says the Women’s HIV Program (WHP) has turned to an innovative approach to intervention–theater. In a unique collaboration between the WHP and the San Francisco group Cultural Odyssey, HIV-positive women go through a year-long workshop. At the end of the year, the women disclose their HIV status publicly in a performance called Dancing with the Clown of Love.

“None were completely out about their diagnosis prior to participating, and now all of them are out publicly – to their families, and friends and entire community,” said Machtinger. ”The women who participated described it as transformative.”

Cassandra Steptoe is one of those women. Steptoe was diagnosed with HIV in 1987, a time when she was working as a prostitute to support her own heroin and cocaine addictions, as well as her then-husband’s addiction. She didn’t reveal that she was HIV-positive for almost two decades. Steptoe says she was frequently beaten, both by her husband and her clients.

“At that point I felt that my life was useless,” said Steptoe. “I didn’t have no hope. Because 1987, when I was diagnosed, there was a lot of people dying in the circle of men and women that I would hang around with. They was dying. And so I just waited around, wanting to die and wondering when I was gonna die. But in the process I was still shooting dope, I was still selling my body, I didn’t care about life, period. I lived in a dark world.”

Steptoe lived on the streets for much of the next two decades. Then in 2001 she was sent to a drug treatment center in San Francisco. That’s where she met Machtinger, and was introduced to the HIV-positive women’s theater workshop. In the workshop, HIV-positive women like Steptoe write and perform their traumatic personal stories, under the guidance of Cultural Odyssey’s Rhodessa Jones.

“Rodessa has a way of having us write our feelings about our past out — the dark places that we wouldn’t go into and we wouldn’t talk about,” Steptoe said. “But because of the safety and trust in this group, I was able to go deeper into my past and write about some things that I didn’t tell nobody. And that freed me a lot about my past.”

Steptoe did her first series of live performances in 2010. She said she now takes all her antiretroviral medications, and works with other HIV-positive women in the community to overcome the shame associated with the virus. ”There’s no reason to feel shame. It’s not a crime to be HIV-positive–it’s a health condition. And you know what? We not alone. We in this together. Let’s have safe sex. We don’t need to keep spreading it. Let’s be open about this.”

Watch Cassandra Steptoe’s performance about her HIV status.