The unique role of doctors in evaluating torture and persecution

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Isolated wooden chair in a dark scary prison with an interrogation spotlightWith applications for asylum in the US increasing sharply, a paper from a team of asylum medicine and law experts highlights the important role of doctors in evaluating refugees’ claims of torture and persecution.

To qualify for asylum in the US, applicants must show they have suffered or will suffer persecution in their home country based on their political opinion, race, religion, nationality or membership in a certain social group, Torture, physical abuse and emotional abuse are considered persecution under US and international law, said Dr Preston Reynolds, an asylum medicine specialist at the University of Virginia School of Medicine who co-authored the new paper.

Physicians have “a unique and special role” to play in the asylum review process by using their diagnostic expertise to review asylum seekers’ claims, said Reynolds, who has performed 40 to 50 forensic exams for asylum seekers. “Training physicians [to conduct these reviews] is a way for them to be involved in global health at a local level,” she said.

When physicians are able to corroborate torture and other forms of persecution through a forensic medical exam, applicants have a much greater chance of receiving asylum. One study found that asylum applicants who underwent a medical exam received asylum 89% of the time, compared with 37.5% of all asylum seekers nationally, according to Reynolds and her co-authors.

Half-day or day-long training sessions are available from asylum medicine centres or human rights groups to teach physicians how to perform the exams and write a legal report that will be used to help determine whether a refugee will receive asylum.

Physicians review an affidavit provided by an asylum seeker, then conduct the forensic exam to determine whether the asylum seeker’s mental and physical injuries match their affidavit. For instance, this could mean reviewing the length and shape of a scar to determine if it could have been inflicted with the weapon described.

While seeking as much detail as possible, exams need to be conducted carefully to avoid re-traumatising the asylum seeker, Reynolds said. “You need to sensitively gather information, periodically re-checking the information to see if there’s more they want to share,” she said.

After the exam, physicians then prepare a legal affidavit of their own, describing how consistent the asylum seeker’s claims of trauma are with the physical findings, based on international guidelines known as the Istanbul Protocol. “The weight placed on a physician’s opinion depends on their perceived independence, as well as on their credentials and the quality and thoroughness of the evaluation and report,” Reynolds and her co-authors wrote.

Getting trained to perform these forensic exams can also help physicians provide better care, especially if they work in areas with large immigrant populations, as one study has found that one in nine foreign-born patients has experienced torture.

“It enhances your ability to deliver comprehensive care and to be even more empathetic because you can engage with them in parts of their lives that remain very painful,” she said.

In 2016, over 65 million individuals were displaced from their homes due to human rights abuses, and 262,000 people applied for asylum in the USA. Individuals who have experienced persecution are present in many primary and specialty clinics. A medical forensic evaluation can increase the likelihood of a successful asylum case. This paper reviews the legal framework for asylum and the contribution forensic evaluations can make to this vulnerable population. Physicians without asylum expertise can help these patients by recognizing their legal right to residential protection and referring them to lawyers and physicians with expert skills. Performing forensic examinations of asylum seekers offers physicians the opportunity to collaborate with attorneys, immigration officials, and human rights experts. Clinicians who do this work find it personally and professionally rewarding, especially when they impart their expert knowledge and skills to future clinicians by involving trainees in these evaluations. Physicians who encounter refugees or asylum seekers in their roles as providers or as preceptors should have familiarity with the field of asylum medicine to enhance the comprehensive care they deliver.

Katherine C McKenzie, Jon Bauer, P Preston Reynolds

University of Virginia Health System material
Journal of General Internal Medicine abstract

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