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DISCLOSURE & ACCREDITATION This presentation is accredited for CME by the Yale School of Medicine. If you wish to receive credit for your participation,

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Presentation on theme: "DISCLOSURE & ACCREDITATION This presentation is accredited for CME by the Yale School of Medicine. If you wish to receive credit for your participation,"— Presentation transcript:

1 DISCLOSURE & ACCREDITATION This presentation is accredited for CME by the Yale School of Medicine. If you wish to receive credit for your participation, you must:  sign in

2 DISCLOSURE & ACCREDITATION Acknowledgement is made on behalf of the Section that: ~ There is no commercial support for this lecture Confirmation is also made that today’s lecture and faculty disclosure have been peer reviewed and: ~There are no conflicts of interest. Acknowledgement is made on behalf of the Section that: ~ There is no commercial support for this lecture Confirmation is also made that today’s lecture and faculty disclosure have been peer reviewed and: ~There are no conflicts of interest.

3 Medical Forensic Evaluations of Asylum Applicants Katherine C. McKenzie, MD Yale Center for Asylum Medicine Yale School of Medicine Katherine C. McKenzie, MD Yale Center for Asylum Medicine Yale School of Medicine Photo: Robert Lisak

4 Asylum Applicants “Clients” not Patients Photo: Robert Lisak

5 Medical Forensic Evaluations of Asylum Applicants Asylum Torture Medical Evaluations at Yale Evaluation Process Asylum Cases Asylum Torture Medical Evaluations at Yale Evaluation Process Asylum Cases

6 Asylum According to the UN Universal Declaration of Human Rights (1948): “Everyone has the right to seek ….in other countries asylum from persecution.” “No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment.” According to the UN Universal Declaration of Human Rights (1948): “Everyone has the right to seek ….in other countries asylum from persecution.” “No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment.”

7 Asylum Applicants “An alien in the US …..who is ….unable or unwilling to return to his or her country because of persecution or…fear of persecution…..must be based on the alien’s race, religion, nationality, membership in a particular social group or political opinion….” US Immigration and Nationality Act 101 (a)42 “An alien in the US …..who is ….unable or unwilling to return to his or her country because of persecution or…fear of persecution…..must be based on the alien’s race, religion, nationality, membership in a particular social group or political opinion….” US Immigration and Nationality Act 101 (a)42

8 Every year, thousands of torture victims from other countries seek refuge in the US Many are sent back to the countries from which they have come, as they cannot prove they were tortured In 2012, almost 30,000 applicants were granted asylum in the United States Medical forensic evidence substantially increases the likelihood that asylum will be granted (30% vs 85%) Every year, thousands of torture victims from other countries seek refuge in the US Many are sent back to the countries from which they have come, as they cannot prove they were tortured In 2012, almost 30,000 applicants were granted asylum in the United States Medical forensic evidence substantially increases the likelihood that asylum will be granted (30% vs 85%) Asylum Applicants HealthRight International US Dept of Homeland Security

9 Refugee versus Asylum Status Refugee are admitted to US with legal status Asylees enter with or without legal status Refugee are admitted to US with legal status Asylees enter with or without legal status HealthRight International

10 Torture Officially condemned by most nations Continues to be carried out in almost 150 countries; it is widespread in more than 70 Officially condemned by most nations Continues to be carried out in almost 150 countries; it is widespread in more than 70 Examining Asylum Seekers, PHR

11 UN General Assembly Convention Against Torture and Other Cruel, Inhuman and Degrading Treatment and Punishment (CAT) 1984 “Any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person Information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain and suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity. It does not include pain or suffering arising only from, inherent in or incidental to lawful sanctions. “

12 Convention Against Torture (CAT) States must take effective measures to prevent and punish torture [It] prohibits States from returning a person to a State where he or she is in danger of torture [It] requires States to offer sanctuary to people who demonstrate that they could be tortured No specific quota States must take effective measures to prevent and punish torture [It] prohibits States from returning a person to a State where he or she is in danger of torture [It] requires States to offer sanctuary to people who demonstrate that they could be tortured No specific quota

13 Torture vs Persecution Torture Intentional infliction of severe mental or physical pain Persecution Wider spectrum of hardships inflicted on an individual due to their race, religion, nationality, social group, or political opinions

14 Torture vs Persecution Torture is a form of persecution Both qualify a client for asylum status Torture is a form of persecution Both qualify a client for asylum status

15 Common Forms of Torture: Waterboarding or Suffocation Examining Asylum Seekers, PHR

16 Common Forms of Torture Burns Sexual assault (Rape, Female Genital Mutilation/Cutting) Forced positioning Suffocation/waterboarding Electrical torture Burns Sexual assault (Rape, Female Genital Mutilation/Cutting) Forced positioning Suffocation/waterboarding Electrical torture

17 Common Forms of Torture: Burns

18 Common Forms of Torture: Lacerations/Cuts Doctors of the World 2009 Annual Report

19 Common Forms of Torture: Blunt Trauma/Beating Examining Asylum Seekers, PHR

20 Common Forms of Torture: Forced Positioning Examining Asylum Seekers, PHR

21 Common Forms of Torture: Sexual assault

22 Physical Sequelae Scars Chronic pain Infertility/sexual dysfunction Neurological injuries Scars Chronic pain Infertility/sexual dysfunction Neurological injuries

23 Psychological Torture Deprivation Humiliation Torture/persecution of others Threats/blackmail Harassment/interrogation Inhumane conditions of detention/imprisonment Deprivation Humiliation Torture/persecution of others Threats/blackmail Harassment/interrogation Inhumane conditions of detention/imprisonment

24 Psychological Sequele Anxiety Depression PTSD Failure to thrive Insomnia/nightmares Sexual dysfunction/dyspareunia/erectile dysfunction Anxiety Depression PTSD Failure to thrive Insomnia/nightmares Sexual dysfunction/dyspareunia/erectile dysfunction

25 Manifestation of gender inequality Most common in Africa; also practiced in India and Middle East Entrenched in social, economic, political and religious institutions “Coming of age” ceremonies; usually ages 0-15 Perceived social benefits to families outweigh harms (ostracized by society) Ensure virginity, decreases female desire Enhances male sexual pleasure Manifestation of gender inequality Most common in Africa; also practiced in India and Middle East Entrenched in social, economic, political and religious institutions “Coming of age” ceremonies; usually ages 0-15 Perceived social benefits to families outweigh harms (ostracized by society) Ensure virginity, decreases female desire Enhances male sexual pleasure Female Genital Mutilation/Cutting (FGM/C)

26 FGM/C Classified as follows: Type 1: Partial or total removal of clitoris and/or prepuce Type 2: As above, plus removal of labia minor and/or majora Type 3: Narrowing of introitus by suturing labia minoris or majoris, +/- clitoris excision (infibulation) Type 4: All other harmful procedures to genitalia: pricking, piercing, incising, scraping, and cauterization Classified as follows: Type 1: Partial or total removal of clitoris and/or prepuce Type 2: As above, plus removal of labia minor and/or majora Type 3: Narrowing of introitus by suturing labia minoris or majoris, +/- clitoris excision (infibulation) Type 4: All other harmful procedures to genitalia: pricking, piercing, incising, scraping, and cauterization

27 Medical Forensic Evaluations at Yale Photo: Robert Lisak

28 Referring Groups Yale Law School-Jerome N. Frank Legal Services Organization Jean Koh Peters, Faculty advisor –Law students University of Connecticut School of Law-Legal Clinic Jonathan Bauer, Faculty advisor - Law students Yale Law School-Jerome N. Frank Legal Services Organization Jean Koh Peters, Faculty advisor –Law students University of Connecticut School of Law-Legal Clinic Jonathan Bauer, Faculty advisor - Law students

29 Referring Groups Physicians for Human Rights Private lawyers (pro bono) Physicians for Human Rights Private lawyers (pro bono)

30 Referring Groups HealthRight International HealthRight International-Human Rights Clinic Private lawyers (pro bono) HealthRight International-Human Rights Clinic Private lawyers (pro bono)

31 Medical Forensic Evaluations at Yale Law school clinics Medical evaluations Medical consultation Mentoring Advocacy groups Mentoring Resident teaching Law school clinics Medical evaluations Medical consultation Mentoring Advocacy groups Mentoring Resident teaching Photo: Robert Lisak

32 Role of Clinician Examiner Not responsible for: Verifying identity of client Confirming veracity of client’s testimony Determining whether claims of persecution meet CAT criteria for torture Predicting what would physically happen if client returned to their country Deciding whether client qualifies for asylum Not responsible for: Verifying identity of client Confirming veracity of client’s testimony Determining whether claims of persecution meet CAT criteria for torture Predicting what would physically happen if client returned to their country Deciding whether client qualifies for asylum

33 Role of Clinician Examiner Cannot provide medical care Objectivity strengthens testimony given to court Expert testimony, not advocacy work Cannot provide medical care Objectivity strengthens testimony given to court Expert testimony, not advocacy work

34 Evaluation Process Arrival at US airport Can enter society if have tourist visa If no visa, may be sent to detention center Arrival at US airport Can enter society if have tourist visa If no visa, may be sent to detention center Physicians for Human Rights

35 Applicants Awaiting Asylum Decision Cannot work legally Not eligible for government assistance Legal maneuvers can take years Cannot work legally Not eligible for government assistance Legal maneuvers can take years

36 Evaluation Process Referral from law school or advocacy group Attorney provides client declaration or affidavit and country report Translator arranged if needed Referral from law school or advocacy group Attorney provides client declaration or affidavit and country report Translator arranged if needed

37 Medical Evaluation Meeting with client Review/reiterate/expan d declaration Physical exam Document findings with photographs and/or body diagrams Meeting with client Review/reiterate/expan d declaration Physical exam Document findings with photographs and/or body diagrams Photo: Robert Lisak

38 The Interview Independent expert Sensitivity, compassion, respect Allow client to feel some control while reliving trauma in during the interview and exam Elicit as detailed information as possible Referral to mental health professional, if necessary Independent expert Sensitivity, compassion, respect Allow client to feel some control while reliving trauma in during the interview and exam Elicit as detailed information as possible Referral to mental health professional, if necessary

39 Poor Recall/Inconsistent Memory Traumatic brain injury Sensory deprivation PTSD/depression Traumatic brain injury Sensory deprivation PTSD/depression

40 Physical Examination Limit to area of body where scars exist Note unrelated scars Body diagrams Photographs Describe injury as well as treatment: medication, sutures, surgery, hospitalization Limit to area of body where scars exist Note unrelated scars Body diagrams Photographs Describe injury as well as treatment: medication, sutures, surgery, hospitalization Photo: Robert Lisak

41 Physical Examination

42 Physical Findings of Torture Physical findings can provide important evidence Key to distinguish non torture scars from those related to specific torture Sometimes physical evidence is absent (especially in cases of rape) Psychological symptoms can be powerful evidence Physical findings can provide important evidence Key to distinguish non torture scars from those related to specific torture Sometimes physical evidence is absent (especially in cases of rape) Psychological symptoms can be powerful evidence

43 Physical Findings of Torture “Diagnostic of” “Consistent with/highly consistent with” “Typical of” “Not consistent with” “Nonspecific” “Diagnostic of” “Consistent with/highly consistent with” “Typical of” “Not consistent with” “Nonspecific”

44 Report Write declaration/affidavit Attorney review Court testimony –Telephone –Cross examination Write declaration/affidavit Attorney review Court testimony –Telephone –Cross examination

45 Report

46 Asylum Cases DK-Raped, cut, burned, inhumane conditions DLJ-Beaten, cut, burned FT-FGM/C, domestic violence PM-Abducted, raped, beaten, interrogated DK-Raped, cut, burned, inhumane conditions DLJ-Beaten, cut, burned FT-FGM/C, domestic violence PM-Abducted, raped, beaten, interrogated

47 Asylum Cases DK-Raped, cut, burned, inhumane conditions DLJ-Beaten, cut, burned FT-FGM/C, domestic violence PM-Abducted, raped, beaten, interrogated DK-Raped, cut, burned, inhumane conditions DLJ-Beaten, cut, burned FT-FGM/C, domestic violence PM-Abducted, raped, beaten, interrogated

48 Referred from Yale Law School From Guinea Member of opposition political group Chased and arrested while participating in an opposition rally Fell while being chased Taken to detention facility Interrogated/threatened Raped Burned on hip with hot iron, beaten Referred from Yale Law School From Guinea Member of opposition political group Chased and arrested while participating in an opposition rally Fell while being chased Taken to detention facility Interrogated/threatened Raped Burned on hip with hot iron, beaten Client DK

49

50 Asylum Cases DK-Raped, cut, burned, inhumane conditions DLJ-Beaten, cut, burned FT-FGM/C, domestic violence PM-Abducted, raped, beaten, interrogated DK-Raped, cut, burned, inhumane conditions DLJ-Beaten, cut, burned FT-FGM/C, domestic violence PM-Abducted, raped, beaten, interrogated

51 Client DLJ Referred by University of Connecticut Attacked by political enemies in Haiti Assaulted while 7 months pregnant Attackers threatened to burn her house down Beat and kicked her with fists and batons Arm cut with machete Burned on legs with ? hot iron Lost consciousness: due to head trauma vs psychological trauma Referred by University of Connecticut Attacked by political enemies in Haiti Assaulted while 7 months pregnant Attackers threatened to burn her house down Beat and kicked her with fists and batons Arm cut with machete Burned on legs with ? hot iron Lost consciousness: due to head trauma vs psychological trauma

52 Client DLJ Uterine hemorrhage/cervical rupture/delivered baby prematurely/postpartum hysterectomy Required hospitalization and transfusion Sutures to right arm laceration Burn care to arm Disabled child Sexual dysfunction Uterine hemorrhage/cervical rupture/delivered baby prematurely/postpartum hysterectomy Required hospitalization and transfusion Sutures to right arm laceration Burn care to arm Disabled child Sexual dysfunction

53 Client DLJ

54 Asylum Cases DK-Raped, cut, burned, inhumane conditions DLJ-Beaten, cut, burned FT-FGM/C, domestic violence PM-Abducted, raped, beaten, interrogated DK-Raped, cut, burned, inhumane conditions DLJ-Beaten, cut, burned FT-FGM/C, domestic violence PM-Abducted, raped, beaten, interrogated

55 Client FT Referred from Yale Law School From Ivory Coast Muslim Arranged marriage to second cousin Chased by elders before FGM; injured leg on gate FGM immediately before marriage with no medical care and intercourse shortly after FGM Referred from Yale Law School From Ivory Coast Muslim Arranged marriage to second cousin Chased by elders before FGM; injured leg on gate FGM immediately before marriage with no medical care and intercourse shortly after FGM

56 Client FT Chronic domestic violence and rape throughout the marriage Polygamy Three miscarriages, attributed to scarring related to FGM One live birth: a daughter Fled country because of fear of daughter undergoing FGM Chronic domestic violence and rape throughout the marriage Polygamy Three miscarriages, attributed to scarring related to FGM One live birth: a daughter Fled country because of fear of daughter undergoing FGM

57 Client FT

58 Asylum Cases DK-Raped, cut, burned, inhumane conditions DLJ-Beaten, cut, burned FT-FGM/C, domestic violence PM-Abducted, raped, beaten, interrogated DK-Raped, cut, burned, inhumane conditions DLJ-Beaten, cut, burned FT-FGM/C, domestic violence PM-Abducted, raped, beaten, interrogated

59 Client PM Referred by Physicians for Human Rights Gay man living in Uganda, a society intolerant of homosexuality Neighbors reported, “….unnatural things; it is un- African.” Abducted from home Referred by Physicians for Human Rights Gay man living in Uganda, a society intolerant of homosexuality Neighbors reported, “….unnatural things; it is un- African.” Abducted from home

60 Client PM Taken to unregistered holding cell for 33 days Inhumane conditions Threatened with death if his homosexual activities continued Beaten and interrogated Exhorted to report partners Gang raped Taken to unregistered holding cell for 33 days Inhumane conditions Threatened with death if his homosexual activities continued Beaten and interrogated Exhorted to report partners Gang raped

61 Client PM

62 You can look at a scar and see hurt, or you can look at a scar and see healing. -Sheri Reynolds

63 For More Information um/index.aspx

64 Acknowledgements YIMA administrative staff: Yvonne Augur, Theresa Harris, Hillary Marino, Beverly Shanks YIMA administrative staff: Yvonne Augur, Theresa Harris, Hillary Marino, Beverly Shanks


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