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DISCLOSURE & ACCREDITATION
Acknowledgement is made on behalf of the Section that:
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Medical Forensic Evaluations of
Asylum Applicants
Photo: Robert Lisak
Katherine C. McKenzie, MD
Yale Center for Asylum Medicine
Yale School of Medicine
Asylum Applicants
Photo: Robert Lisa
“Clients” not Patients
Medical Forensic Evaluations of Asylum
Applicants
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Asylum
Torture
Medical Evaluations at Yale
Evaluation Process
Asylum Cases
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.”
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
Asylum Applicants
•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%)
HealthRight International
US Dept of Homeland Security
Refugee versus Asylum Status
• Refugee are admitted to US with legal status
• Asylees enter with or without legal status
HealthRight International
Torture
• 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
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. “
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
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
Torture vs Persecution
• Torture is a form of persecution
• Both qualify a client for asylum status
Common Forms of Torture:
Waterboarding or Suffocation
Examining Asylum Seekers, PHR
Common Forms of Torture
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Burns
Sexual assault (Rape, Female Genital Mutilation/Cutting)
Forced positioning
Suffocation/waterboarding
Electrical torture
Common Forms of Torture: Burns
Common Forms of Torture:
Lacerations/Cuts
Doctors of the World 2009 Annual Report
Common Forms of Torture: Blunt
Trauma/Beating
Examining Asylum Seekers, PHR
Common Forms of Torture: Forced
Positioning
Examining Asylum Seekers, PHR
Common Forms of Torture: Sexual
assault
Physical Sequelae
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Scars
Chronic pain
Infertility/sexual dysfunction
Neurological injuries
Psychological Torture
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Deprivation
Humiliation
Torture/persecution of others
Threats/blackmail
Harassment/interrogation
Inhumane conditions of detention/imprisonment
Psychological Sequele
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Anxiety
Depression
PTSD
Failure to thrive
Insomnia/nightmares
Sexual dysfunction/dyspareunia/erectile dysfunction
Female Genital Mutilation/Cutting
(FGM/C)
• 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
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
Medical Forensic Evaluations at Yale
1999-2013
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
Referring Groups
• Physicians for Human Rights
• Private lawyers (pro bono)
Referring Groups
• HealthRight International-Human Rights Clinic
• Private lawyers (pro bono)
HealthRight International
Medical Forensic Evaluations at Yale
• Law school clinics
Medical evaluations
Medical consultation
Mentoring
• Advocacy groups
Mentoring
• Resident teaching
Photo: Robert Lisak
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
Role of Clinician Examiner
• Cannot provide medical care
• Objectivity strengthens testimony given to court
• Expert testimony, not advocacy work
Evaluation Process
• Arrival at US airport
• Can enter society if have tourist visa
• If no visa, may be sent to detention center
Physicians for Human Rights
Applicants Awaiting Asylum Decision
• Cannot work legally
• Not eligible for government assistance
• Legal maneuvers can take years
Evaluation Process
• Referral from law school or advocacy group
• Attorney provides client declaration or affidavit and
country report
• Translator arranged if needed
Medical Evaluation
Meeting with client
Photo: Robert Lisak
• Review/reiterate/expan
d declaration
• Physical exam
• Document findings with
photographs and/or
body diagrams
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
Poor Recall/Inconsistent Memory
• Traumatic brain injury
• Sensory deprivation
• PTSD/depression
Physical Examination
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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
Physical Examination
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 of Torture
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“Diagnostic of”
“Consistent with/highly consistent with”
“Typical of”
“Not consistent with”
“Nonspecific”
Report
• Write declaration/affidavit
• Attorney review
• Court testimony
– Telephone
– Cross examination
Report
December 2, 2008
UNITED STATES DEPARTMENT OF JUSTICE
IMMIGRATION COURT
In the matter of the Application for
Asylum of DC
Declaration of Katherine McKenzie, M.D.
QUALIFICATIONS: I, Katherine C. McKenzie, hereby declare as follows: I am a General
Internist and Assistant Professor of Medicine on the full time teaching faculty at Yale School of
Medicine and a member of Yale Internal Medicine Associates for the last 14 years. Since 1999,
our practice has interviewed and examined a number of applicants referred from both Yale Law
School and the University of Connecticut Law School. I have used the material prepared by
Physicians for Human Rights to aid in my evaluation of asylum applicants. I have also
participated in training presented by Doctors of the World. My training as a Board Certified
internist qualifies me to perform this kind of examination.
INTERVIEW: I interviewed Ms. C in my office on Thursday, November 20, 2008. Ms. C speaks
fluent English.
HISTORY: Ms. C is a 31-year-old Tutsi woman from the city of Lubumbashi in the Democratic
Republic of Congo (Congo). She is seeking asylum in the United States of America. While she
was in Congo, she was abducted, beaten and raped by the
Congolese Security Forces operating under President Laurent Kabila. She also witnessed the
murder of her father by the security forces.
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Asylum Cases
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DK-Raped, cut, burned, inhumane conditions
DLJ-Beaten, cut, burned
FT-FGM/C, domestic violence
PM-Abducted, raped, beaten, interrogated
Asylum Cases
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DK-Raped, cut, burned, inhumane conditions
DLJ-Beaten, cut, burned
FT-FGM/C, domestic violence
PM-Abducted, raped, beaten, interrogated
Client DK
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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
Asylum Cases
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DK-Raped, cut, burned, inhumane conditions
DLJ-Beaten, cut, burned
FT-FGM/C, domestic violence
PM-Abducted, raped, beaten, interrogated
Client DLJ
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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
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
Client DLJ
Asylum Cases
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DK-Raped, cut, burned, inhumane conditions
DLJ-Beaten, cut, burned
FT-FGM/C, domestic violence
PM-Abducted, raped, beaten, interrogated
Client FT
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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
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
Client FT
Asylum Cases
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DK-Raped, cut, burned, inhumane conditions
DLJ-Beaten, cut, burned
FT-FGM/C, domestic violence
PM-Abducted, raped, beaten, interrogated
Client PM
• Referred by Physicians for Human Rights
• Gay man living in Uganda, a society intolerant of
homosexuality
• Neighbors reported, “….unnatural things; it is unAfrican.”
• Abducted from home
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
Client PM
You can look at a scar and see hurt,
or you can look at a scar and see
healing.
-Sheri Reynolds
For More Information
http://medicine.yale.edu/intmed/genmed/asyl
um/index.aspx
www.physiciansforhumanrights.org
www.amnesty.org
www.healthright.org
Acknowledgements
YIMA administrative staff:
Yvonne Augur, Theresa Harris, Hillary Marino, Beverly
Shanks