Medical report (victims of torture)
According to the medical literature between 5 and 30% of all asylum seekers arriving in Western countries have undergone torture or other severe maltreatment. Often these experiences have a direct bearing on applications of asylum, both in providing a (the main) reason for fleeing one’s country of origin and in altering the applicant’s physical and mental health so that his chances of applying successfully are diminished.
The Aims of Medical Reports
Medical reports should be independent and neutral assessments. The aim is to help the court in assessing a claim for asylum. A report will
- assess the account on medical plausibility (mechanism of injuries, healing, medical procedures etc.)
- document all physical findings and assess whether these are consistent with an account of torture,
- document innocent and unconnected findings together with the client's explanation for these
- document psychological symptoms and signs and assess whether these are consistent with an account of torture
- give advice whether any mental health problems could have or could interfere with performance in the asylum interview and/or appeal court
A formal conclusion whether a client was definitely submitted to incidents as alleged is under normal circumstances virtually impossible. When there are reasons to doubt the account or parts thereof, these will be highlighted and discussed. If there were serious discrepancies between account and the examination or other serious reasons to doubt the account of torture than no report should be issued.
The Lay-Out, Guarantee
Medical reports should follow a clear lay-out.
- a short curriculum vitae of the examining doctor
- declaration of objectivity,
- an introduction,
- the client's account (including general background, incidents of note, consequences of medical or psychological nature),
- an examination (physical and psychological), assessment, and conclusions.
Possible additions include a review of GP notes (if available) and review of other material offered by the client or his solicitors.
It is important to note that
- the client's account is an entirely subjective account, taken down as given, maybe edited of superfluous material, but not altered in its relevant content. It should not be understood as the doctor's opinion.
- The examination is recorded in all findings, including findings of innocent, doubtful or contradictory nature. This part of the report is factual and objective.
- The assessment included in description of certain findings is kept to a minimum of interpretative effort, stating simple age of a scar and whether ore not it is consistent with the account given
- The conclusions and summary are the opinion of the examiner, reflecting his experience and the sum total of all findings.
This should be guaranteed by the examiner's signature.
General Practitioners are well aware of the natural course of most common illnesses and injuries or know where to get the relevant information. Similarly they have a well rounded knowledge of the general treatment of most common conditions, including surgical treatments, without obviously being able to provide many of said treatments.
Based on this general medical knowledge doctors can assess a client's account for its medical plausibility. This is sometimes made difficult by the common misconceptions of lay people about medical procedures, general lack of knowledge of bodily functions et cetera.
Nevertheless it is often possible to classify an account relating to medical procedures, illness or healing process etc. as 'medically plausible' or not.
This information in turn will be used to make sense of the physical and psychological findings during examination.
It is also evidence in its own right, particularly when medical details are given which are not readily accessible or in public knowledge, or unique features of a particular problem suggesting personal experience rather than malingering.
Assessment of Physical Findings
Scars and other objective findings related to torture shoudl be classified along with the protocols of the Istanbul Protocol as "consistent", "entirely consistent", "characteristic" or "pathognomonic".
- Consistent means that there are no discrepancies in the appearance of a finding with the account. Other explanations remain possible. These will not be discussed.
- Entirely consistent means other explanations are unlikely. This will be discussed in detail.
- Characteristic means other explanations are extremely unlikely.
- Pathognomonic is a finding completely diagnostic of a certain method of torture. An examination many months or years after an alleged incident will normally produce only findings of the former two grades.
Other (innocent) scars should be noted, but only discussed in detail if there appears to be an important reason to do so.
It is usually impossible to ascertain the age of scars beyond a period of about 6 months to one year.
Apart from scars, the examination will look at the general health state, integrity of musculoskeletal apparatus, neurological status or any other organ system, depending on the individual situation
Sometimes it is impossible to find any clear indication how a particular problem or finding has come about. The examining doctor will then explain whether such a finding is unusual for the age-range, gender etc of the client. A typical example are joint and back pains, frequently complained of after prolonged forced positioning, but usually without any objective findings apart from maybe some diffuse tenderness.
Assessment of Psychological Findings
Psychological findings are of dual nature.
There are firstly the problems of psychological nature related by the client. While here is no way to ascertain whether certain complaints are real, e.g. sleep problems, careful questioning will often reveal a lot of information which can be trusted.
Secondly one can observe and test the client throughout the interview for mood, reactivity, distress (including physiological signs, which are usually not under conscious control), evidence of psychotic disorders, irritability etcetera.
Taking into account further available information, e.g. copies of GP notes, one is then often able to come to conclusions regarding current mental health status and occasionally can make predictions about likely course and ability to participate in court proceedings.
As said above it is usually impossible to come to a formal conclusion whether a client was definitely submitted to incidents as alleged. Nevertheless with some consideration and drawing together of all available evidence it is often possible to come to a clear opinion, rather than just providing snippets of information. At the very least a report – if issued – should conclude, whether there is reason to doubt from a medical point of view.
Other factors e.g. presence of innocent wounds etc should be highlighted.
Occasionally one can give medical advice to the court regarding the ability of the client to attend court or to undergo cross-examination. The usual reasons to advice the court not to cross-examine someone are severe ongoing mental or physical illness, suicidality etc.
Similarly medical advice might be added regarding the assessment of credibility. It is not the medical examiner’s job to assess credibility, but there are certain medical conditions where the behaviour of a client might be so influenced by his current medical or psychological problems, so that the court has to be aware of the impact of these. Common examples of these are memory problems due to a diagnosis of depression or Post traumatic stress disorder.
- Medical Foundation for Care of Victims of Torture
- DH page with resources for asylum seekers and refugees (some of the ASCT newsletters you can download from that page contain some very useful links).
- DH leaflet for refugees and others ("This fact sheet has been written to explain the role of UK health services, the National Health Service (NHS), to newly-arrived individuals seeking asylum. It covers issues such as the role of GPs, their function as gatekeepers to the health services, how to register and how to access emergency services.")
- Asylum Support
- Refugee Council