What constitutes a high-quality, comprehensive medico-legal asylum affidavit in the United States immigration context? A multi-sectoral consensus-building modified Delphi

In the United States, clinicians are often called upon to provide their expertise to generate expert evidence in cases of individuals seeking asylum or other forms of international protection. Due to a lack of validated guidelines specific to the U.S. immigration context, clinical evaluations produced for immigration proceedings in the United States vary in their format, structure, and content, which can be confusing for practitioners and for adjudicators assessing the weight these evaluations should be afforded in asylum proceedings. We sought to review critical components of a medico-legal asylum evaluation from an interdisciplinary perspective of key stakeholders, by collecting and synthesizing expert opinions to reach consensus on what constitutes a high-quality, comprehensive medical or psychological affidavit for U.S. immigration cases. The consensus process incorporated a three-step modified Delphi method, which took place between September and December 2021 and consisted of two rounds of online questionnaires and a synchronous video conference meeting. The areas most experts agreed on included, by order of highest agreement (combining answers of "strongly agree" and "agree"): A narrative form or checklist is preferable to a predetermined template (95%); Primary care physicians should describe their qualifications to diagnose mental health conditions (81%); Use of citation is helpful, with caveats (77%); Clinicians should include an assessment of malingering (72%); Clinicians should include an executive summary/summary of conclusions at the top of the affidavit (72%); Clinicians should reference the Istanbul Protocol and explain its relevance (66%); It may be beneficial for clinicians to describe the anticipated process of healing (57%); Clinicians may include treatment recommendations (52%). Results of this and future consensus-building efforts and resulting guidance should be used to enhance overall quality of medico-legal reports and incorporated in training programs developed for clinicians, attorneys and adjudicators.

Intentional burn injury: Assessment of allegations of self-infliction

This study investigates the question of whether there is evidence that suggests the possibility of self-infliction, or self-infliction by proxy, of burn injury among a group of asylum claimants in the UK who have attributed such injuries to torture, and how such evidence might be assessed. The question arose from the observations of doctors at the UK-based charity Freedom from Torture that increasing numbers of individuals from Sri Lanka who described a history of torture had suffered severe and disfiguring burn injuries from heated metal objects, and the suggestion from asylum decision-makers that in some cases such injuries could have been acquired deliberately by self-infliction or self-infliction by proxy rather than by torture as claimed. This suggestion has not been confined to Sri Lankan cases, but due to the large numbers of Sri Lankan asylum claimants referred to Freedom from Torture in recent years, including many with this type of injury, the case set for this study was drawn from this population. As many of these injuries are found to be on the back, where self-infliction would be extremely difficult, the possibility of self-infliction by proxy was specifically investigated. An observational data set was examined in detail, comprising medico-legal reports for Sri Lankans with heated metal object burn injuries documented in 2011-14 by the Medico-Legal Reports Service at Freedom from Torture. All had described detention in Sri Lanka since the end of the civil war in 2009. The study reviewed the documented evidence of these injuries alongside other physical and psychological evidence attributed to torture and relevant contextual factors documented in each case. Findings were compared with previous research on torture in Sri Lanka and patterns of injury identified in forensic medicine for both self-infliction and self-infliction by proxy. Thorough examination of the evidence found no indication in this data set to suggest the possibility of self-infliction or self-infliction by proxy and supported the view that, as indicated in the Istanbul Protocol, the overall conclusion on likelihood of torture should be made on evaluation of all the physical and psychological evidence over and above the scrutiny of an individual lesion.

Child sexual abuse--Medical statement conclusions in criminal legal process

OBJECTIVES

To evaluate medical statement conclusions in the criminal-legal process in suspected cases of child sexual abuse (CSA).

STUDY DESIGN

An observational study of a random sample of 130 medically examined, police reported CSA suspected cases during 2001-2009. Medical statements were evaluated and their conclusions were analyzed with an end-point in the legal process. The data consists of official investigation documents from the University Hospital records, the Police, crime laboratories, the State Prosecutor, and the Courts of Law.

RESULTS

The median age of the children was 5.3 years (range 11 months-17.3 years) at the time of the suspected sexual abuse. In most cases (76.2%, 99/130) medical statement conclusions neither supported nor excluded the suspicion of CSA. Twenty-one (16.2%) medical statements supported and in 10 cases (7.7%) the conclusion did not support the suspected CSA. Of the suspected CSA cases a hundred (76.9%) proceeded to the Prosecutor. The charge filing rate was 41.5% (54/130). The final conviction rate was 30.8% (40/130) and 74% in the charged cases. Medical statements were mentioned as evidence in the Prosecutor's decision to file charges in 18 (33.3%) of suspected CSA cases and in 15 (36%) of verdicts. A child's clear disclosure of CSA (p<0.001) and medical statements (p=0.037) had a significant role in decision making on convictions.

CONCLUSION

In medical statement conclusions, physical findings with proper documentation and interpretation are needed to avoid misunderstandings in the legal process. The present study supports a routine medical statement peer review to minimize the risk of neglect caused by lack of knowledge among authorities working with sexually abused children.