Methodology for the identification of vulnerable asylum seekers

Analysis of the health conditions of migrants and asylum seekers in reception centers: From scene investigation to the evaluation of signs of torture

The phenomenon of migration is an international issue that mainly concerns Europe. In Italy, because of its close proximity to Africa, there are many migrant landings, especially on the islands of Lampedusa and Sicily. Migrants and asylum seekers suffer torture on their journey to their destination country, however, most of the time the signs are not always recognizable. In the present study, a scene investigation was carried out in a reception center for level II immigrants in Sicily, in order to evaluate the hygiene conditions of the migrants and asylum seekers inside this center. Subsequently 26 migrants and asylum seekers, all minors and males, were examined in a clinic of the Department of Forensic Medicine of the University of Catania, with the help of a native speaker interpreter and applying the Istanbul Protocol. The scene investigation demonstrated the poor clinical conditions of the reception center and the failure to comply with emergency regulations. The physical examination of the migrants and asylum seekers demonstrated that all the torture reported had taken place in Libya. However, only 4 migrants and asylum seekers showed signs of violence consistent with torture, compatible with the Istanbul Protocol. Nine migrants and asylum seekers (34.6 %) reported having pathologies and asked to undergo a medical examination in a hospital but were not listened to by the reception center staff. Two migrants and asylum seekers reported having worn the same clothes for several weeks to the reception center staff. In particular, all the migrants and asylum seekers reported having suffered torture using blunt instruments, especially beatings with truncheons. One migrant and asylum seeker reported being detained for days without food, instead 1 migrants and asylum seekers reported being kidnapped-blindfolded-stripped naked for days, and 1 migrants and asylum seekers reported having contracted infections, including scabies, with electrical and thermal trauma. Despite the international commitment to the phenomenon of migration, migrants and asylum seekers continue to receive abuse and torture. Furthermore, most migrants and asylum seekers studies primarily involve surveys, and few have applied the Istanbul Protocol to a sizable sample. An original aim of the study is the use of forensic tools to assess the sanitary and hygienic conditions of a migrant reception center, with the secondary aim of assessing alleged cases of torture.

Forensic medical examination after conflict-related sexual violence: A scoping review of the literature

Conflict-related sexual violence (CRSV) is a form of gender-based violence and a violation of human rights. Forensic medical examination of victims of CRSV can be performed for the clinical and forensic management of patients or as part of the medical affidavit in judicial protection procedures. The aim of this scoping review was to summarize the knowledge on the forensic medical examination of survivors of CRSV by analyzing what types of violence were described by survivors, as well as the outcome of medical examination and evaluation of the degree of consistency, and of protection procedures. After the screening process, 17 articles published between January 1st, 2013, and April 3rd, 2023, on PubMed, Scopus, and Web of Science were eligible for inclusion. The findings of our review confirm that literature addressing forensic medical examination of victims of CRSV is scarce, as well as studies describing physicians' opinion on the consistency of the findings and protection outcomes. Trained and experienced professionals are needed in order to document human rights violations, including CRSV-specific lesions.

Ethical and Forensic Issues in the Medico-Legal and Psychological Assessment of Women Asylum Seekers

Asylum-seeking migrants represent a vulnerable segment of the population, and among them, women constitute an even more vulnerable group. Most of these women and girls have been exposed to threats, coercion, and violence of many kinds, including rape, forced prostitution, harassment, sexual slavery, forced marriage and pregnancy, female genital mutilation/excision, and/or other violations of their rights (e.g., deprivation of education, prohibition to work, etc.). The perpetrators of the violence from which they flee are often their own families, partners, and even institutional figures who should be in charge of their protection (such as police officers). In the process for the acceptance/rejection of an asylum application, the forensic and psychological certification can make the difference between successful and unsuccessful applications, as it can support the credibility of the asylum seeker through an assessment of the degree of compatibility between the story told and the diagnostic and forensic evidence. This is why constant and renewed reflection on the ethical, forensic, and methodological issues surrounding medico-legal and psychological certification is essential. This article aims to propose some reflections on these issues, starting from the experience of the inward healthcare service dedicated to Migrant Victims of Maltreatment, Torture, and Female Genital Mutilation operating since 2018 at the Institute of Forensic Medicine of the University Hospital of Palermo.

Physical assessment of tortures: Interobserver analysis of medico-legal degrees of consistency based on the Istanbul protocol

The Istanbul Protocol section on medicolegal evaluation delineates the guidelines for the correct management of the physical examination and the methods of assigning the degrees of consistency. Considering that most cases exhibit highly heterogeneous lesions, the examiner is forced to rely on his own experience, and their evaluation may be very subjective. The purpose of this work is to understand how subjective such an evaluation may be and whether the "experience" factor, interpreted as years dedicated to this profession and the number of cases evaluated, is statistically significant. To this end, a survey containing eleven cases of pre-evaluated asylum seekers was sent to thirty Italian clinical forensic practitioners. The participants were invited to assign a degree of consistency to each case according to the Istanbul Protocol guidelines, besides answering a few questions regarding their professional record. The doctors were divided into groups based on the number of cases evaluated and the experience collected expressed in years, and then interobserver analysis was performed. Results showed that the Fleiss' Kappa coefficient acquired significant values when attention was turned to the sub-samples composed of more experienced participants. Therefore, the introduction of appropriately trained health professionals - "experts in migrations and torture" - could lower the risks of misinterpretation and make the assessment as reproducible as possible.

Impact of (forensic) expert opinions according to the Istanbul Protocol in Germany-results and insights of the in:Fo-project

As part of a third-party funded project, expert opinions according to the Istanbul Protocol (IP) standards were compiled in Germany on a larger scale for the first time. The assessment process was initiated for 130 project participants. Statistical analysis on numerous variables was performed to test the impact of the expert opinions, foremost of the forensic medical expert opinions, on the individuals' asylum proceedings. The variables were drawn from forensic medical expert opinions and reports of findings, questionnaires for the study participants' counsellors in the project and a query on the asylum status of the study participants. Regression analysis and bivariate analysis on two dependent variables-subjective impact on the asylum procedure from the counsellors' point of view and objective change in the asylum status-were performed to test for an influence on asylum procedures. No statistically significant results were obtained for the objective change of the study participants' asylum status. For the subjective dependent variable, a positive prediction was possible when simultaneously controlling for the independent variables introduction of a forensic medical expert opinion and highest IP grade; a negative prediction was possible when simultaneously controlling for the independent variables introduction of a forensic medical expert opinion and use of IP grading. Apart from the statistical analysis, a positive effect of the assessment on the psychosocial well-being of the study participants could be demonstrated. The results differed from other European studies which demonstrated a correlation between the objective outcome of an asylum procedure (asylum status) and, for example, specific types of violence or the number of documented injuries. Differences also occurred in the use of the plausibility grades proposed by the IP, which questions their use in cases in which the reported torture happened a relevant time ago. Therefore, compiling individually worded evaluations instead of using the IP grading system-if possible, by an experienced forensic physician-is recommended in this scenario. Still, the assessment of alleged torture experiences should follow the IP guidelines, since psychological assessments are of especially high importance in cases with healed physical injuries and since the results also demonstrated a positive effect on the psychosocial well-being of the study participants.

Patterns and evidence of human rights violations among US asylum seekers

BACKGROUND

Asylum seekers report exposure to human rights violations associated with a range of psychological and medical sequelae. Clinical evaluators can provide forensic evaluations that document evidence associated with their reports of persecution. The aim of this study was to characterize the forms of abuse experienced by asylum seekers, the psychological consequences of abuse, and the frequency with which clinician-evaluators found evidence that corroborated asylum seekers' reports.

METHOD

We completed a retrospective chart review of 121 asylum seekers who received pro bono medical-legal evaluations through a human rights program and analyzed data using the constant comparative method.

RESULTS

Eighty-eight percent of the clients reported experiencing multiple human rights abuses. Ninety-one percent of the clients who received psychological evaluations presented with symptoms associated with depression, anxiety, or trauma and stressor-related disorders. Clinician-evaluators found physical or psychological evidence consistent with the clients' reports in 97% of cases. Forms, perpetrators, and psychological consequences of abuse varied significantly by gender and geographic region.

DISCUSSION

Asylum seekers report diverse forms of persecution in their countries of origin that differ by gender and geographic region. Clinician-evaluators overwhelmingly found physical and psychological evidence consistent with the asylum seekers' accounts of persecution.

Migrants’ and refugees’ health: towards an agenda of solutions

Despite the greatly increased numbers of migrants and refugees worldwide in recent years, insufficient attention has been paid to addressing their health needs. While a variety of international instruments assert the right to health, in practice, migrants and refugees—especially those awaiting clarification of their status, such as asylum seekers and those without documentation—often fall in cracks between service providers and humanitarian relief programmes at national and regional levels.

This report provides a summary of the current state of knowledge regarding the health issues of migrants and refugees and of the extent to which they are being met. It highlights, through a series of case studies, the diverse approaches to policies, entitlements and services provided in different jurisdictions, ranging from regional (Europe) and country (Germany, Iran, Italy, Turkey, South Africa) levels to provinces and cities (Quebec/Montreal, Berlin). These provide evidence of successes and challenges and highlight areas requiring further effort, including in the domains of policy, service design and delivery, education and training, research and communication. They also underscore the challenges of highly neglected aspects such as mental health and the critical importance of developing cultural/transnational competence in the health professional individuals and institutions working with migrants and refugees.

Results from discussions taking place in an M8 Alliance Expert Group Meeting (Rome, 23–24 June 2017) and from the literature are synthesised to develop an ‘agenda of solutions’. This agenda aims to provide a comprehensive framework, which bridges humanitarian, ethical and rights-based imperatives to provide a framework for action to tackle this crucial area.

The effect of the medico-legal evaluation on asylum seekers in the Metropolitan City of Milan, Italy: a pilot study

In the present-day situation, the clinical forensic documentation of an asylum seeker's narrative and his or her examination, together with the physical and psychological findings, may have very important effects on the outcome of the request for political asylum. Since 2012, the Municipality of Milan, the University Institute of Legal Medicine, and other institutions have assembled a team with the task of examining vulnerable asylum seekers and preparing a medical report for the Territorial Commission for International Protection (Prefecture, Ministry of Interiors), who will assess the application. We compared medico-legal reports and outcomes of 57 cases which were evaluated by the Commission after having undergone a medico-legal evaluation through the Istanbul Protocol criteria and examined, in particular, which medico-legal variables seem associated to the outcome. The results show that forensic assessment seems to have a significant and interesting correlation with the final assessment given by the Commission. For example, the higher the level of consistency, according to the Istanbul Protocol, the more frequently protection is granted. These data show how important clinical forensic medicine can be in such scenarios and how the presence of clinical forensic experts should be encouraged in such evaluations, as has been recently enshrined in Italy in the guidelines of a Ministerial Decree of April 3rd, 2017 for the assistance and the rehabilitation as well as the treatment of psychiatric disorders in refugees and asylum seekers who have undergone torture, rape, and other severe forms of psychological, physical, or sexual violence.