The numerous scars marking his arms, legs, back, chest, and face told the story of the horrific, state-sponsored torture that Mr. A had endured. Mr. A, a 25-year-old man from a small country in West Africa, was persecuted because his HIV/AIDS advocacy contradicted a false “presidential cure” contrived by the ruling regime. On multiple occasions, military police detained Mr. A in a squalid prison where they beat him with metal cables, wooden rods, and plastic clubs; battered him with the butts of their AK-47 rifles; threatened to feed him to the president's crocodiles; simulated drowning by forcibly holding his head underwater; chained his wrists and ankles for hours on end; deprived him of food and water for days at a time; and stripped away his dignity through a variety of other tactics.
Each year, tens of thousands of individuals like Mr. A flee their home countries to seek asylum in the United States (asamonitor.pub/3lNpzCx). To prevail in their asylum claims, applicants must demonstrate that they have been persecuted or have a well-founded fear of persecution based on their race, religion, nationality, political opinions, or membership in particular social groups (e.g., LGBTQ). Whereas individuals indicted for a crime are innocent until proven guilty, asylum applicants bear the burden of collecting evidence that proves their claims. The scars that asylum seekers carry on their bodies and in their minds may serve as the only proof of their trauma. Through forensic medical evaluations, clinicians can identify physical signs and psychological sequelae of torture. Documenting these findings in medical-legal affidavits provides forensic evidence that corroborates asylum applicants' narratives of abuse. Medical professionals can additionally testify as expert witnesses in immigration court, where they can explain their findings and dispel commonly held misconceptions about the effects of trauma.
My colleagues and I met Mr. A through a forensic evaluation organized by the Weill Cornell Center for Human Rights, one of 35 student-initiated asylum organizations housed at medical colleges across the U.S. (asamonitor.pub/39FZL8F; asamonitor.pub/2JMuaas).Nationwide, fewer than 40% of applicants are granted asylum (J Immigr Minor Health 2008;10:7-15). Mr. A, along with 97% of the applicants who received forensic evaluations through a medical college's asylum clinic, was granted legal protection, suggesting that forensic medical evaluations can significantly increase torture survivors' access to safety (Health Hum Rights 2019;21:309-23).
“By identifying and documenting the medical sequelae of abuse, anesthesiologists can uncover forensic evidence – perhaps the only evidence – that bolsters an asylum seeker's petition for legal protection.”
Owing to their clinical expertise, anesthesiologists – particularly those trained in chronic pain or regional anesthesia – are uniquely equipped to recognize the pain syndromes and nerve injuries precipitated by physical torture. Foot whipping or beating (also called bastinado, falanga, and falaka) can result in peripheral neuropathy, suspending an individual from their arms (as in corda, strappado, or reverse hanging) may injure the brachial plexus, forced stress positions that hyperextend the legs may engender lumbosacral plexopathies, while other forms of abuse may leave victims with myofascial or neuropathic pain (N Engl J Med 1982;307:1341; Spinal Cord 2002;40:213-23; J Glob Health 2017;7:010303). Mr. A, for example, continued to experience tenderness over his ribs where officers had bludgeoned him with the butts of their rifles years earlier, a symptom that suggested chronic myofascial pain.
By identifying and documenting the medical sequelae of abuse, anesthesiologists can uncover forensic evidence – perhaps the only evidence – that bolsters an asylum seeker's petition for legal protection. Physical marks that were once visible may fade in the time that it takes an applicant to secure an evaluation, and many forms of torture beget chronic pain without leaving lasting marks. Moreover, the standard forensic medical evaluation may fail to identify pain diagnoses in as many as 80% of cases, which represents a substantial unmet need that could be addressed by anesthesiologists (PLoS Med 2020;17:e1003108). Anesthesiologists can additionally leverage their expertise to help immigration officials understand the consistency between an applicant's pain symptoms and the described mechanism of torture.
The assistance that anesthesiologists can offer torture survivors extends beyond uncovering forensic evidence. An estimated 1.3 million refugees who survived torture – a figure that fails to account for the many asylum seekers who were tortured – currently reside in the U.S. (asamonitor.pub/3ga8qRX). As many as 83% of torture survivors experience chronic pain – including headaches, back or neck pain, generalized musculoskeletal pain, and joint pain – arising directly from their injuries or from overactive protection mechanisms that unconsciously increase muscular tone (Pain 2007;133:5-8; Pain Rep 2019;4:e794). Their pain, however, is frequently misunderstood or misattributed to psychological distress (Pain Rep 2019;4:e794). We are likely to encounter survivors of torture in our routine clinical practices, and the possibility of torture should be suspected and sensitively investigated for any refugee or asylee who presents with chronic pain or poor mental health (Pain Rep 2019;4:e794). By remaining vigilant, we can recognize undiagnosed pain and help direct survivors of torture to care that can significantly improve their quality of life.
More forensic medical evaluators are desperately needed. The backlog of pending immigration cases soared past 1.2 million this year (asamonitor.pub/3lNpzCx). As of yet, anesthesiologists remain underrepresented in the field. Because they already possess most of the requisite skills, licensed physicians need only attend a day-long training and possibly observe one or two cases before performing forensic medical evaluations independently. Interested clinicians can readily learn more through the websites administered by Physicians for Human Rights or the Weill Cornell Center for Human Rights (asamonitor.pub/39FZL8F; asamonitor.pub/2JIzonU). The importance of this work cannot be overstated. Healing begins with safety; obtaining asylum ensures access to safety and, free of the fear of further persecution, allows healing to begin.
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