Testifying to torture: How doctors find the truth

Allen Keller, MD, remembers the first torture survivor he saw as a physician. He was a resident at the New York University School of Medicine and observed as another physician examined a student activist from an African country who authorities had arrested, beaten and tortured.

"What will happen to you if you return to your country?" Dr. Keller asked.

The man paused. "Then," he said, "I will surely die."

It is this kind of valid fear of persecution based on religion, race, nationality, ethnicity, social group or political opinion that U.S. law recognizes as grounds for granting asylum -- permanent, legal protection from deportation. But the law requires asylum seekers to prove affirmatively that their fears are well grounded -- a daunting prospect for refugees who often flee their homes with little but the clothes on their backs and a set of phony travel documents.

Here is where doctors help those in true need.

Many refugees cannot help but carry the physical and psychological scars of their persecution. The marks of torture come as skin lesions, broken bones or mutilated genitalia. Evidence of torture also presents itself as psychiatric disorders that accompany any violent trauma. Physicians such as Dr. Keller who evaluate asylum seekers can document these sequelae and substantially improve an asylum seeker's chance of finding safe harbor in the United States.

These doctors save lives by testifying to torture.

When asylum seekers claim that they are torture victims, asylum lawyers around the country often tap the Asylum Network, part of the 20-year-old nonprofit Physicians for Human Rights in Cambridge, Mass. The Asylum Network coordinates physician education, training more than 600 physicians using a set of well-established protocols for detecting the physical and psychological symptoms of torture. The group publishes a 200-page handbook for asylum examiners based in part on the so-called Istanbul Protocol, guidelines for documenting torture that the United Nations adopted in 1999. More than 90% of the refugees whom Asylum Network doctors evaluate are granted asylum.

Physicians who do asylum work range from doctors who might see only one asylum seeker in a year to experts such as Dr. Keller, a primary care physician and program director of the Bellevue/NYU Program for Survivors of Torture. Dr. Keller has trained thousands of health professionals on how to document torture evidence. During an evaluation, doctors determine how consistently a person's story of persecution and torture matches up with physical and psychological evidence.

Evaluating asylum seekers can be a grueling process, said Marion L. Brown, DO, a 67-year-old ob-gyn who in 2002 retired to Mt. Pleasant, S.C. She spends anywhere from three to six hours doing a single evaluation and so far has seen 12 asylum seekers.

"You have to spend time talking to them," she said. "You need to develop a rapport and get their confidence and trust. That's sometimes very difficult, because they're very scared."

This was especially so for the African victims of female genital mutilation whom Dr. Brown has seen. Dr. Brown usually photographs evidence of torture, but in these cases she draws a diagram of the genital area to respect the asylum seekers' privacy.

Dr. Keller said it is essential for physicians to ease into discussing the trauma an individual has suffered.

"You don't just start, 'Hi, my name is ... now tell me what happened,' " he said. Instead, asylum examiners start by asking more general questions about the individual's prior health and life in the country of origin.

"You often have to pause," Dr. Keller said. "As physicians, we're often not comfortable with silence. Allowing that silence is really important. The individual may be re-experiencing intrusive memories or a flooding of emotions."

An asylum seeker's level of fear and reprehension depends on the individual but also on the circumstances of the evaluation. Doctors see asylum seekers under one of two circumstances. In the affirmative asylum process, individuals arrive in the United States and file for asylum protection within the law's one-year deadline. Their cases are heard by U.S. Citizenship and Immigration Services asylum officers in a nonadversarial hearing, for which a doctor needs to submit only a written affidavit.

In the defensive asylum process, individuals have been detained by immigration authorities and plead for asylum to stop deportation. Those cases are processed by the Justice Dept.'s Executive Office for Immigration Review, and immigration judges make a decision in an adversarial court setting at which doctors' live testimony often is required.

Asylum seekers sometimes lie, though bogus torture claims rarely get as far as a physician evaluation because they are first vetted by refugee groups and asylum lawyers. In cases where physicians don't believe torture took place, doctors are not obligated to file an affidavit saying their findings are inconsistent with the asylum seeker's story. Instead, the absence of physician testimony severely weakens a person's chances of being granted asylum.

While many physicians evaluate asylum seekers on the basis of a single, lengthy encounter, some doctors specialize in refugee and asylum work and have the luxury of more than a single visit. Either way, it often takes time for people to talk about the trauma they have experienced.

Alejandro Moreno, MD, MPH, recalled the case of an Albanian Muslim who fled the Balkans conflict in the late 1990s. Dr. Moreno visited with the dignified, hard-working man more than a dozen times and was evaluating his asylum case. The case did not look good, said the man's asylum lawyer. There was not much hard evidence -- no physical marks -- to support his claim. The night before the deadline to submit his affidavit, he visited Dr. Moreno one last time.

"I had a hunch that there was something there, but I couldn't put my finger on what it was," said Dr. Moreno, an assistant professor of internal medicine at the University of Texas Medical Branch, Austin program, who has testified in court in 15 asylum cases and written affidavits in more than 60 cases.

Asked again about his numerous stays in Albanian prisons, the man told the same story of beatings that left no scars. As the man turned to leave, he said, "I'm not sure if this is of interest to you, but my wife keeps complaining that I soil my pants." Eventually, the man told his humiliating tale. Police had sodomized him with a club during his first detention. He had been living with a ruptured sphincter ever since. Tests confirmed that, and the man received asylum.

The emotional toll

Hearing tales of torture and persecution can be hard, physicians say. Linda Piwowarczyk, MD, MPH, co-founder of the Boston Center for Refugee Health and Human Rights, quotes an African proverb that says, "Whoever wants to hurt never misses the target."

"You evaluate these people and you start saying, 'I don't believe this. This is not true,' " Dr. Moreno said. "You start second-guessing, and the patients immediately notice it -- that you're not trusting, that there's no empathy, that you've put up a barrier."

Experts say physicians who evaluate asylum seekers regularly risk vicarious traumatization and experience their own nightmares and flashbacks. The Asylum Network's mentor program not only helps new volunteers learn how to document torture and properly file affidavits but also gives them an experienced colleague to talk with after particularly stressful encounters.

But the rewards of asylum work are great, volunteer physicians say. "The therapeutic efficacy of the interventions is so powerful," Dr. Moreno said. "Every patient who you help get asylum -- you have saved their life or really improved their life. ... With hypertension, you have to treat hundreds of patients to prevent a stroke or a bad outcome."

Dr. Brown, the retired ob-gyn, gives asylum seekers her cell phone number to build trust and give them a point of contact at a frightening time. Some people she has evaluated call her every year on the anniversary of their asylum grant.

"You can't put a price on somebody saying thank you," she said.