Welcome to today's webinar, the second in the series, Medical Forensic Examinations for Asylum Seekers, the Clinical Interview and Considerations for Vulnerable Populations, brought to you by the International Association of Forensic Nurses. In just a moment, I'll introduce today's presenters. First, however, I want to mention that continuing education is offered for attending today. To receive your certificate, you must first complete an evaluation. I also need to let you know that the planners, presenters, and content reviewers of this webinar have disclosed no conflict of interest. Case studies presented in this webinar are based on real-life examples, and identifying details have been purposefully withheld to ensure confidentiality is protected. Let me introduce today's presenters, Amanda Payne and Dr. Altaf Saadi. Amanda Payne is a board-certified forensic nurse examiner, currently working on the forensic assessment and consultation team at Inova in Fairfax, Virginia. She was trained in the medical forensic examination of asylum seekers through Physicians for Human Rights at the Yale Center for Asylum Medicine. She's a member of IFN's Social Justice Committee and has served as a representative on the Georgia State Human Trafficking Task Force. She recently authored the paper, SANE, Forensic Examinations for Immigrant Victims, a case study published earlier this year in the Journal of Forensic Nursing. Dr. Altaf Saadi is a practicing neurologist and a graduate of Yale and Harvard Medical School. She is a current health sciences clinical instructor of medicine at UCLA and a fellow in the National Clinician Scholar Program. The goal of the National Clinician Scholars Program is to cultivate health equity, eliminate health disparities, invent new models of care and achieve higher quality healthcare by developing leaders which serve as national change agents. The program drives policy relevant research and partnerships to improve the healthcare system, government, foundations and think tanks in the United States and around the world. Throughout her career, Dr. Saadi has been an outspoken advocate for promoting social justice through equity in healthcare, focusing her research on vulnerable populations, including refugee populations. Dr. Saadi takes asylum cases with physicians for human rights and recently had the opportunity to tour the South Texas Detention Center and Laredo Processing Center to assess conditions and access to healthcare services for detainees. The trip was organized by Human Rights First, who recently released a report on detention conditions there. We are so excited to have her on the webinar today to speak directly about her experience in this field. At this point, I am pleased to turn this over to these highly qualified presenters, Amanda Payne and Dr. Altaf Saadi. Hello, my name's Amanda Payne and welcome to the second webinar in the five-part series, Reviewing the Medical Forensic Examination of Asylum Seekers. The series is tailored for current forensic nurses at all levels who would like to improve their understanding, cultural competency, and framework for working with immigrant populations. It's also intended for those who would like to expand their current clinical practice to include working within the U.S. and international immigration systems. As some of you may have realized in the last webinar, if you're currently working with an immigrant population within the realm of civil or criminal law, your work may not just help solve a crime, it also impacts your patient's immigration status and potentially provide some protection from deportation in an increasingly aggressive immigration climate within the United States. It's important to know that this entire webinar series is founded upon the recommended training content from the Istanbul Protocol. Published in 1999 by the United Nations, the Istanbul Protocol was developed over the course of three years by a team of 75 doctors, physicians, psychologists, human rights monitors, and lawyers representing 40 organizations and institutions from 15 countries. This series is intended to be cumulative and we hope that you've had a chance to listen to the first webinar on the legal framework for immigrant victims and introduction to the Istanbul Protocol. This legal primer is an integral part of understanding how to most effectively evaluate your patients. If you haven't listened yet, it's available for you in the IFN Learning Center. In this webinar today, we'll be discussing the clinical interview and considerations for vulnerable populations. We hope by the end of this session, you will understand the basic elements and best practices of conducting a comprehensive forensic interview of someone seeking asylum or protected legal status within the United States and how to provide trauma-informed, culturally competent care while maintaining your duty as an examiner. In part three in February 2019, we will review the physical examination, torture methods, and their physical and psychological consequences with Dr. Mary Jo Fink, who is the Medical Director of the Human Rights Initiative at Columbia University Medical School and long-time evaluator for Physicians for Human Rights. In part four, we're going to review the evaluation of female asylum seekers, go over gender-based violence, and do an in-depth training on genital mutilation with Dr. Deborah Ottenheimer, a New York-based OB-GYN and evaluator with both the ICAN School of Medicine, Human Rights Clinic in Mount Sinai and the Weill Cornell Center for Human Rights, aiding victims of female genital mutilation, domestic violence, and sex trafficking and their application for asylum to the United States. In part five, we will be with Professor Leila Halaf, who joined us on the first webinar to review writing a medical legal affidavit and providing expert oral testimony in immigration courts. Professor Halaf's teaching and scholarship focus on law, policy, and practices that affect access to justice within the realm of immigration law. Before joining Tulane Law School in 2017, Professor Halaf taught at Boston University's School of Law as a clinical associate professor at Georgetown University Law Center as a clinical teaching fellow and at Loyola University New Orleans College of Law as a staff attorney and Equal Justice Works Fellow in their immigration clinic. Professor Halaf serves on the board of the ACLU of Louisiana and the Clinical Legal Education Association. I'm so grateful that these amazing experts have agreed to contribute to this endeavor. Their willingness and enthusiasm speak directly to the dire need to increase awareness and train more physicians and nurses to conduct these types of exams. Increasing accessibility and availability of trained clinicians around the nation will undoubtedly have a profound impact on individuals and families currently applying for protection in the United States. There are a number of common considerations anyone must make when interviewing an asylum applicant. This applies to medical evaluators as well as lawyers or human rights monitors. The first rule is to remember that the broad purpose of your interview is to establish facts related to alleged incidents of torture or persecution as defined by international immigration law. The person you're interviewing may have gone through multiple traumatic events. However, these may not be qualifying events to receive protected status. And you must remember that to qualify for asylum or protected status in the United States, applicants must show that they meet the definition of a refugee. A refugee is an individual who is outside his or her own home country because of a well-founded fear of persecution on the account of religion, race, nationality, membership in a particular social group or political theme. When persecution is institutionalized within a society or where police and rulers can act with impunity, the threshold at which persecution is seen as an appropriate tool can decrease. The targets of torture and persecution can be those who are obvious political and prominent opponents to those in power or those who are under-recognized as targets, the poor, marginalized, ethnic, cultural, religious, or sexual minority, women and children, or accidental victims, which would be the civilians caught in the crosshairs of wars or conflicts across borders. These marginalized groups can constitute many of the asylum applications in the United States. As we defined and discussed at length in the first webinar, there are many other forms of relief and protection that can be offered in addition to asylum. But for the purposes of your interview strategy, this foundation is important to review here as you consider how interviews are best conducted. Medical evaluations and documentation have a broad scope of use in legal context because they may identify possible responsible perpetrators and bring them to justice, provide supporting evidence in asylum applications, establish conditions under which false confessions may have possibly been obtained by state officials, establish regional practices of torture, identify the therapeutic needs of survivors, and serve as testimony in international human rights investigations. The purpose of the medical forensic affidavit or any oral testimony which you may provide after your interview and exam is twofold. It serves to educate the judiciary and any other legal bodies or communities on the psychological and physical sequela of persecution and torture. It also serves to provide an expert opinion on the degree to which your examination findings may correlate with the allegations of persecution or torture found in the interview. As a medical forensic evaluator, you must be able to communicate your findings clearly and effectively and feel confident in your objectivity and assessment skills. Now that we have a reminder of the purpose and scope of the interview and evaluation, let's get into the circumstances which you may be interviewing someone. Asylum applicants, their lawyers or relatives have a right to request a medical evaluation to seek evidence of torture or ill treatment. Within the United States, however, the burden of proof is on the person seeking asylum. So it's unlikely you'll ever be asked to perform a medical forensic evaluation by a public official. Likely, the request will come from an attorney, legal advocate, or patient themselves or networks you may have set up with your local immigration advocacy agency. Depending on the circumstances, you can ask a few important questions prior to seeing the applicant in order to get a general idea of what resources you might need. Typically, if the request is coming via legal entity, the asylum applicant's lawyer has already done an intake interview. I always ask to see this and ask if it's been done, but it might not be prepared prior to your evaluation depending on the circumstances. At minimum, you should be given a general summary of the persecution. This is a valid time to ask questions and you shouldn't be asked to perform a medical forensic evaluation if it's not appropriate. So, for example, I was once asked by a lawyer who I knew through social circles to see one of his pro bono clients applying for asylum for female genital mutilation. I didn't ask enough questions. I've done so many public exams, I was so happy to see her, but after interviewing her, I realized that she had never actually experienced female genital mutilation. Her family members had. So this was really an inappropriate use of my time and hers to perform a physical exam. You should always ask if there's a suspected genital injury. That's always something you need to ask. This will help you get an idea if there are any gender concerns, how much privacy you need, and if you need access to a pelvic bed or a pulpiscope. In addition to this information, it's reasonable to ask a lawyer for a medical release and access to any available medical records prior to an interview or exam. These records are extremely helpful when writing an affidavit later on, and also give some background on what questions to ask in the interview. As a general expectation, there should be a medical paper trail. If someone declared themselves as an asylum seeker at a border or legal port of entry, those entering the United States at these ports of entries are usually immediately screened for TB and communicable diseases, and they're usually seen in a public health clinic or clinic associated with a detention facility. This is a great source for previous documentation related to your client or patient. This photograph here was provided by the United Nations High Commissioner on Refugees. This is at one of the 45 reception centers for asylum seekers in Belgium, managed by the FEDESIL or the Belgian Red Cross. These are open centers. This means that the residents are free to enter and leave the center. Here, a mother and child receive medical assistance by a nurse who works in the center. Her documentation and evaluation, just like yours, is valuable in immigration proceedings. Some of you may actually work in these clinics close to the border that see newly arriving immigrants, or you may work within the Immigration and Customs Enforcement Health Corps or a contracted detention facility. This training is just as applicable to you and your work as it is for forensic nurse examiners that independently take immigration cases. Many proposals have aimed to improve healthcare and detention facilities, primarily from a legal perspective, by examining due process and constitutional and international human rights violations. Protecting detainees and prisoners from inhumane and degrading treatment, however, takes a multifaceted and interdisciplinary approach, an approach that provides for procedural safeguards as well as actively involved healthcare providers trained and able to provide trauma-informed care within a human rights framework. Such an approach is especially important because there's a high incidence of trauma reported in the detainee population in immigration detention centers. Even if you're not in a position to spend hours interviewing and examining an individual patient, writing a follow-up affidavit and testimony, don't underestimate the potential value and impact of the questions you ask, the care you give, and the documentation you provide within your role. So because of my own personal time constraints and limitations on access to clinic space, I nearly always consent someone, interview them, and then directly perform an exam. However, there are a number of evaluators that perform interviews and then schedule an exam at a later date. You'll have to decide what works best for you and your practice, patient, and resources. The asylum seeker's lawyer should be available before and after your exam to answer questions. However, unless there's a serious safety risk, any police, law enforcement, and even your lawyer should not be present during your interview and exam. If you're seeing someone within a detention facility, you're within your rights to insist on an evaluation at an official medical facility and not at a prison or jail, this request may or may not be honored. If I'm seeing someone in a clinic space or in their lawyer's office, I'll generally block off two to three hours for the interview and exam. If you're asked to go into a detention facility, expect to reserve an even greater time in your schedule. Detention facilities also require a pre-clearance process, and you'll likely be limited in what you can wear and bring with you. Dr. Sati will go into more detail about detention facilities later in this webinar. Before we get into the actual content of what an interview looks like, we'll go over a few best practices. Paramount remembers that the principles of trauma-informed care when interviewing asylum seekers. I personally like the Substance Abuse and Mental Health Administration's definition. They define trauma-informed care as a program, organization, or system that realizes the widespread impact of trauma and understands potential paths for recovery, recognizes the signs and symptoms of trauma in clients, families, staff, and others involved in the substance abuse system, and responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively address re-traumatization. I'm sure this is a review for all of you, but in order to integrate our knowledge about the potential trauma that asylum seekers may have undergone and its aftereffects, we must ensure that the care we provide must promote first physical and emotional safety, and we must establish trustworthiness by maintaining appropriate boundaries and making sure that our tasks are very clear. We must prioritize feelings of control for our patients, and we must maximize collaboration with them, and we must empower them to make decisions about their own life and care. I've never met someone seeking asylum that didn't have an overwhelming sense of powerlessness. Often this feeling of powerlessness is in addition to having some form of physical ailment and post-traumatic symptoms. In my experience, the most important component of the interview and exam is informed consent. This is the perfect interlude after introductions when you can establish a trauma-informed clinician-patient relationship. It's the time where you can most easily set the expectation that you will be a compassionate, accommodating presence. Explaining in detail your role, why you're there, why evidence is being sought, which parts of the investigation will be public or confidential, and giving them the freedom to make choices and refuse will give your patient a sense of control they need to be open with you. Simple accommodations like getting someone a Coke, making eye contact, and providing reassurance go such a long way to establish rapport and trust prior to asking them to disclose the most painful and intimate parts of their lives. It's also important to be informed about local immigration resources and support groups. If you can give people a sense of control while they tell their story, you can empower them when they leave your office by giving them resources on the way out. Even though this isn't a treatment relationship, this is one way you can still provide a therapeutic experience. Prior to your interview, please try to educate yourself and become aware of the religious beliefs, cultural norms of the person you're interviewing. Translators can sometimes help if you have questions before an interview. I can't emphasize this enough. For example, some cultures can avoid eye contact, think you're disingenuous if you smile too much, feel disrespected if you offer a handshake, or be so respectful of medical personnel that it's hard to elicit open message. You may not be able to avoid every taboo, but it's important to be aware and respectful. So gender. Part of providing trauma-informed care is respecting the vulnerability of certain populations. As experienced and practicing forensic nurses, we all operate in this space already. Because sexual abuse is so common among survivors of torture and persecution, same-sex interviewing is often recommended because it could influence disclosure. It's important to note here that male survivors may be more reluctant to disclose sexual abuse. It's important to be sensitive to these things. Please do your best to respect individual choices and try to be as considerate as possible of cultural and individual factors in determining if you're the most appropriate evaluator and the strategies you choose to use during an exam. Children are another special population that need really special care. A parent or guardian should always be involved and present for a detailed history and exam. As a general rule, pre-pubescent children's injuries should be documented and managed by those who are pediatric specialists. If you're not currently trained on the assessment and evaluation of physical and sexual abuse of pre-pubescent children, I would caution you against seeing that population without support. If you work closely with a board-certified child abuse pediatrician or a pediatric forensic interviewer, these are great resources to pull in. If you're requested to do this and you don't have resources and feel uncomfortable, I would contact your local child advocacy agency to see if you could find resources to help. All right. There are obviously certain exceptions and extenuating circumstances to consider for children. You'll need to review each case that's referred to you and use your best judgment. For example, if a parent was claiming asylum because their child was born with albinism, if people in their country had attempted to hurt the child. So these are two sisters, I don't know if this video is going to play, from Tanzania who were granted asylum for this reason. I don't think the link is active. So one of these girls, these were two albino sisters, one of the girls was left missing digits and a limb from an attack related to her albinism. Some people in Tanzania believe their rare genetic condition was related to witchcraft and that their limbs and other body parts carried magical powers and therefore it could be sold. Amazing to me. The girl came to the United States after being sponsored by a charity so they could have surgery. USC's immigration clinic represented the girls with an asylum claim which included a medical evaluation. So in a case like this you can absolutely interview the parent and child depending on the age and document the child's injuries. As an experienced forensic nurse you're likely adept at medical history taking and interviewing in cases of sexual assault, child abuse, or domestic violence and there are some broad commonalities to asylum interviews and exams. Every one of us has likely used a translator before and all the same rules apply as using a medical translator in your current practice. If possible, use someone who's not related or biased in any way. If you go into a detention facility, if possible, bring your own translator. Do not use a guard or other law enforcement official and this has specific importance to asylum applicants. Many asylum applications are based on police or governmental brutality in their home country. Police presence should be noted in the medical report, your affidavit, and it might be grounds for disregarding a negative report. During an interview with a translator, it's important to maintain eye contact with your patient and refrain from the tendency to speak directly to the interpreter. It's also important to observe the body language, tone of voice, facial expressions, and gestures of your patient. During your interview, any statements you make should be based on answers given in response to non-leading questions. Non-leading, open-ended questions are ones that do not make assumptions or conclusions and allow for the person to offer the most complete and unbiased testimony. An example of a non-leading question would be, what happened next compared to, did he hit you then? Avoiding asking questions with lists or demanding a sequential account of events is also important. Often those who've experienced trauma can tell stories which are nonlinear and associative. This isn't news for many of you. As the interviewer, you must be prepared to let the asylum seeker tell their own story as a free narrative, but offer assistance by asking questions that increase the specificity if needed. Questions focused on their sensory experience, like was there any lighting or what did the food taste like? That helps encourage memory recall. Asking too many questions too quickly might confuse the individual or even remind him or her of being interrogated. So instead, wait for breaks in their narrative. Encourage a person to account for what they saw, smelled, heard, and felt during traumatic events. This is often a great cognitive tool to clarify their story without asking pointed questions. Patience is so important here. Another important thing to remember is that the effects of trauma can cause difficulties in recalling and recounting elements of traumatic experiences. Blindfolding, disorientation, lapses in consciousness, organic brain damage, psychological sequelae of trauma, fear of personal risk or risk to others, and lack of trust in you, the examining clinician, can all contribute to inconsistencies or lapses in memory. This is another reason why trauma-informed care is so important in this scenario. Not only is it better for the patient, but you're more likely to elicit a more comprehensive account of events if your patient feels safe, in control, and finds you as a clinician trustworthy. So now that we've discussed the setting of the interview and just general best practices, let's jump into the logistics and basic elements of the interview and exam. These are the components that the Istanbul Protocol recommends in a medical forensic affidavit. The items in red we're going to cover during this webinar. We're going to discuss detention and torture, which may or may not be applicable to certain patients. Don't feel as if you have to frantically take notes here. You'll be provided a packet including a general outline or checklist of an asylum interview following the Istanbul Protocol legal standards with the completion of this webinar series that includes all the items we'll discuss today, and that includes examples of informed consent forms. So after introduction, make sure you obtain informed consent. Informed consent should include your purpose and objective, making sure the person knows this is not a treatment relationship. That's often confusing for many people. It's good to explain that in detail. Consent should include permissions for the use of photography, use of an interpreter if needed, and the limits of your confidentiality. We gave a primer of the rights and expectations of non-U.S. citizens in the first webinar, but you can also discuss your limitations and ask questions of their lawyer if they're available. As you go over their rights and expectations, make sure you define the time allotted to talk, role of anyone else in the room, and offer breaks, snacks, or water. I always offer breaks periodically during the interview, especially if someone is beginning to appear overwhelmed. As part of your affidavit, you'll include your personal qualifications to perform a medical forensic exam, and we'll go over how to do this in the last webinar. But just as a note, I also go over this information verbally with my patients. In general, I find it extremely helpful for patients to feel comfortable and know their incompetence. So the first portion of the interview is to do a normal psychosocial intake in history with a few elements you may not normally ask. The psychosocial history is particularly important in understanding the meaning that individuals assign to traumatic experiences. So name, age, sex, sexual orientation, and identity need to be addressed. Sexual orientation and identity is an important topic here. Not until 1992 did the World Health Organization remove homosexuality from its international classification of diseases. Amazing to me. Depending on the cultural understanding, they may not identify as such, but they may have had same-sex affinities and been persecuted for it. So the discrimination, the social isolation, and stigmatization experienced by LGBTQ people considerably contributes to ill health. That's something that you can go in depth and explore. It's important to be sensitive to the fact that medical professionals in other countries may have been complicit in institutional homophobia. So make sure that you're reassuring your patients. It's so important to make them feel comfortable with you. You should also ask about occupation, hobbies, languages spoken, their education, family structure, and the composition of family, interests, or future plans. Those are all going to be included in your affidavit. Someone's occupation or hobbies may be of particular interest because of the differential diagnosis from, say, lesions on the hands or chronic back pain. So keep this in mind. Occupational records can also be a great source of evidence of changes in cognitive and or psychosocial function. So that's another thing that you can request either prior to or after an interview. You also may need to discuss political, cultural, or religious affiliations and get a sense of what their support system and networks look like. While some of these items are unusual for a normal medical intake, it can be specific and crucial to some asylum claims, but may be unnecessary for others. So you'll have to use your judgment here. Taking a history of alcohol, drug, or tobacco use are necessary. You should also ask about coping habits, sleep hygiene, nightmares, and probe for symptoms of depression and anxiety. Make sure you have an understanding when these coping behaviors or symptoms began and if they're relevant to the asylum claim. So after you take a psychosocial history, you'll need to do a detailed medical and developmental history. Because this webinar is directed at experienced professionals, I'm not going to explain here how to take a comprehensive medical and surgical history. I'm assuming you know how to do this, and we'll review specific items in the next webinar when we go over the physical exam. But you do need to know about taking a medical history of an asylum seeker is the importance of developing a picture of what someone's health looks like prior to and then after the events they're alleging in their asylum claim. So let's look at an example. So recording the develop- recording developmental history for asylum seekers that may have been children or adolescents during traumatic events. So one of my cases was a child used a slave labor on a coffee bean farm and exposed to significant pesticide poisoning. We discussed what her development, cognition, and motor skills were like prior to the exposure and then after the exposure. This type of documentation can be really significant for asylum claims. So later when you put together your affidavit, you can also document your clinical findings with research that can corroborate your findings. So for this particular case, I referenced clinical research on neurodevelopmental effects of pesticide poisoning and matched it with her physical history and evaluation. I also referenced research from the Pan-American Health Organization on the prevalence of certain pesticides and poisoning cases in the area she was from. This can be really powerful documentation and connections. So go in depth. Another good example is history taking about reproductive health. I recently had a woman who was applying for asylum based on female genital mutilation. She recently given birth to a daughter and didn't want to return to her home country because she was so scared her daughter would be subjected to FGM. When I took her medical history, we discussed her reproductive health prior to FGM, post FGM, the acute complications that she had with the genital mutilation. We discussed her sexual health and the psychological impact the FGM had, and we also looked into her inability to deliver her child vaginally. I was able to back this up with medical records from her obstetrician who documented at length in her intrapartum notes the concern of obstructed labor and postpartum hemorrhage. The most important thing to ask yourself as the evaluator here is what's relevant to the case. You're there to document physical and psychological evidence of injuries and abuse, so to correlate the degree of consistency between your exam findings and the statements of the individual. So you have to have a good picture of what their health was like before and after. Okay, so before you dive into asking detailed descriptions of persecution or torture, make sure you ask them to summarize with dates and locations first. This is a trick that will help you later on in the interview and when you sit down to write your affidavit. Once you start getting nonlinear emotional descriptions of events or associative statements, it becomes so incredibly difficult to map out a clear timeline of events for court. Because each case is so different, I sit down before each interview and try to map out what dates and times I'm going to need to figure out. Sometimes if there's been a significant global travel involved, I get out an actual physical map too, and this sometimes can help people illustrate their journey to the United States, because I don't know world geography by heart. So because some survivors may have been tortured or detained on multiple occasions, they may not be able to recall exactly where and when each event occurs. In that circumstance, you may just record by method of abuse rather than documenting it as a series of linear events. So we'll use a mock patient here to illustrate. You get a call from a local immigration attorney who asked you to interview her client. So his ex was the daughter of an opposition leader in her home country. She made a statement to her lawyer that she couldn't return home because she had been detained, sexually assaulted, and tortured on three occasions by government officials who sought to punish her father. So before you get into the details of that detention and torture, try and clarify. Where was she born? Where did she subsequently live? When did her father first become an opposition leader? What were the dates and locations she was threatened and detained by officials? And the dates and path of her travel to the United States? So depending upon the case, sometimes you can ask the referring attorney for your client to sit down and write these details down prior to the interview. However, sometimes that this can be way too psychologically difficult for people. It just depends. The next part, we're going to discuss detention specifically, interrogations and torture. It's important that we go over this. However, these questions and details are also applicable for other forms of abuse and persecution that are relevant to other asylum claims in the United States. If there's been an arrest or detention in their home country, the description you elicit should include these details. To try and get an idea about the circumstances surrounding someone's detention, you could ask these questions. What time was it? Where were you? What were you doing? Who was there? Can you describe the people who took you? What did they look like? Were they military or civilian? Were they in uniforms or in plain clothes? What type of weapons were they carrying? What was said? Was there an identification process of some kind? Did someone record your personal information, take your fingerprints or photograph you? Were you asked to sign anything? Were you restrained? How did they transport you? Make sure you specifically note if restraints or blindfolds were used. The means of transportation and the names of officials that they're known. Next, have them provide a detailed description of their space, the actual physical space that they were detained. You can ask them about the size and shape of the room, its temperature and ventilation, where they slept. Were there insects or rodents? You can ask them about what the person heard, saw, or smelled. What did they eat? You can have them describe conditions related to overcrowding or solitary confinement. So especially if someone was detained for a very long period of time, try and get an idea of their daily routine. You can ask for descriptions of the food and water, their toilet facilities. Were feminine hygiene products available? I found this to be really important. Did the person get sick in detention? If they did, try and ask yourself why. So just like that pesticide poisoning case, the patient hadn't put this together. She'd never seen a medical professional, and she had described all of these symptoms that were really consistent with pesticide poisoning. So try and make those connections if you can. Ask if they had had any contact with other inmates, their family, lawyers, or health professionals while they were detained. Witnesses that can corroborate someone's claims can be really powerful. So if you go further into your interview discussing possible torture, physical, or psychological trauma, make sure you're thinking really critically. It's important to remember that any of these elements may produce physical or psychological manifestations in your patient. I can't overemphasize that it's not sufficient to only document physical symptoms, injuries, or scars. You must document the descriptions of psychological responses to trauma. So discussing detention settings can sometimes be a huge trigger. So during the interview, make sure you're observing your patient's eye contact, startle responses, or other signs that they're feeling stressed. These are important things to document in your affidavit. The next step of the interview is to request a detailed description of the torture, persecution, or interrogation your patient had undergone. I always offer a break at this point to give them a chance to collect themselves if needed. There's a list of a few common forms of ill treatment or torture, and this in no way is exhaustive. We will review torture methods and their medical consequences in detail in part four and go over common regional forms of torture as well, but it's important to remember that international definitions of torture are generally deliberately avoided because torture is such a complex phenomenon. If international bodies created a definitive list, perpetrators would find their way to circumvent it. So make sure you're sort of at least familiar or aware of regional forms of torture and abuse and their terminology prior to beginning your interview. So it's important to remember here that torture trauma doesn't have to be inflicted physically, but even if you're solely a physical evaluator, don't shy away from going to depth about their psychological experience. Even if you can't diagnose PTSD, you're not an advanced practitioner, you can at least document the symptoms that they're going through. So with each traumatic event, you need to ask who was present, have them describe the location and objects they observed around them, ask about their sensory input like temperature or smell. If it's possible, have them describe each instrument that was used in detail. So if electrodes were used, ask what color they were, what size, how many, they can remember. I once had a case where a soccer trophy was heated and then applied to the skin. So my patient's description of the object became really useful because we can match the burn pattern with the object she described. So if they remember anything that was specifically said during the event, make sure you document this in quotation. So it's important, just like we do in normal documentation of patient statements. So it's important to document their positioning, restraints, nature of contact, including duration, frequency, anatomical location, and the area of the body affected. Ask if there was any bleeding, head trauma, or loss of consciousness. It's usually really significant. Ask yourself, was the loss of consciousness due to head trauma? Was it due to asphyxiation or pain? And then, was there medical care provided? And what kind? And can we get that documentation? So after the event is described in detail, you should ask about their physical condition after the fact. Did they walk? Could they use the bathroom the next day? That's usually a big one. Were their feet swollen? There's unfortunately no exhaustive list of questions or a checklist I could give you here to cover every possible scenario. So as an experienced forensic evaluator, you should be able to determine the follow-up questions that are necessary to determine what possible subsequent healing processes may have taken place and what chronic issues they may be dealing with now. So for example, that patient that I talked about with the trophy burn, the metal trophy that it burned, she had complicated healing and had multiple infections. So we were able to document all those things. So you need to ask and assess thought content, affect, and psychological symptoms during and after the event. And as a reminder of best practices, questions should always be open-ended, non-leading, and designed to elicit the most coherent narrative account possible. This will create an opportunity for a more complete description and a checklist. So after you've concluded documenting the detailed narrative from your patient, it's important to document any subsequent symptoms, disabilities, and health issues may be related. So looking at their current health. So in Webinar 3, we'll review the physical assessment of acute and chronic issues associated with specific forms of torture and abuse. But really we should look at their current health now, and even if you didn't know all of those things, you can really get a good picture of what someone's health is now by doing a normal medical exam. So do they have high blood pressure, do they have trouble sleeping, do they have pain, chronic pain anywhere? So as you wrap up the interview, make sure you ask your patient if there's anything else they wish to tell you. Make sure you recognize and acknowledge any emotions they may be dealing with. As you move from the interview to the physical exam, offer your patient a break if it's needed, and then explain the subsequent exam, what you'll be looking for and photographing, and if there are any resources or referrals that may be necessary. So we're going to look at a case study here. This is theoretical. This is somebody who's been in the news lately. So if this person had come to the United States. So reports have recently come out about education and training centers in Jing province in China where authorities have detained members of ethnic minorities who are largely Muslim. So this person, Kairat Samarkand, I may be mispronouncing that, is an ethnic Kazakh who grew up in the mountains of this rural province, which is on the border of Kazakhstan. When he was 11 years old, his parents died, and this person was trafficked. Both his legs were forcibly broken so he'd be able to beg on the streets for this gang, and then he was later forced to sell drugs. He was arrested as a teenager and then sent to one of these re-education camps. So I want you to think critically about what questions you might ask. So how would you look at before and after? What sort of physical and psychological symptoms that he might have? So first we could discuss his family, life, schooling, and development prior to his parents dying. We don't know how his parents died, so that might be significant. It could also be part of his fear in returning to his home country. That's an important thing to explore and discuss. We can discuss the period in which he was trafficked. We can ask him how exactly his legs were broken. What was he able to do before? So could he do normal things that 11-year-old children do? Could he climb trees? Could he play soccer? Did he have friends? So get him to describe these things in his life in detail, what it was like afterwards and then today. So was he in pain? Is he in pain now? What about the psychological impacts of being trafficked? Who did he live with at the time? Who fed him? Where did he sleep? And then we can discuss the re-education camp. So Mr. Smartman had described in interviews about being interrogated, described being awake for 72 hours with cameras aimed at him. So you can ask him about this specific event. So how was he brought there? Who were the people in the room? Ask him about sensory details. So were there bright lights? What was he wearing? Did he go to the bathroom during that 72 hours? Did somebody give him something to drink or eat? He described in the re-education camp about speakers in his room, being woken up with the call to prayer at all hours and being blasted with recordings of a child asking for his parents. So get him to describe all of those things. What was the room like? Ask about sensory input. How many nights was he without sleep or how much sleep did he get? Was he tired during the day? How does he feel whenever he hears the call to prayer now? So here's a quote from one of his interviews from the re-education camp. So they made me wear what they called iron clothes, a suit made of metal that weighed over 50 pounds. They made people wear this thing to break their spirits. After 12 hours, I became soft, quiet, and lawful. The questions you could ask here, let's look at before and after. So if he not soft, quiet, and lawful before being forced to wear the suit, what was he like before? What was he like after? So we would ask about his schedule at the camp. What was a normal day like? He said that the camp no one was ever beaten or tortured, but they were threatened. They were forced to sing songs praising their leaders and to make his bed, have the guards mess it up and make it again. So did that make him scared? How does he experience the world before and after these events? So try and get a good picture of that. So finally, Mr. Smarklin described a suicide attempt which allowed him to leave the camp. He beat his own head against the wall until he lost consciousness. But as an interviewer, what would you do? Would you talk about what drove him to do this? How did he feel beforehand? What were the events building up to that attempt? And then what happened after? When he lost consciousness, where did he wake up? How did he feel? Does he have neurological deficits? Does he still think about harming himself? How is he sleeping and eating? Is he able to listen to music? Does he have nightmares? These are just things you need to start thinking about what you're going to ask in an interview. I hope that was a good example. So now let's examine the interview process. Dr. Saadi is going to discuss the current conditions of detention centers for asylum seekers in the United States. to review the specific challenges of conducting asylum exams in these conditions and what the ethical considerations may be for nurses and health care personnel who work in these centers. Thanks so much, Amanda. I'm really excited to get to talk with this group. So I wanted to begin with a very broad overview of the issues in immigration detention and how that's evolved over the past few years, just to give context of the experiences of individuals in U.S. immigration detention. So one is that there is a bed quota in immigration detention that was placed in 2009 and has increased every year. There's no other law enforcement agency that's subject to a statutory quota on the number of individuals who are held in detention, but obviously this prevents immigration enforcement officials from exercising discretion or even expending alternatives to detention, like sending out people to the community, even for people who pose no risk for public safety to be released to their families. Second, there's been a trend toward increased privatization of immigration detention. So current estimates, there's about two-thirds to three-quarters of detainees who are held in facilities run by private prisons. And what's important, the reason I mention that is because we know, and this is mirrored in data from correctional health, that private facilities have a significant profit motive and they tend to cut corners on services in order to cut costs. And that includes medical staff or care. And this obviously has a significant impact on the healthcare that's provided for individuals in detention, including both physical and mental health services. And in my experience, mental health services, as is the case more broadly, usually tend to see those costs being cut more than others. And third is that the population that we're seeing that's entering detention now is looking very different than individuals who were in detention before. So before, there might have been more individuals being sent out to their families on parole while they waited resolution of their cases. But now we're seeing more children that are being detained. There's been about a five-fold increase just in the past year. And this is not just individuals who are entering a country newly, but again, children that otherwise would have been released to live with their families. There's also new policies that include detention of pregnant women, asylum seekers. And in the case of asylum seekers in particular, and this applies to a lot of people in detention, but as Amanda highlighted, this is a population that has significant trauma exposure. And there have been a lot of reports that discuss how conditions of detention really exacerbate trauma for many of these individuals. There's also been increase in individuals being detained who don't have a criminal history and those who have been living in the US for years. And then lastly, we're also seeing an overall increase in how long people are detained, with those who are held in private prisons actually held for longer. And this is now we're seeing individuals who are being held up for a year or longer. And as a result, we're seeing more chronic health issues that are not being addressed, like diabetes or hypertension. For example, in one of my visits, I spoke to an individual who had a hypercoagulable clotting disorder and then had a DVT while she was in detention. There was a delay in her receiving anticoagulation. And then when she did receive it, was getting very infrequent checking of her INR. So we're seeing a lot more chronic disease management in addition to management of mental health issues and acute urgent care issues, which is sort of a change in how the change in how US immigration detention has looked. So I just wanted to mention these to keep these bigger picture issues in mind, if you were to go see clients in detention. In terms of logistics, Amanda mentioned in terms of the longer time. So there's the pre-work in terms of getting security approval. Typically in my experience, this has included some form of government-issued ID and medical professional license. But this is a lot of times very facility-dependent, so sometimes they've requested multiple forms of IDs or a CV. And so it really depends on the facility. And there's always not the best communication between detention officers. So I always try to go prepared with a paperwork that's stated that I've been approved for an examination and a number for the lawyer. I make sure that the lawyer is available because sometimes there are issues and I've needed to escalate to have the lawyer sort of contact detention officers officially because they've given me resistance in terms of entering the facility. In terms of the exam, the timing, Amanda mentioned roughly two to three hours, but in detention can take much longer. I've needed to spend up to an entire day just for a single exam because of delays because an individual was transported for a hearing, so I was waiting and they hadn't informed me of that in advance. In another instance, I had an individual that was caught up in roll call, so I usually go with a book, a computer. A lot of these detention facilities are in very remote areas, so the internet connection is not very good. So I usually go with a book or something that doesn't require Wi-Fi. But again, there's incredible variation, and I think it's really good to ask the lawyer in advance in terms of the particular context of that facility. And then the conditions for the exam itself can be subpar, so you're very limited materials that you can take in with you. So in asylum evaluations I've done in the community, I'll have a computer or a laptop that sometimes I'll take notes on, but that's certainly not allowed. You're also not typically allowed to bring in a phone or camera to document pictures, for example. So if there are things that I feel like the lawyer could benefit from documenting, I will just let them know. And in their evaluations, whose lawyers are typically allowed to have phones, they might take pictures themselves. You know, you typically... I've had an instance where I could not even take my own pens because the detention officer told me that they had a scenario where someone brought in a pen and was taking, you know, a fancy pen that was taking pictures, and so they had to provide me a pen. And I couldn't even take my own sort of pen and paperwork. So again, a lot of variation, but just overall that you'll have less materials, but typically a pen and paper just so that you can take notes. And then in terms of other just things to be prepared for, you know, sometimes the client or the patient might come to you in shackles and sort of little room in terms of negotiating around that. But again, thinking about someone who has significant trauma exposure being brought to you in a state of even further dehumanization or re-traumatization is something to keep in mind. I've had to perform the exams behind soundproof glass, using handheld jail phones. Obviously, those are substandard, but you sort of do the best that you do. I also have had instances where detention officers have sort of tried to pressure me to wrap up my evaluation. But one of the most important things I've learned in these situations is that you can push back, something not easy for a lot of healthcare professionals to do, myself included, and something I've developed over the time that I've been doing these visits to detention centers. But I think generally just to recognize that a lot of these rules are not set in place and they're very arbitrary in how they're applied. And so generally you can push back and say, look, I know that I can evaluate my patient for as long as I need. And then generally just important to document any of these circumstances. So let's say if someone comes in shackles or if you're being pressured to wrap up your time and you're not successful in negotiating with the officers around this, just document these very carefully. You can mention it to your lawyer as well as documenting it in your affidavit, because that obviously influences the evaluation that you've conducted. And then in terms of the fourth bullet point here, in terms of the trauma that's endured in detention, I just wanted to go into a little bit more in detail about that, because this is really above and beyond trauma that's experienced in their home countries. So within detention centers, experiences of sexual assault, daily dehumanization. In one of my most recent trips to a detention center in California, people described being called trash, nobody, racial slurs. But there's also nutritional issues of being given spoiled or inadequate food. And then also the use of solitary confinement or isolation tactics, oftentimes to manage mental health issues or if someone is acting out in a certain way because of their mental health needs, can be countered with isolation or solitary confinement. So that's something important to ask about. And then another example is I've had a lot of individuals describe having 24-hour lighting in certain housing units, and obviously that affects sleep, cognition, mood. So just thinking about the trauma that's endured in detention and how that can affect your evaluation and sort of how the person who's coming to you, how they're speaking with you. And then in terms of thinking about healthcare beyond the clinical space, so obviously I mentioned the food, right? There's also waiting in line for a pharmacy. There's also issues with transportation. I've had individuals who describe, you know, let's say not being given, you know, wearing like a thin shirt and then being in transport for hours and the AC blasting. Clothing issues, I've had scenarios where women describe getting frequent vaginal or urinary tract infections because of being given dirty clothes. So thinking about healthcare really beyond just what's provided between the clinician and the patient in the detention center. And it really gives you a bigger picture of, you know, a human being who's gone through various forms of trauma, even beyond their immigration experience and within detention centers. And then sometimes there is opportunity for sort of direct or immediate advocacy. So, you know, you write up your affidavit, but sometimes I've had scenarios where I'll discuss with a lawyer, look, I saw this patient, it seems like they really, you know, they haven't been given their hypertension meds. And so sometimes the lawyer sort of can advocate for that patient for a medical need in detention center that's beyond sort of the scope of the affidavit. So it's always good to have that communication and line of communication be very clear. And I think lastly, I just wanted to end is I can't emphasize enough how you can bring humanity to this process because of who you are and just by listening and being empathic. Just a few months ago, I spoke to an individual who had been in detention for about two years, and he was almost tearing up because he said, you know, this is the longest conversation I've had with anyone over the past two years. And it also made me tear up, but I think it was just so meaningful for him to be actually spoken to like a human, you know, for a while, you know, for an extended period of time and being able to share his story. So I really can't underestimate the impact of that just in terms of having this very meaningful connection, even if it's just for a few hours. So then that's where I will end. I think we're open for questions now. I see a question. Should I go ahead and answer it? It's someone is asking, is there an organization that monitors the facilities? So there is supposed to be the Department of Homeland Security has a separate office, the inspector general that is supposed to audit these facilities and provide feedback. And obviously it's sort of like JCO visits. When they announce it, everyone prepares for them well in advance and there are no issues. But sometimes there have been really significant reports coming from the inspector general out of this office of different detention facilities. And then sometimes different immigrant rights groups have authority to monitor these facilities. I just finished a trip with Disability Rights California, which is one of the organizations that does have some overview capacity of these detention facilities. So I think a lot of this is going to be in your state or local area, probably different organizations in addition to the inspector general that is supposed to monitor these facilities as well. Does anyone else have any questions? Thank you so much, Dr. Sadi, for being on this webinar with us. Of course. I want to thank you both for doing this fabulous webinar. It's been really very interesting. Lots of information to digest. Thank you, everyone, again for joining us this afternoon. And we look forward to picking a date for our third in this series for asylum seekers. Have a great rest of your day. Thank you.

webinar

medical forensic examinations

asylum seekers

immigration detention

vulnerable populations

logistics

challenges

advocating for patients' rights

trauma

compassionate care

clinical interview

informed consent

psychosocial history

trauma-informed care

detention centers

private prisons

forensic nurses