Okay. Hello, everyone, and welcome to today's webinar. It is being recorded. This is the fourth in our series on Medical Forensic Examinations for Asylum Seekers, brought to you today by the International Association of Forensic Nurses. We will be offering continuing education for attending today. To receive the certificate, you have to complete an evaluation. So, at this point, let me go ahead and introduce today's presenters, and we'll start with Amanda. I will let you introduce yourself. Hi. My name is Amanda Payne. I'm a board-certified forensic nurse living in Washington, D.C. I've been seeking asylum cases through Physicians for Human Rights since 2016. Physicians for Human Rights is a Nobel Prize-winning NGO, which trains persona immigration attorneys and medical forensic evaluators across the country. I've been the guide through this webinar series. Okay. And Dr. Ottenheimer. My name is Deborah Ottenheimer. I am an OBGYN. I started out doing asylum evaluations with Physicians for Human Rights, as well, about 15 years ago. I've done about 100 asylum evaluations at this point, most of which have been positively adjudicated. And I do a lot of lecturing about this particular topic in an effort to foster increased collaboration between the medical and legal worlds on behalf of asylum-seeking women. Okay. Great. And so, I guess at this point, I will turn it over to you, Dr. Ottenheimer, and you can begin our presentation. So, I would just say, since we are a pretty small group, I will try to attend to the chat box at the bottom. I'm not that familiar with the hands raised function, but if you do raise your hand, I'll try to notice and we'll answer your questions as we go. It seems like a small enough group that we can be a little interactive. I don't have any disclosures. You know that already. But I am going to find my arrow. There we go. So, just overall, we're going to talk about the specifics of the evaluation of women asylum seekers, which is a little bit different than the more traditional vision of asylum seekers who have been imprisoned or are victims of political persecution. We're going to start out talking about gender-based persecution around the world. We'll describe some of the major forms of violence against women that are grounds for asylum. About half of my time is going to be spent talking about female genital cutting, because that is a space that many American practitioners have very little experience with. And then we'll spend a little bit of time talking about writing up your findings and ways that you can tell the story in a convincing way. So, I'm a little bit of a history geek, I have to admit. And I do like legal history, even though I'm a doctor. And I just want to point out that the first notion of human rights was really enshrined in the Universal Declaration of Human Rights, which was ratified in 1948 as a response to the atrocities perpetrated in World War II. At that time, not surprisingly, the UN was, well, it still is, largely male-dominated. And they put together a beautiful document, but they really failed to recognize that some people are more disenfranchised than others, and less likely to be able to obtain these rights. And there are lots of groups, religious, sexual orientation minorities, but a really big group of people that they left out was women. So, it took a long time. It took until 1979 for that to be officially recognized by the body when they passed the Convention on the Elimination of Discrimination Against Women, which is another amazing document, very inspiring. And they have, they list a specific mandate to eliminate a number of kinds of discriminatory behavior, and systemic around the world, but they also missed a really huge problem that is going to be the focus of what we talk about today, which is violence against women. Really without, with the exception of the trafficking prohibition, they don't address that in the document. So, I'm sure you all know because of the nature of your work that women suffer violence throughout their lives at the hands of multiple perpetrators. This talk is about asylum, so we're mostly focusing on things that are happening to women outside of the United States that is in no way meant to excuse what, excuse the behaviors that we see here in the U.S., it's just that it's not relevant to asylum. But the life cycle of violence against women around the world really starts before birth with sex-selective abortions, and it continues through infancy with differential access to resources, female infanticide, child marriage and girlhood, sexual abuse, female genital cutting. In adolescence, there's also forced marriage and dating violence, etc. Reproductive age, and then all the way to old age where there is targeted abuse of widows and older women. And then at any age, women in conflict zones are targeted as victims of sexual violence as an instrument of war. So, I'm sure that you heard about the five protected grounds for asylum, I'm going to guess in your first talk. But just to review really quickly, there are five protected grounds on which you can base your asylum claim. You have to show a past or well-founded fear of ongoing persecution on account of race, religion, nationality, political opinion, or a membership in a social group. And that last one is a pretty gooey legal construct, and that is where violence against women sits. That is where asylum cases being argued on the grounds of LGBTQ status are also situated. And your fear has to be based on actions committed either by a government or by persons a government is unable or unwilling to control. And again, usually in a violence against women or a gender-based case, you're talking about the latter group of perpetrators who the government is largely unable or unwilling to control. So, what's different about prosecuting human rights violations against women is that you really have to situate the violence in the context overall cultural disregard and discrimination. And you need to be aware of that when you talk to your clients. We do call them clients, not patients, because the asylum interview is not for rendering medical care, but it's really for a forensic evaluation, which I'm sure you guys are more aware of than most. The human rights against violation may be so common that it's not even considered persecution in the country of origin. It's often culturally sanctioned, even if it's illegal. So, that speaks to the persecutors who the government is unwilling or unable to control. And women rarely seek help from the police or other authorities since they are often perpetrators of abuse themselves. So, this really stands in contrast to the stories of political persecution or imprisonment that you see in asylum cases where there's a real clear beginning, middle, end. The perpetrators are nameable. They often wear uniforms. This is a much more difficult case to argue and a much more nebulous space that we occupy. And so, when we present the case, all of this needs to be put into context for our readers in terms of the readers of the affidavit. So, persecution in gender cases is judged on the nature of injury inflicted, the severity of the harm, the patterns of abuse by a particular perpetrator against the victim, and the existence of permanent or serious sequelae, mental or physical. So, that is – those are really important points to remember later when we're talking about writing the affidavit. So, just a little bit more legal scholarship, I guess. This is really new. So, until 1995, we really weren't looking at violence against women as a justification or a basis on which to claim asylum. In 1995, the most amazing lawyer ever, Karen Musalo in California, argued and won the matter of Kasinga, which was the first time that a female genital cutting case was considered grounds for asylum. And then, it was a long time. 2012 was the first sex trafficking case, and 2014 was the first domestic violence case. So, this is pretty new case law. And those of us who've been doing this for a while, we're getting super excited until 2018 when Jeff Sessions, then the Attorney General, reopened the matter of AB, saying that the Board of Immigration Appeals had made a mistake in their judgment and that, in fact, this woman from Guatemala, who had been a victim of severe and ongoing domestic abuse that was quite life-threatening, should not have been admitted to the United States as an asylum seeker, should not have been granted asylum, and then went on in his advisory to really undermine a lot of the pre-existing case law. So, actually, Karen Musalo was the lawyer on that case as well, and I called her up after that decision was rendered pretty much in tears, and she said, you know, all is not lost. Domestic violence victims, other victims of gender-based violence can still be granted asylum, but it's going to be a lot harder. She reminded me that the opinion is a guidance, but it's not binding, and every judge and every asylum officer has the right to consider the case on its own merits, and, in fact, they must be still considered individually, but it really, really increases the need for evidence and expert testimony, and that is why we're here today, because many of us who've been doing this for a while believe strongly that the medical-legal partnership is going to become vital for the defense of asylum claims. So, and, of course, this has been in the press a lot lately, and we see a lot of conflicting stories. I don't know if you didn't see these stories in the New York Times. I would definitely have a read, but there are lots of them, and they're confusing to the public and even to people who do this all the time, because on the one hand, as the system reaches breaking point, and on the other hand, you have stories of women who are suffering unbelievable violence, particularly in the Northern Triangle. So, we're going to talk briefly about a few different forms of gender-based violence. You're going to see a lot of maps. I wouldn't get too worried about them. They are all from my favorite data website called Women's Stats, which is an incredible repository of data about the treatment of women all over the world. In this particular case, these maps are looking at an aggregate estimate of women's physical security, and I think the take-home point is that the map on the left is from 2009, and the map on the right is from 2014, and the world has gotten a lot redder. Women are much less safe than they once were, and we were never all that safe to begin with. Some forms of gender-specific violence are not so common here in the United States. One of them is acid attacks. The incidence of acid attacks is actually unknown. It used to be very much in the news, especially in the UK. Now, not so much, but it's a common practice in Southeast Asia. It is on the rise in Europe and the Middle East. It's very cheap. It's very easy. It's basically someone drives by on a motorcycle and throws acid at someone. It's most commonly aimed at women to destroy their beauty, usually in response to a perceived slight rejection of a suitor or immodest behavior. A much more severe issue is that of honor killing. Honor killing is perpetrated usually by a woman or a girl's male relatives and sometimes accompanied by men in the community. It is enacted in retaliation for perceived immodesty, whether it's in dress, or being overeducated, or being seen talking to someone you weren't supposed to be talking to, specifically a man, not having your head covered properly. These two stories are a little bit old. One of them, the one on the right, was actually made into a movie. Women do survive these attacks, but many don't. It's thought that there are about 5,000 cases a year, or at least that's what we know of, but that has to be an underestimate since 800 million women live in the United States. It's a very small number, but it's a very small number. It's about 1,000,000 women live in honor-shame societies where this is an accepted practice. By honor-shame society, I mean that the honor of the family, or the shame of the family, resides with the perceived chastity and purity of the women in the family. Some more maps. Again, the take-home is really that the world got more orange and red, but essentially this is showing that the inequity in family law around the world has also increased. That is to say, women are less able to own property, less able to take custody of their children, less able to get divorces, et cetera. They're much less protected under the law. That is part of the argument for asylum cases, which is that the government will not control the perpetrators. In these articles, they're just press articles talking about domestic violence, which we know, even when it is illegal, is often left unpersecuted. A lot of times I get some comments about the fact that, well, what about female violence on men? That certainly happens. Certainly, there's intimate partner violence in same-sex couples as well, but the vast majority of intimate partner violence is male on female. Almost one-third of women around the world who've been in a relationship report some sort of physical or sexual violence at the hands of an intimate partner. Thirty-eight percent of murders of women are committed by a male intimate partner. Factors associated with increased risk for violence and homicide are low education, exposure to violence in your own family or child abuse suffered by the perpetrator, alcohol abuse, and, of course, cultural attitudes accepting the violence, accepting violence and gender inequality. The sort of final culmination of that is femicide, which is very common in South and Central America, and one of the reasons we see so many women and families trying to come to the United States from the Northern Triangle, femicide is different than honor killing. Obviously, in both instances, the murder is the intent and often the result, but the antecedent intentions are different. So, in honor killing, it's really a punishment to a woman for somehow sullying the family honor by misbehaving. Femicide is really an extreme form of domestic violence that is tolerated in places where women's lives are not particularly valued. So, in the literature, there's a kind of a false division between physical violence, sexual violence. I'm going to sort of go with that, although I think we all know that it lives on a continuum. And the sexual violence you guys are really familiar with, and rape is the same no matter what country you're from, but one thing that you may encounter in asylum work is the concept of conflict-related sexual violence, which is a little bit different. In 2017, the UN did a long report about conflict-related sexual violence. They defined it as rape, sexual slavery, forced prostitution, pregnancy, abortion, sterilization, and marriage. And they did include men, women, boys, and girls in their report, although the vast majority of the victims were women and girls. They reported on 19 nations in current or past conflict, and I didn't list all 19, but this is just a few chosen to show you that this is a worldwide phenomenon, that it's not centered in one part of the world more than the other, more than another. So, the International Criminal Court has declared that conflict-related sexual violence is a crime against humanity. It is used as a strategic tool to destroy communities and shift ethnic balances to cause community demoralization, and there is also financial gain, particularly in trafficking women and girls from the conquered population. On the right, you can see a few examples of some of the more famous instances of massive sexual violence in conflict zones. Of course, the Democratic Republic of Congo is an ongoing conflict, and that's a super old number. And most of these are never prosecuted, and most are never documented. Maybe more familiar are the stories of the Yazidi women who were taken by the Islamic State to be sex slaves and basically passed from soldier to soldier before they were to go serve as suicide bombers, and they were very systematic and deliberate about their use of women down to the fact that they also purchased huge amounts of birth control so that they wouldn't be inconvenienced by an accidental pregnancy. But you may run across these kinds of stories when you are seeing asylees, and so it's important to understand the context. Human trafficking is another form of violence that often forms a part of a woman's story. In 2015, the world map looked something like this, and I would say the really sad part about this map is that there's no country that's bright green, so there's no country that meets the criteria of the Women's Stats folks for being classified as trafficking is illegal and rare. Most of the places, well, the United States, Canada, Europe, and Australia are all sort of have enforcement issues, but a striking amount of the world is yellow, orange, and red. So the definition of human trafficking is pretty long, and I'm not going to read it to you, but suffice it to say that it involves recruitment, transportation, and exploitation of human beings through coercion, abduction, or deception. And it includes not just sex slavery, but also forced labor, servitude, and also the removal of organs. Human trafficking is no more and no less a modern form of slavery. It is an extreme form of labor exploitation, regardless of what labor is required, and it is the second largest criminal industry in the world. It's the fastest growing criminal industry. The only thing that's bigger is drug trafficking, and about 45 million people were estimated to have been trafficked in 2016. Women and girls are particularly vulnerable to trafficking because of the overall lack of opportunities worldwide and the overall poverty of many women and girls. In a video I watched recently from a town in Mexico, which is known as the sex trafficking capital of the world, Teninzingo, one of the traffickers said, you know, it was way better to traffic in women and girls because unlike drugs, which can only be used once, you can sell women and girls over and over and over. So trafficking in women and girls includes sex trafficking, but it also includes forced marriage. Forced labor is usually split evenly between men and women, male and female victims. Forced marriages usually involve young girls or teenagers marrying older men, so boys are not usually part of that space. And it's important to remember that child marriage is operationally forced marriage since children really can't consent. And this is a very common piece of my asylum client's stories. So of course poor girls are two and a half times more likely to marry as children, and in many ways child marriage fits the definition of slavery as girls are often forced to work under threat of punishment, they're treated as property, their movements are restricted, and they're certainly forced into sexual servitude and pregnancy. So the practice of child marriage is still pretty red and yellow in the world. So the map on the left, again, is from 2007, and the map on the right is from 2015. And child marriage happens everywhere, and it certainly happens in the United States, but like I said, that's something that we're not going to talk about today because that's a different topic. And these are just some examples from articles of what child marriage might look like. Imagine this little girl who gave birth to this little boy. So as medical professionals, the obstetric complications inherent in that picture are unbelievable. These little girls are going to be basically treated to resolve a family dispute, and then these little girls are all getting married all together on the same day. So we're going to spend the rest of our time, well, most of the rest of our time talking about female genital cutting. Depending on where you live, you will encounter it more or less in both your daily work and your asylum work. And I just lost my mouse, sorry. So the World Health Organization defines FGC as all procedures that involve partial or total removal of the external female genitalia or other female genital organs for non-medical reasons. And I do a lot of work and research around this topic, and again, not for this particular talk, but there is obviously a lot of controversy about the practice of cosmetic genital surgery in Western countries and its relationship to female genital cutting in other nations. So there are a lot of false assumptions about female genital cutting. The biggest one is that it only happens to Muslims, which is absolutely not true. It happens in the Christian community. It happens in animist communities. It is not only children who are at risk. They certainly feel pain, although there is some thought in some communities that if you cut a baby that they won't really feel it, and so then it won't be so bad. FGC is a crime in the United States, and if anybody's been following the federal case from Michigan, you know all about that. And if you haven't, I can tell you where to read about it. It does occur in the United States. It has many physical and psychological consequences. It's really not okay in a medical setting. There's some thought. Some people believe that if it's a doctor or a nurse who's doing it, that that makes it okay, but international medical guidelines say otherwise. And finally, it is different from male circumcision in some pretty fundamental ways, and that's a big ethical debate that we also can't enter into in this forum, but I think it's an important point. So overall, the international community agrees that female genital cutting is a human rights abuse. It violates discrimination, edicts about discrimination against women, the rights of the child, and the Universal Declaration of Human Rights. And in 2008, the UN put out a multi-agency statement calling for the elimination of the practice. So one question that always comes up is, well, this is a cultural practice. How can we say that it's not okay? And international law speaks to this, as do a lot of ethicists, and basically you're free to practice your culture and your religion until you impinge on the rights of the individual, and that is where your right to your own freedom stops. And it is a really complicated issue. So Dr. Tubia is an OB-GYN who was at Columbia for a long time and now is home in Khartoum, and her book was written extensively on FGC, and she points out that we have to really engage the practice in its fullest social complexity before we can eliminate it or talk about it respectfully with people who may favor the practice for one reason or another. And that's the only way we'll ever change minds and eliminate the practice. So a lot of women and girls in the world are affected by this. About 200 million women worldwide is the current estimate. We often think that this is just an African problem, but it really is not. Girls in Africa are affected, but so are girls in Indonesia, so are girls in the Bora community in India, so are Kurdish women in Iraq. In Yemen, it happens in – there was actually a recent article about an FGC clinic in Moscow. It happens in Georgia, not the state but the country. It happens everywhere, and I think it's also important to remember that it's something that we also did. Until 1977, the United States insurance industry was paying for clitorectomies, which were deemed as medical treatment for girls who were seen as hypersexual or excessively masturbating or lesbians. So globally, another map, just to, again, bring home the fact that this is not a problem that's – a practice that's relegated only to the African subcontinent. And it is also present in the United States, partly because of – or largely because of immigration patterns throughout the world. So most recent estimate for us is about half a million girls and women in the U.S. are cut or at risk, although the CDC would be the first to admit that those are pretty sketchy numbers. So those are pretty rough estimates based on immigration from practicing nations multiplied by the number of women, multiplied by the practice in the home nation. Right now, they're actively working on putting together a project where real numbers and real intervals will be had, although it will be difficult to collect that data in a time when immigrants are not feeling terribly trusting. And we're asking them to talk about something that is not considered acceptable in the United States to begin with. There are two primary ways that girls in America are at risk, whether they were born here or brought here as little children. Often girls can be sent to their home country for what's called vacation cutting, because they go home over summer vacation. Around the world, summertime is known as cutting season, because girls can undergo the procedure and recover without missing school. There are also reports of cutting happening in the United States of communities coming together to pay someone to come and do the procedure on multiple girls in the community. Also in the United States, the clusters of women and girls who are affected are in the pink states. New York and New Jersey are home to about 65,000 potentially affected or cut women and girls, and that's where I'm from. And these clusters are largely an artifact of refugee resettlement, and there are lots of other areas that are affected. There's a big FGC project in Portland, Maine. There's another one in Phoenix, Arizona, but these are the most prominent places. So performing female genital cutting is not what we would want to think about so much in terms of surgical procedures. On the right side is a picture of sort of an old-fashioned set of tools, but I've certainly had asylum clients describe these kinds of knives and homemade tools to me as the implements that they were cut with. A more modern kit is on the left, and at the very least, the razor blade is wrapped, but still not quite what you'd want for a surgical procedure. And in many instances, there is coercion, there's abduction. I've never heard of it being done with anesthesia, and very often, there is binding of the girls afterwards, depending on the tradition and the ethnic group from which she originates. And it's usually done in groups, so these little girls were all cut and they're being checked by older women to see how they're healing. Most of the time, the blood is stopped using local herbal medications. I have had a number of clients who reported having to go to the hospital afterwards because of infections or hemorrhage, but the initial treatment is usually local herbal medication. In terms of terminology, which is important when you write an affidavit about this, the WHO defines four major types, and we'll talk about the subtypes in a few minutes. Just fair warning, we're going to look at real pictures, which I just thought I'd let you know in advance. They can be a little disturbing, but I don't need to read all four of these to you. I would say that in terms of professional discussions, those of us who work in this field try to avoid the use of the word circumcision with colleagues or in talks because it implies equity with male circumcision. Although, when I talk to my clients or my patients during visits, I use whatever words they are comfortable using. This is just a cartoon to help you remember what the different types are as well. This is a cartoon of normal female anatomy, which is familiar to all of us, I think. Type 1 is the removal of the clitoral hood or the prepuce, and that would be type 1A. Type 1B also includes the removal of the clitoris or the external clitoris, because there's quite a lot of clitoral tissue inside the vaginal vault. This is what it would look like, which if you're in a hurry, you might miss, or if you're a student, because this could be subtle if you're not really looking on the outside. When I teach residents, I always remind them their job is not to just get the speculum in there. They have to look at the entire vulva. Type 2 is divided into three subtypes. Type A is the removal of the labia minora. They can be fully removed or sometimes they're just partially removed, but the telltale is that the edges of the labia minora are straight instead of the naturally occurring, more redundant and regated appearance. Type 2B involves removal of the labia minora as well as the clitoris and clitoral hood, Type 3, they also slice off the external, the labia majora, so that you end up with a completely flat vulva. Type 3 is really any of the above with the apposition of the labia. Type 3A is when they sew together the labia minora. Type 3B, they sew together the labia majora. Underneath the scar, the clitoris may still be intact. It may not be. It may have been removed. It might not have been, same with the labia minora, but ultimately the distinguishing feature here is that the vaginal orifice is largely obscured, which you can see here. This person has a couple of stitch marks. You can see that one better. And this little hole is where menses and urine have to exit. And so you can imagine a multitude of complications as a result. And Type 4 is kind of the catch-all for everything else. I find it interesting that this paper chose piercing as the example since it's also common in so many other settings. But pricking, pulling, scraping, cauterization, I've had clients tell me that someone put in a caustic substance into the vagina to cause a seal basically was acid that caused the vagina to scar closed. But really anything that doesn't fall into those other three categories is Type 4. And some of my clients, these are two of my clients, were then marked as having been cut. That way, potential suitors or suitor's families didn't actually have to look to verify that they had been cut. They just had to find the marks to show that it had happened. And so if in the course of an asylum evaluation, you see marks like this, it doesn't necessarily mean that they're related to female genital cutting, but you absolutely need to ask what they mean to that person in that person's community or ethnic group. I was asked specifically to address some pediatric questions since some of you work with the pediatric population. And it is a really tricky space. Dr. Janine Young, who's at the University of Colorado, is sort of the expert in the United States on pediatric female genital cutting. And she was kind enough to lend me some of her slides. We forget that it is really a pediatric problem and a pediatric practice. There are no national or international clinical practice guidelines. There are no training slides. There are no standards requiring training at all. Janine is currently working on guidelines through the American Academy of Pediatrics, and we're hoping that they'll be published soon, sometime in the summer maybe. And we think of it as a problem of grown-up women because we think of it in terms of obstetrics. But when you look at the age at which daughters were cut according to their mothers, the vast majority have been cut before the age of 14. So they're all pediatric cases. And depending on the country, the practices are different. Some places cut newborns or toddlers. Some places sort of more middle-aged children. Overall, the age of cutting is going down. Some people think that's because there is an increasing body of law that makes it illegal in many practicing countries. And so if you cut the children younger, the thought is that they won't be able to tell what happened to them as well. It's also worth saying that generally speaking, the severity of the cutting is starting to march towards the less severe types. So for those of you who don't look at little girls too often, this is a normal pediatric vulva, obviously, in the operating room. But the labia minora are really small. The labia majora are big and puffy, and when you're not spreading them, they cover just about all of the structures. The vagina is small, the urethra is a little bit hidden, and the clitoris and clitoral hood are not particularly prominent. So a big problem with diagnosing female genital cutting in infants is that there are a lot of lookalike conditions, including labial agglutination. So in this particular case, if you weren't really on the ball, you might think that this was a case of female genital cutting, although here's the vaginal opening. And this is the agglutinated labia, and the labia minora and clitoris and clitoral hood are all intact, and probably so is the labia majora, we just can't see it. So this is a great masquerader, and it's really hard to tell the difference sometimes, like in the next two slides. So this is an example of labial agglutination, and the labia are kind of stuck over top of the, oops, I didn't mean to leave that arrow there, stuck over top of the clitoral hood. And this is a case of, my slide not going forward, there we go. And this is a case of either type 2B or type 3A female genital cutting. They look pretty similar. So this person, here's the remnant of the labia minora, here's the vaginal orifice. The clitoral hood has been taken away, and the 3A question mark is, has this been purposefully sutured in the center or not? But when you compare it to this, it's pretty hard to tell the difference. So that is a really good example of where the story and the cultural situation is a vital part of your assessment. And then finally, in the pediatric world, this other one, this scar that you can see, there's a question about whether it's type 1B, so was the clitoral hood and clitoris removed, or is it type 4, where a ritual nick was made, and that's the leftover scar? And obviously, if you had the child in your presence, it might be easier, but this picture was evaluated by a number of experts, and there was a lot of disagreement on which one of those it was, based on the photo evidence. So we're going to turn quickly to complications of FGC. Most of them you can imagine pretty easily. What's important when you write your affidavit is to educate the adjudicators about the fact that it's not a one-time event, so that we meet the criteria for ongoing harm, and so that we can talk about the severity of the harm. So there are short- and long-term physical consequences, psychological consequences, and the other thing that's super important is that some women require opening before their first intercourse, like this person, right, this, whoops, this person cannot possibly have intercourse. And in countries that practice this type of, this severe type of FGC, often the opening will be performed by a traditional cutter, maybe even the person who did the original procedure, or sometimes it's incorporated into the ceremony. There are places where it's the husband's job to open his wife before he can have sex with her. And then there are other traditions that demand reclosure after childbirth, which means that women are open to give birth and then reclose, and then they get pregnant again, and they're opened and reclosed. I recently had a case where that happened to someone four times. So short-term medical sequelae are exactly what you might imagine, hemorrhage, pain, infections, especially with multi-use of unsterile instruments. I would say in all of the women who I've interviewed for asylum cases, every single one of them either saw someone die on the day of the cutting or knew or had a relative or a friend who had died due to complications later on, usually obstetric. Long-term medical sequelae include genital tissue damage, a lot of chronic vaginal discharge and vaginal itching, menstrual problems, especially in the more severe types where the vaginal opening is blocked, reproductive tract infections, chronic pelvic pain, chronic UTIs and pain on urination. There are obstetric complications as well. Caesarean section is much more common. The scar tissue is not as stretchy as the normal originals or the uncut originals, so obstetric tears and lacerations are more common, and there are some effects on the infants as well. It's really important to remember, and this is another thing I try to educate the adjudicators about, the severity of the complications, whether they're mental or emotional or physical, is not linearly related to the severity of the cutting. They relate to the trauma. They relate to the unique way in which each woman heals from her injuries as well. Of course, disorders of sexual function are an issue, and these are all things that I talk about in my affidavits. And then psychological sequelae, the immediate ones often involve feelings of betrayal and mistrust since it's often aunties and grandmothers who initiate this practice, sometimes through some trickery or abduction. And long-term, there is the issue of sexual dysfunction or the fear of intercourse. PTSD, anxiety, and depression are very common. I just finished a—we just did a study last year at Mount Sinai, and over 90 percent of our clients had at least two, if not all three, long-term psychological sequelae present. And then finally, of course, there's the fear for their daughters. Okay. So we're going to talk briefly about the asylum interview, and then I think we'll be good for questions. Are there any questions so far? Okay. Oops. The screen blinked, but I'm going to say no. Okay. Oh, somebody talking? All right. Amanda, are you speaking? No? Oh, it said speaking. So when you're writing your affidavit, and I'm sure you talked about this in the other seminars, it's really important—and I probably beat this to death now—to describe the culture in which the events occur. It's super important in gender-based violence cases, and it's also really, really important to educate the judge and educate the—or the asylum officer about in-country conditions for specifically women in our case, and about the fact that there are likely to have been multiple types of abuse. So this is from a paper that we're just putting out from Cornell. We looked at five years' worth of female asylees who presented to the Weill Cornell Center for Human—Clinic for Human Rights, and we found that when we look at all women, almost all of them experienced physical, psychological, and sexual trauma. Only two in our entire sample of almost 90 experienced only a single type of abuse, and the vast—all the rest experienced at least two, and usually three. And they experienced these abuses at the hands of families, partners, and other, including strangers, police, government officials, and political groups. And again, it's unusual for anyone to have suffered abuse at only the hands of a single perpetrator. Most people suffered multiple abuses at the hands of multiple perpetrators. And that's an important piece to bring to your asylum affidavit. Super important details is to talk about family structure, education, were they allowed to work outside of the home, was their marriage arranged, was it a punishment, was there a financial transaction, how many years older is the husband than your client. What number wife was she? Very often, my clients have been wife number two or three or four. And again, just to educate your readers about the physical, psychosomatic, and psychological consequences of violence against women and girls. A lot of the judges don't get it. They don't know. And it's surprising what they don't know. I had one case where a woman was repeatedly beaten severely in the abdomen to cause miscarriage, which succeeded. And the judge did not believe that that was a phenomenon until I wrote my affidavit and explained at some length that actually abdominal trauma can cause, severe abdominal trauma can cause miscarriage. And because I was able to educate that judge, that person was granted asylum. So we have a really important role to play. Particular to the exam, and you probably, although I'm not sure, you did hopefully go over this in other talks, but you must have a non-related translator. I mean, you should in the regular medical clinic as well, but especially in a legal proceeding, the translator can't be the kid or the friend who speaks English. It has to be a non-related translator, preferably a certified translator. Something that happens a lot in these interviews is that you'll be sitting with your client and a translator, and they'll start having a conversation. And that's not the job of the translator. You need to redirect them and remind them that their job is to only translate the words that go from you to the client and the client back to you, not to interject their own conversation. So if they have a five-minute conversation and then translator said, she says, no, you kind of know that that's not what she said. And it should be the job of the attorney asking for your services to arrange the translator. You always need to use a trauma-informed approach in these exams. The client should be allowed to specify the gender of the examiner. I don't allow male observers. Occasionally, I have had male translators, and we have worked around it, but it's not ideal. As a physician, I never wear a white coat, but certainly don't want to wear the trappings of authority in these settings. I always acknowledge what my client has been through. And I remind them that I know that this is a really traumatic and re-traumatizing telling of their story, but that it's really important for their asylum application. And I usually apologize for that, because it is a terrible system, and it's terrible what we have to put people through to get the affidavits written. Modesty is super important. I usually examine my patients in like an extra large cloth gown so that they're completely covered from head to toe as much as possible. And while I do examine every part of their body, I only uncover a little bit at a time so that they don't feel vulnerable. And then finally, a lot of us who aren't mental health professionals end up getting asked to do at least a little bit of a psychological evaluation. There just aren't enough mental health professionals doing this work right now to meet the need. And one way that you can do that is to learn how to administer some standardized questionnaires like the Hopkins Symptom Checklist, which looks for anxiety and depression, the Harvard Trauma Questionnaire, which looks for PTSD, or the PHQ-9, or the GAD-7. All of them give scores, which I've had really good luck with, with the judges and the officers, because that way they don't have to read a whole psychological description. They can just go right to the score, and it's a deceptively simple construct that's probably not that accurate, but for the purposes of the affidavit, it's really useful. Just like in the sexual assault work that you all do, obviously trauma can affect your interview. People who've been traumatized often have disruptions in memory. They have a hard time concentrating. Asylees may feel really hopeless. They've had a long, long journey before they ever get to your office. They may have a really hard time trusting, and you are asking them some really intimate questions. You may find that they're very detached and sort of wooden in their responses. They may have flashbacks or re-experience their trauma while they're telling you, and they may experience extreme shame, especially with regards to sexual assault, and that's even more true, actually, for men who've been raped. It is a tremendously difficult thing for them to reveal. I find very often that as a female evaluator, a lot of my clients have male lawyers, and I am the one who finds out about the sexual assault because they're just too ashamed to tell their male lawyer about it or about the chronic fecal incontinence that they have been experiencing since they were gang raped 10 years ago or whatever. Those are things that a lot of women find difficult to express and really hard to express to a man. Specific to FGC, you want to talk about what is the age. You want to paint a really vivid picture for your adjudicator. The circumstances, what did it look like? Who brought her there? How many other girls? What did she see? I had a patient, a client, who told me recently that she can't get the smell out of her nose of the burning of the cloth that was performed after everyone was cut. All of the bloody cloths were burned, and she could still smell that in her sleep. What happened afterwards? Were there rituals? Did they go home? What were the medical complications that they remember? I always talk about the immediate and the long-term complications. If your client has girl children, and part of her asylum request is based on the claim that she needs to protect them from being cut, you really have to examine the children to prove that they haven't been cut yet. The court, especially in this day and age, is not going to just accept someone's say-so that the girls haven't been cut. They're going to want to see documentation that they haven't been cut, and so I often do that on a second visit. Usually the first visit is traumatic enough, and the client needs to be able to trust me before they're going to trust me with their daughters. And just some final thoughts about the affidavit, and we can call it a day, I think. Remember that this is a collaborative effort, so I think we're really accustomed to thinking of lawyers as the enemy. I for sure, as an OB-GYN, have had contentious relationships with attorneys, but it's pretty wonderful and refreshing to have a collaborative relationship with attorneys. The other thing to remember is that they're the drivers, so they really know what they need, and they are really in charge of the format and all of that. They can't ask you to write something that's not true. They can't ask you to attest to something that makes you uncomfortable, but it is really important to talk with them and resolve any appearance of inconsistencies. That's one of the main ways that people fail their asylum interviews, is by appearing inconsistent, which of course happens all the time when you're a victim of trauma. And there are little ways that you can give clients a bit of wiggle room, so if someone said to me that she was raped by four people, and someone said to their attorney that she was raped by three people, we could all just write a few, because it was definitely three or four, and maybe it was five. But it's hard to be sure that someone is going to say the same thing in an incredibly stressful situation, like the one presented by an asylum interview on which so much rides. When I write, I write in plain English. I really try to minimize jargon. If I use a little bit of medical jargon, I always put a translation, and things that you wouldn't even think about. So we say bilateral all the time. That's not a common word. I always write both sides. I also put citations in my affidavits. It looks more scholarly. I don't believe that any of the adjudicators ever actually look them up, but maybe they do, and they could if they wanted to. They have the opportunity to educate themselves. I try to be concise. I try not to repeat the whole story. So the adjudicators are reading pages and pages and pages, and there are hundreds of thousands of cases behind. You don't need to repeat the whole story, which is hard, because the stories are compelling. You really only want to talk about the parts of the story that are relevant to your findings. And the final piece of advice is do not ever render judgment or give an opinion. We're just bearing witness to the physical evidence, nothing more, nothing less. You can obviously write more forcefully or less forcefully, but you can't say things like I believe this person or this person is credible, because credibility is actually a legal term with legal weight. You never want to say something like I believe this person should be granted asylum. You're not doing your client any favors, because it really pisses off the judges, and things might go badly for your client. So our last slide, which I think is going to—oh, not quite, but in summary, just to remember what we all know, that violence against women is ubiquitous. Women often or generally suffer multiple abuses from multiple perpetrators. Female genital cutting is common all around the world with profound health consequences, and as the United States asylum law has become more and more restrictive, the medical-legal collaboration is critical, and the forensic evaluation of asylum seekers will become an essential part of their dossier. And for those of you who would like some further readings on FGM, I think that your hosts will circulate this set of references from which most of the pictures were pulled. So if that's a concern that you want pictures and diagrams, they're going to be all in there. And I think we're about ready for questions. Thank you so much. Folks, if you have any questions, you can type them in the chat box. Okay. They're just absorbing all the wonderful information you shared. On this last slide, with all these references, I am going to distribute this reference list for you all when I email you out the evaluation. I would say the one-stop shop on FGC is this last one from 2018, and these are all available online. Let me ask, could you enlighten us about the wording about female genital mutilation versus cutting? Yeah. So what I usually say to people, and my nomenclature changes depending on where I'm speaking. I think when I'm wearing my activist hat, I don't really have a problem saying mutilation. But when I'm talking to a client or a patient, I would never use a term that's really pejorative unless they used it too. So if my client refers to it as mutilation, then I'll use that word, but most of the time they don't. In the asylum setting, women are generally not in favor of the practice, but in my clinical setting, I do have patients who don't feel bad about it. In order to render appropriate care, I need to speak with them respectfully. So it really depends on whether I'm wearing my provider hat or my forensic hat or my activist hat. Great. Thank you. We just had a question come in asking, if you're an ER provider who finds evidence of recent FGM on a minor, is that reportable, and if so, to whom? Yeah. So that is a great question, and it's really complicated. So if you're an ER provider or a pediatrician or a gynecologist or a family practice provider or any of the above, if you see a kid who's been cut and it's old, it may have been done not in this country, and it's not ongoing or acute, and that probably doesn't need to be reported, although you need to, because the kid is not an imminent danger, you absolutely need to talk to the family. You need to educate them. If there are other girl children who haven't been cut in the family, even more so. It is generally, in terms of reporting and mandatory reporters, it generally falls under the rubric of child abuse, but I will tell you that even in New York City, if you call the child abuse services and you say, I have a case of FGM, they are not going to have any idea what you're talking about, so you need to, I would say, couch it more in terms of sexual assault, if it's something that you see as an acute injury or you're not going to get a good response. There is a national hotline, but that's not local at all. If you live in a high-incidence area, you might talk to your local child and youth services folks and see what the local law is for your area, but by and large, it's the same rules as child abuse, and that would be who you would report it to, although I would say that many of us would encourage you to speak with the family first, because some families feel like this is in the best interest of their child, and while it is abuse, they might not be perpetrating other kinds of abuse, and they may have an otherwise pretty intact and functional family, so I think there's a gray area there that any of us who deal with children and child abuse are very familiar with, but ultimately, it's reportable under the child abuse laws. That was a long answer. Sorry. Esther, in the interview, your patient discloses family members' experiences that were traumatizing. Do you include this in the affidavit as part of their claim of credible fear? Nope, because it's not about them, so just because your sister was... It depends. If you saw your sister die, because I had a client that this happened to, because she bled to death next to you and was cut on the same day, that's your trauma, but if your sister was traumatized, but you're kind of doing okay, the fact of your sister's trauma is irrelevant to your affidavit and your claim for asylum. Okay. I think that wraps up our questions. Thank you so much for a great presentation. Thanks to everyone who joined us. Those of you who joined us, watch your email in the next couple of business days, hopefully today. If not, on Monday, you will see an email with further instructions about your evaluation and your contact hours, as well as this list of resources. If you have any questions, you can always reach out to us at elearning at forensicnurses.org. Otherwise, thanks again for joining us, and have a great rest of your day. Have a great day, everybody.

webinar

medical forensic examinations

asylum seekers

female genital cutting

violence against women

gender-based violence

trauma-informed approach

asylum interview

effective affidavit

collaboration

cultural contexts

forensic evaluations

collaborating with attorneys

trauma-informed care

reporting cases

minors

detailed documentation