by Alison Mosier-Mills and Katherine C. McKenzie, MD
The identifying details of the case mentioned in this piece have been changed.
In asylum medicine, we document trauma. More specifically, we evaluate the scars that result from “pre-migration” incidents: enduring marks that, when detailed in a legal affidavit, can serve as evidence in immigration court. The descriptions we record—physical (skin lacerations and burns) and invisible (insomnia or anxiety)—substantiate a narrative of trauma so unrelenting that the sufferer fled their home and sought asylum in the United States.
As medical or psychiatric evaluators, we do not advocate for an asylum seeker’s right to remain in the United States. Instead, our task is to determine the consistency of their scars with the history they’ve presented. It’s the attorney’s responsibility to argue that the client experienced the sort of trauma, in their place of origin, that U.S. law recognizes when considering these cases—and that its severity precludes the possibility of ever returning.
M.A., an asylum seeker from Central America, was referred to us by her immigration attorney. She came to our center in July, accompanied by a Spanish interpreter. We found an empty exam room in the adult primary care clinic and ushered the two of them in, taking care to emphasize that although we were meeting in a hospital setting, the evaluation wasn’t a clinical encounter and we weren’t providing care.
Despite the fast pace of the surrounding clinic and the improvised nature of our space, this sort of evaluation usually feels relaxed. Other clients we see are held in detention centers. Visiting them requires governmental approval, advanced scheduling, hours of waiting, and contending with arbitrarily-enforced restrictions: no language interpreters, no measuring instruments, no electronic devices, no visits longer than a certain number of minutes. The only way to prepare is to resign ourselves to the inevitable capriciousness of facility policies. But in a clinic room we know what to expect, and we have the tools necessary to ensure that the exam is thorough.
Through her interpreter, we asked M.A. if she understood our role in her asylum application process. We reiterated that we’d already read her affidavit—the attorney sent us a twenty-page document detailing the domestic and gang violence she’d faced for decades in her home country—so we were interested in examining the physical scars that resulted from the incidents she’d described. We would document them and characterize their consistency with the expected healing process: “an oval-shaped nonspecific scar, 2 cm in length, on the temporal region of the head, consistent with a scar from an abrasion from concrete fragments; a curvilinear, hypopigmented, slightly raised scar on the submental area, consistent with a scar from a laceration from a sharp object.” A mental health colleague would conduct a psychiatric evaluation that described M.A.’s enduring symptoms of depression and anxiety. Together, this evidence of pre-migration trauma might support her request to remain, protected, in the United States.
* * *
The “pre-migration” realm in which we work establishes the spatial and temporal elements of asylum medicine. The court is persuaded by detailed descriptions of where, when, and how a client’s experiences unfolded. To those seeking to more comprehensively understand trauma, however, this approach is incoherent. While a traumatic event may create an irrevocable sense of before, the aftereffects of the incident may be consuming in a way that defies the linearity of a timeline, the geographic confines of a map, or the clear causality of a legal argument. Trauma often embeds itself, insidiously and intrusively, in the fabric of a life. It can re-script the past, inform the present and foreshorten the future. Knowing this, the questions we might want to ask as caregivers are misaligned with the objectives of the asylum interview.
“We’re working in two contradictory spaces,” says Dr. Jennifer McQuaid, a clinical psychologist who performs forensic psychiatric evaluations. “We’re exploring fear in a way that’s reliable and containable and should be linear and logical, because we have to fill out a form and use words like ‘credibility.’ Yet the reality is that the fear and anxiety related to trauma is often dysregulating, so it’s not going to emerge in a coherent narrative.”
But, to the court, the place matters and the time matters and the causality matters, so we ask about those things. We’re also clear that this isn’t a therapeutic conversation. In some ways, we hope that the asylum process will be a stepping stone towards a healing process; to Dr. McQuaid, the most satisfying cases conclude with a clear handoff to an organization connects the client to mental and physical healthcare services after they’ve been granted asylum. And we’re aware that the evidence is powerful: the organization Physicians for Human Rights reported that immigration courts granted asylum to 89% of petitioners who submitted medical evaluations, compared to the 37% national average. While timelines and maps may be ineffective in constructing a true understanding of the complex, overlapping, and contradictory pain of trauma, they are nevertheless an important avenue towards protection, because in a legal sense, they are true.
There are other practical benefits to using these tools. Dr. McQuaid considers them helpful in diffusing the evaluator-client power dynamic during psychological evaluations. Allowing the client to construct their own map and timeline can enable them to regain a sense of narrative authority. Shifting the record of trauma to the paper may also serve as a reprieve from measuring and photographing the body as forensic evidence. Furthermore, the sense that the process is collaborative can differentiate this interaction from previous, more combative, immigration interviews.
Perhaps the most salient benefit of the timeline, however, is in assuaging a client’s anxiety that their trauma won’t be comprehensively described. For many asylum seekers, the timeline of the past serves as a backdrop to the looming countdown of the future: they’re racing to assemble the evidence necessary to support their claims before their deportation date. Timelines are thorough; they offer the comfort that important things won’t be forgotten.
* * *
For the purpose of her asylum claim, M.A.’s timeline stops at the point when she saved enough money to pay a smuggler to transport her and her oldest son through Mexico and into the United States. Crossing the southern U.S. border renders her subsequent experiences—now “post-migration”—only relevant insofar as they are “ongoing effects of pre-migration trauma.” Yet in situating M.A.’s post-migration timeline adjacent to the chronology of U.S. asylum policy, a sinister story emerges. In early 2018, just after she and her son were arrested by immigration officials in southern Texas, the Trump administration enacted a new policy with the intention of deterring migration into the United States: separating families at the border.
M.A. was only given fifteen minutes to say goodbye to her son. For months, she was not permitted to speak with him; she only knew that he had been transferred to a children’s facility in New York. During this time, M.A. was informed that she would be deported on the erroneous grounds that she’d been affiliated with a gang—a particularly wrenching claim, given that she’d fled her country after being tortured for resisting gang membership. Immigration officials asked her to decide whether she would take her son back to her home country or let him remain, alone, in a U.S. detention center.
Wracked with guilt and faced with a seemingly impossible choice, M.A. became despondent and depressed. She recalls her body beginning to break down: her extremities shook incessantly and severe insomnia left her in a constant state of exhaustion. After several months in detention, she attempted to commit suicide. She was transported to a hospital and began seeking psychiatric treatment.
* * *
In an asylum evaluation, the embodiment of trauma becomes an avenue for protection, but this protection is contingent upon an understanding of trauma as imported. To name the United States as an instigator of cruelty would undermine the fundamental purpose of an asylum claim, which is to secure a position in a safer place. In this sense, the “pre-migration” rhetoric is a distancing mechanism: the violence happened before, and it happened elsewhere, in places where governments don’t protect people.
By labeling trauma as an “other,” we bound our sense of safety within a time and place. Doing so ignores the dissonance of navigating the present while simultaneously processing the past. It also absolves the immigration infrastructure of its complicity in this pain. While a timeline is an imprecise way to measure the aftereffects of trauma, it might be more effective as an instrument of accountability. A thorough timeline—inclusive of post-migration events—would legitimize the suffering in U.S. detention, name those responsible for inflicting it, and, maybe, serve as a step towards true protection.
As of November 2019, M.A.’s case is pending. Her affidavit and medical evaluation provide evidence of the trauma she endured before migrating to the United States. It’s difficult to determine where the compounded trauma of family separation—a pivotal component of her narrative, distinct from her experience at home—fits into an argument that she would be protected by remaining in this country.
Alison Mosier-Mills assists with forensic evaluations, scholarly work, and advocacy at the Yale Center for Asylum Medicine. Previously, she researched barriers to healthcare access among refugees in Malaysia and asylum seekers in Israel. She studied History of Science & Medicine at Yale University and is interested in the intersection of health, migration, and narrative. Alison recently completed the postbaccalaureate premedical program at Bryn Mawr College and plans to pursue a career in medicine that incorporates social justice and medical humanities. Twitter: @AliMosierMills
Katherine C. McKenzie, MD, FACP is the Director of the Yale Center for Asylum Medicine. She and her colleagues at the Center provide objective forensic medical assessments of people seeking asylum in the United States. She works with attorneys from Yale Law School and the University of Connecticut School of Law, as well as the advocacy groups HealthRight International and Physicians for Human Rights. She received her medical degree from Boston University School of Medicine and completed her residency in internal medicine at Boston University Hospital. Twitter: @KMcKenzieYCAM