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Medical case study

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Gender violence and multiple trauma

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Christina* is 32 years old, married with two children, when she comes to iMMO for an investigation. Originating from an Asian country, she states that after her marriage in 2015, she was kidnapped, abused and raped by an extremist group which had deeply traumatic consequences. When she goes to the authorities to seek protection, she is also abused by them.Because of cultural stigma and trauma, she can hardly speak about it. Together with her husband and two children, she flees to the Netherlands.

At the FMMU examination for the IND hearings, no obvious impairments are yet seen, although she already has sleep complaints and is tense. A few years later, however, the psychological symptoms have greatly increased. Christina receives treatment and is diagnosed with severe and complex PTSD because she was also multiple sexually abused in her childhood. The trauma is recalled by events in the AZC. For example, the placement of an unknown man in her home has led to re-experiences, intense fear and severe disruption. In addition, she states that she was raped by two men in the Netherlands. She has very limited ability to speak about this. She experiences much shame, guilt, avoidance and has difficulty with emotion regulation.

The IND rejected her first asylum application in 2019. While her identity and nationality are considered credible, the IND found her husband’s account implausible. With that, her own account, including her abduction and undergone sexual abuse, both by rebels and authorities, is also deemed implausible. The IND points out that they have been able to leave the country legally and, in conjunction with her husband’s account, which is considered implausible, sees no real risk of a violation of Article 3 ECHR. The position of the IND was also confirmed in appeal, appeal and the final decision of the Council of State.

In the repeated asylum application, Christina’s attorney requests an iMMO examination. Her psychological symptoms, described by experts as severe, trauma specific and appropriate to PTSD, could possibly explain why she was previously unable to explain fully, chronologically and in detail about the sexual violence. Shame, dissociation, avoidance and anxiety are well-known symptoms within PTSD that can severely limit the ability to explain.

The iMMO study shows that the person’s psychological symptoms – including dissociations, avoidance, shame, reliving, nightmares and physical stress reactions – are emphatically consistent with the alleged violence and, according to the gradations of the Istanbul Protocol, are assessed as typical of the sexual and physical abuse she described. The physical issues are of limited relevance, but do support the overall picture.

iMMO concludes that her mental condition most likely limited her ability to make complete, coherent and consistent statements as early as the initial proceedings. For the subsequent application, these limitations certainly interfered with her statements.

The iMMO report is inserted into the repeat application.

Read on here for the legal follow-up.

(* Names are fictitious)

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How do you express homosexual feelings?

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iMMO recently assessed Jamar*, a 40-year-old man from an African country where homosexuality is prohibited. His application for international protection was rejected because his sexual orientation (homosexuality) was deemed implausible.

During his interviews at the Immigration and Naturalisation Service (IND), he described the development of his friendship with his school friend. They had known each other since childhood, and when they both reached puberty, they secretly discovered their sexual orientation together. They were intimate and cared deeply for each other, but in public, they were no more than close school friends.

It is striking how Jamar repeatedly stated during the hearings that he didn’t know the words and didn’t know exactly what they were doing at the time or what the consequences would be. Their sexual intimacy was something they were discovering together for the first time; therefore, it remained secret, especially when it became clear to them that it was “not appropriate” and very dangerous.

Jamar’s friend was murdered after neighbors accused them of being homosexual. Jamar calls it “man-to-man business.” He subsequently fled abroad.

The iMMO investigation revealed that Jamar suffers from multiple psychological issues (specifically PTSD and depression) that, according to the Istanbul Protocol, are typical of the violence he describes. The psychologist describes how difficult it is for Jamar to mentalize.

Mentalization is the ability to understand and articulate one’s own thoughts, feelings, and motives—and those of others. This can be difficult due to various factors, such as intellectual disability, high stress, or because it wasn’t learned in the upbringing and culture in which one grew up. This can make it difficult to answer specific questions about one’s sexual orientation and its development.

In the Netherlands, we are accustomed to using words and expressing feelings. The development of sexual preference is discussed, including in the education system. However, in many cultures, this isn’t the case. Nevertheless, people applying for asylum are expected to be able to think and express themselves in the Dutch, rather direct, way.

This case illustrated the high expectations we can have for asylum seekers’ ability to articulate their emerging feelings or involvement with a queer community. Both mentalizing and using words for homosexual feelings can be entirely new to some.

*) Names have been changed.

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Exorcism and abuse

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Ibrahim* is a 24-year-old young man from West Africa. He is gay and says he has always had to lead a double life because same-sex relationships are punishable in his country. After experiencing multiple violent incidents and out of fear of arrest, Ibrahim decides to flee. Initially, Ibrahim secures a place to study in Ukraine, but he comes to the Netherlands when Russia invades the country in 2022. When the Netherlands revoked the residency rights of so-called “third-country nationals,” he applies for asylum.

The Immigration and Naturalization Service (IND) considers Ibrahim’s identity, nationality, and origin credible, but not his homosexuality. He claims Ibrahim made too general statements about these matters and failed to make his homosexuality sufficiently concrete. His application for international protection is rejected. Ibrahim’s lawyer requests a forensic medical examination from iMMO.

During the iMMO examination, Ibrahim reveals that he was caught having sex with his best friend at the age of 13. After that, his life changed completely. He was abused by his father, and when he ran away, he hit his forehead against a wall. His mother, a pastor, took him to several exorcisms to “cure” him of his homosexuality. During these rituals, Ibrahim was slashed multiple times with a razor and his leg was burned with a torch. He was ostracized and discriminated against by his community.

Ibrahim says that during his studies, he had a relationship with a head teacher, who also abused him. The head teacher paid Ibrahim’s tuition and asked for sexual favors in return. When Ibrahim indicated he no longer wanted this, the head teacher threatened to destroy Ibrahim’s life. The head teacher had taken photos and videos of him and used them to blackmail him. This led Ibrahim to flee. He was able to travel to Ukraine with a student visa. When war broke out there, he fled to the Netherlands.

Examination

During the physical examination, several scars were found and assessed. The scar on his forehead, which he sustained when he hit his head hard against a wall, was assessed as consistent with the Istanbul Protocol. Because a forehead wound can easily be accidental, and hitting your forehead can easily result in a laceration or deep abrasion, the grade was not high.

The scars Ibrahim sustained from the exorcism ritual, during which he was cut multiple times with a razor, were assessed as typical of this alleged violence. The scar Ibrahim sustained from the torch burning was assessed as highly consistent.

The psychological examination revealed clear psychological symptoms that, according to the Istanbul Protocol, are typical of the violence Ibrahim described. For example, he avoids talking about the violence he experienced, talking about it visibly causes him tension, and he experiences specific flashbacks to his father’s abuse and the exorcisms. It becomes clear that seeing and discussing his own scars triggers flashbacks.

The report was submitted during Ibrahim’s initial proceedings. Six months after the iMMO report was submitted, Ibrahim finally received his residence permit.

(*) Names have been changed.

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Tortured for insulting president

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Mahmoud is a 31-year-old man from a Middle Eastern country. When he is 18 years old, he is drafted for military service. During his service, he is arrested and tortured for allegedly insulting the president. After time in prison, he has to return to the army. The year after he was discharged, war broke out and he fled because he did not want to fight. In the Netherlands, his story is deemed implausible and his request for international protection is rejected. Mahmoud’s lawyer requests a forensic medical examination from iMMO.

Mahmoud says he had a fine life. His father and mother were loving to him and his siblings. He indicates that he was called up for military service when he was 18 years old. He did not want to go, but the government was harassing his family so he reported anyway.

After four months of basic training, he was transferred to a remote area in the mountains with a notorious unit. He was structurally insulted by the officers. Because Mahmoud resisted how he was treated, he was punished a lot. He was also sexually abused.

One day, another conscript told the officers that Mahmoud had cursed the president. Mahmoud was subsequently detained by the military police. He was beaten up and taken to a security service prison. In prison, he was interrogated, beaten with fists and whipped to force a confession for insulting the president.

He was then taken to another prison where, upon arrival, he was immediately hit in the face with the back of a gun. Because everything became swollen he had difficulty breathing. In this prison, the guards were masked. He stayed in a small cell with no light. There was water on the floor so he could not sit or lie down dry. Sleeping was only possible crouched against the wall. Food was rice thrown through a hatch.

In this prison, he was tortured several times a week. One of the tortures involved putting rope around his legs and using a stick to tighten it more and more. This involved beating on the soles of his feet. This was very painful, his legs became swollen and were full of bruises.

He says that rape was threatened but did not happen. Later he confesses to his lawyer rape dit take place, after which a supplementary investigation was carried out. During the additional investigation, he tells how he was raped by masked guards.

One day Mahmoud was tortured with electricity. He fainted and woke up in the hospital. He was allowed to recover for a week but then had to report back to the army. He says he went back again out of fear.

After a time, his military service was over and he was allowed to return home. A year later, war broke out and he was called up for the army again. He decided to flee.

Examination
Multiple scars are found during the physical examination. The scars on his face allegedly from being struck with the butt of a gun are assessed as consistent. Two scars, according to Mahmoud, were caused by the electric shocks. One is now hidden under a tattoo and is therefore difficult to assess. This one is rated consistent; the other is very consistent.

The scars under his feet from the blows are judged consistent in shape and placement. The scars on his legs that could have been caused by being tied together with a rope are judged to be very consistent. The scars on the legs resulting from metal flying around during a bomb blast are also seen as consistent with the event described.

The reporter psychologically examining Mahmoud sees many PTSD symptoms such as flashbacks, re-experiences, terror, as well as the translation of stress into physical symptoms such as nausea and vomiting. According to the investigator, avoidance is evident when torture is brought up. During the additional inquiry about the possible sexual violence undergone, Mahmoud has to vomit for minutes before he can talk. According to the reporter, there are psychological symptoms typical of the violence described.

The report is brought into the proceedings. Mahmoud is granted a residence permit on appeal.

* Names are fictitious.

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Bisexuality, gang violence and human trafficking

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Kevin* becomes a victim of abuse and violence because of his bisexuality. To protect himself, he joins a gang, but a gang war causes him to flee. During his escape, he becomes a victim of human trafficking and is forced to work in prostitution for years before he is able to escape and seek asylum.

Kevin is a 36-year-old man from an African country. His mother runs a restaurant and his father is a businessman. As an only child, he finds out at an early age that he is different from others. Namely, he falls in love with boys as well as girls. Both at school and by his parents, he is punished for his dealings with boys. In the process, he is beaten with a cane and ruler. His mother sees his bisexuality as a spiritual problem and takes him to different churches to get him cured.

Kevin is smart and goes to college. At college, fellow students catch him with a boyfriend, after which he is assaulted. This involves Kevin being beaten many times and stabbed with a knife in his genitals. There is a group in and around school attacking him. The incidents increase and so do the intimidations.

To protect him, a friend introduces him to a gang. He is sent blindfolded to a forest for a ritual in which he is beaten and stabbed with stones, hoes, knives, machetes, axes and guns by a group of about 40 boys. This eventually renders him unconscious.

Afterwards, he wakes up in his own bed while being cared for by his friend. He now understands that all this time in college he was being harassed by a rival gang. The incidents and harassment cease because he is now protected by the gang he joined.

In his third year of study, violence between rival gangs suddenly flares up. Shots are fired and everyone runs in panic in all directions. Kevin is injured by hail blasts. A traditional healer has been able to remove almost all the pellets of hail.

Soon after, his own gang wants him to take an active part in the fight against the other gang. He does not like this and, in addition, is still wounded by the incident. At this he decides to flee the country. This is difficult because two men are watching him closely. When he can go to the bathroom alone, he escapes and goes on the run. His own gang takes revenge and they kill not only his father but also his friend.

Kevin’s flight goes through Libya where he ends up imprisoned and is severely mistreated. To be released, he must pay a large sum of money. And so Kevin becomes a victim of human trafficking. To pay the debt to the human trafficker, he has to work in a European country in prostitution and as a drug courier. At some point he manages to flee to the Netherlands.

The examination by iMMO identifies many scars. In accordance with the Istanbul Protocol, a number of scars are assessed as typical and highly consistent with the events described. The psychological examination reveals that he has post-traumatic stress disorder-related symptoms and somberness complaints.

The legal follow-up can be found here.

* All names are fictitious.

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Being underage and explaining your asylum claim

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Being underage can affect how an asylum narrative develops as evidenced by scientific research. It has been found that the ability to construct a “life story” is not achieved until late adolescence or during young adulthood (early 20s). At the same time, experiences such as significant psychotrauma or depression can negatively affect an adolescent’s autobiographical memory (1). This can lead to less specific memories of events.

To illustrate, the following case study. 16-year-old Oscar* grows up with his mother in a country in West Africa. He does not attend school, but is home schooled by his mother. His mother was disowned by her family when she had Oscar as an illegitimate child. Oscar and his mother are happy together. As a bastard, Oscar does get teased and bullied, scolded and humiliated by children in the neighborhood. This makes him feel different and less worthy than others.

When Oscar is 14 years old, he is assaulted by several men as he walks outside on the street. He is beaten, stabbed in the legs with a knife and dragged across the street. He is threatened with death; the men indicate that, as a bastard child, he has no right to live. Oscar is very afraid they will kill him. When people come to see what the commotion is about, the men run away. Afterwards, the men turn out to be the brothers of Oscar’s mother.

Oscar and his mother go to hide with a friend out of fear. There they hide for several months before fleeing the country with this friend’s help. With the help of people smugglers, Oscar and his mother eventually reach Morocco. Along the way, Oscar experiences many unpleasant things. He witnesses how human traffickers abuse and shoot refugees.

In Morocco one night they are picked up and taken to the sea. Oscar does not know what is going to happen or where they are going. There are lots of people by the water and Oscar and his mother have to get into a boat. In the middle of the sea, the boat breaks down; everyone is screaming and Oscar hears his mother calling his name. All the people end up in the water. Oscar is rescued by another boat and taken to Spain. His mother drowns. Oscar is in shock and feels very guilty for not being able to save his mother. Eventually, with help, Oscar travels on to the Netherlands where he applies for asylum.

During the iMMO assessment, it is noticeable that Oscar has difficulty talking about the many upsetting events. He falls silent and prefers not to talk about them at all. He indicates that talking about the unpleasant events evokes memories that he wants to avoid. He is troubled by recurring images and thoughts of his mother. In his dreams she is there and when he wakes up, she is suddenly gone. He also suffers greatly from recurring images of the beatings and threats by the men. Seeing the scars on his legs reminds him of this.

In different places on Oscar’s body, dozens of scars are identified. In accordance with the Istanbul Protocol, most of these scars are assessed as typical of the alleged violence that prompted Oscar’s flight. There are also psychological symptoms that can be related to Oscar’s asylum story. The avoidance, specific re-experiences and triggers for these re-experiences are also typical of Oscar’s alleged asylum story. iMMO’s medical assessment reveals clear supporting evidence for his asylum narrative.

The IND objects to Oscar’s testimony as being insufficiently detailed. iMMO’s file review reveals that Oscar was already struggling with trauma and grief symptoms during the interviews at the IND and that he received psychological help. Oscar also seemed to have difficulty understanding some of the questions during the hearings. The iMMO concludes that both Oscar’s psychological complaints and his young age must be taken into account during the interviews and decision making process, as both affect his ability to explain consistently and coherently.

(1) Autobiographical memory: the part of human memory that allows us to recount what we have experienced (specific and general memories about your own life).

(*) Names are fictitious.

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Case study on the paradox of sexual violence

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The scars left by sexual violence are often more psychological than physical. This is also the case with 40-year-old Carolina*. She is an only child and grows up with an aunt because her mother was too young to take care of her. Her father dies when she is still young. Conform local custom her family chooses a partner for her, but she decides to marry the man of her choice. Shortly thereafter, her mother dies. Her family blames Carolina for her mother’s death, proclaiming it is the result of her refusal to consent to the arranged marriage.

Carolina and her husband are happy together. In addition to their work, they help street children. These children are regularly assaulted and sexually abused by soldiers. They give them shelter, food and see to their safety. The soldiers try to counter this. They have to be careful because “the soldiers wanted the children for themselves.”

At one point, riots break out in the country. There is unrest in many places. Soldiers invade the premises of their organization in search of her and her husband. During this time Carolina has to flee several times, is arrested, raped and abused. She is beaten with weapons, kicked, burned with cigarettes and other objects. Furthermore, she is imprisoned several times. She has to stay in crowded cells without toilets and sanitation.

The rapes and beatings continue, until a prison chief hears her crying and mumbling in her native language. He recognizes the language because he is from the same area and helps her flee.

Carolina manages to escape but during the flight she is forced into prostitution several times. She is also raped several times by those who say they want to help her. In Europe, she is supposed to pay back the cost of her journey by working in prostitution. At Schiphol Airport, however, she is stopped by the Dutch military police.

Carolina is ashamed about what she has been through. She ends up in jail in the Netherlands, afraid and no longer trusting anyone. Before the assessment at iMMO, she never told anyone about the sexual violence.

During the iMMO assessment, it is noticeable that she falls silent at times. This happens especially while recounting the sexual violence. When the researchers ask about this, she indicates that she is distracted. The images of these rapes intrude on her. She prefers not to talk about it. In daily life, she has difficulty with loud noises and the smell of excrement. These smells and sounds bring up images she wants to forget. Her most unpleasant re-experiences are the memories of the rapes in the presence of her husband.

Scattered over Carolina’s body, several dozen scars are identified from multiple acts of violence, including a scar in the genital area. In accordance with the Istanbul Protocol, most of these scars are assessed as highly consistent. There are psychological problems that can be related to the asylum story. Specific re-experiences, triggers for the re-experiences, avoidance and distrust are typical in content and nature of the claimed asylum narrative as indicated by her.

In Carolina’s case, there is one genital scar to mark the sexual violence suffered. Often rape leaves no visible injuries or scars. This is the paradox of sexual violence, which often actually produces a lot of psychological damage and relatively few visible physical scars. In this case, the scars from the other violence contributed substantially to the conclusion of the assessment. This illustrates the importance of conducting a full investigation.

The iMMO report was introduced in the repeated asylum application. (See case law for follow-up.)

* All names are fictitious.

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