What constitutes a high-quality, comprehensive medico-legal asylum affidavit in the United States immigration context? A multi-sectoral consensus-building modified Delphi

Abstract

In the United States, clinicians are often called upon to provide their expertise to generate expert evidence in cases of individuals seeking asylum or other forms of international protection. Due to a lack of validated guidelines specific to the U.S. immigration context, clinical evaluations produced for immigration proceedings in the United States vary in their format, structure, and content, which can be confusing for practitioners and for adjudicators assessing the weight these evaluations should be afforded in asylum proceedings. We sought to review critical components of a medico-legal asylum evaluation from an interdisciplinary perspective of key stakeholders, by collecting and synthesizing expert opinions to reach consensus on what constitutes a high-quality, comprehensive medical or psychological affidavit for U.S. immigration cases. The consensus process incorporated a three-step modified Delphi method, which took place between September and December 2021 and consisted of two rounds of online questionnaires and a synchronous video conference meeting. The areas most experts agreed on included, by order of highest agreement (combining answers of “strongly agree” and “agree”): A narrative form or checklist is preferable to a predetermined template (95%); Primary care physicians should describe their qualifications to diagnose mental health conditions (81%); Use of citation is helpful, with caveats (77%); Clinicians should include an assessment of malingering (72%); Clinicians should include an executive summary/summary of conclusions at the top of the affidavit (72%); Clinicians should reference the Istanbul Protocol and explain its relevance (66%); It may be beneficial for clinicians to describe the anticipated process of healing (57%); Clinicians may include treatment recommendations (52%). Results of this and future consensus-building efforts and resulting guidance should be used to enhance overall quality of medico-legal reports and incorporated in training programs developed for clinicians, attorneys and adjudicators.