They come from war zones and terrorist strongholds. From countries or places where being the "wrong" religion, ethnicity or sexual orientation is a crime — or where sexual violence and mutilation are considered normal.

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After a long journey to the United States, another challenge awaits tens of thousands of refugees every year: navigating the long and often arduous legal process that offers their only chance of permanent asylum.

Many such applicants fled their home countries without being able to take evidence of what they endured — key details that could strengthen their case. The only documentation that could prevent their deportation, then, may be the evidence of trauma embedded in their body or their mind.

Which is why American physicians and mental health professionals can play a key role by examining refugees to objectively analyze the scars of physical and emotional abuse, a new study shows.

The research, conducted by a team from the University of Michigan Medical School and published in the Journal of Forensic and Legal Medicine, compiles information from 16 Michigan lawyers who help refugees seek asylum.

Such legal professionals often work for free or at a greatly reduced rate.

But, they told the researchers, their court appearances lack some of the most compelling evidence: an independent report on the mental and physical effects of what the applicants suffered in their homeland.

Such details could include a raised scar, the trace of a broken bone or the telltale symptoms of post-traumatic stress disorder — all detected and documented by a trained clinician.

The study also highlights how many more such exams are needed, based on feedback from the lawyers who handle refugee cases. That translates into a need for more medical professionals to be trained to do the exams and volunteer their time to conduct them and write the medical affidavits that become a formal part of an asylum case.

Even if the flow of new refugees decreases in coming years due to U.S. and United Nations policy changes, there are hundreds of thousands already here who are still building their best case for why our nation should accept one more person.

For each one of them, a thorough third-party exam can provide corroboration for what the refugees have already told their attorneys. It can even reveal additional details. In rare cases, the physical signs conflict with the story that the individual has told his or her lawyer.

A need for care, collaboration

To be most helpful, the written medical affidavits must document an asylum seeker's physical and mental health in a way that attorneys and immigration officials can understand — and not in the medical jargon that doctors usually use in their reports for one another.

The effort to interview the attorneys grew out of the U-M Asylum Collaborative (UMAC), a medical student-run organization that takes in requests for asylum-related medical and psychiatric exams from the organization Physicians for Human Rights (PHR) and from the Freedom House asylum-seekers facility in Detroit.

The students connect with U-M medical faculty who donate their time to conduct hourslong exams and report their findings. U-M medical teams have completed such exams for more than 50 asylum seekers in the past two years — with at least two applicants succeeding in their quest for refuge.

The U-M Asylum Collaborative offers an annual training workshop for medical professionals interested in getting involved. PHR also offers training in other locations.

The first author of the new study, third-year medical student Elizabeth Scruggs, says that the idea to interview lawyers who work on asylum cases came from the collaborative's founders, Anna C. Meyer, M.D., and Jamie VanArtsdalen, M.D., who have since graduated.

"Our sense was initially that there was great potential for an organization like UMAC to have an impact on people who are actively seeking asylum, but who couldn't afford or couldn't find a physician to perform these exams," says Scruggs. "But we also know that there are physicians who are interested in human rights and want to use their skills to help people who are going through the asylum process."

Michele Heisler, M.D., M.P.A., the senior author of the new study, is one of the group's faculty advisors and a professor of internal medicine at the Medical School with additional appointments in the U-M School of Public Health and the VA Ann Arbor Healthcare System. She serves on the board of Physicians for Human Rights, and has volunteered for the group since medical school. She's also a member of the U-M Institute for Healthcare Policy and Innovation.

Many of the asylum seekers also work with U-M Law School students and faculty to build the legal document that they file with the government.

Heisler, Scruggs and their co-authors underscore the potential for much more collaboration between the medical and legal professions around asylum cases.

"What was surprising was seeing how each lawyer handles their cases differently, and how each applicant's story is unique," says Scruggs. "So, a conversation between the doctor and the legal professional about each case before the exam is very important. They need to connect before, and even after, about the level of detail that's needed for an applicant to have a strong case and the way the affidavit is written. They also need to understand any inconsistencies between what the exam shows and what the applicant has said."

Being impartial, she notes, is crucial.

Some attorneys told the U-M researchers that some photos of refugees' scars might not be useful in asylum cases because the quality and resolution can suffer after repeated photocopying of paper applications for evaluation by the relevant agencies. This can even weaken the applicant's case inadvertently.

And while researchers did not assess whether the presence of a medical affidavit in an applicant's file increased the chance of receiving asylum, the attorneys mostly said they felt it did. Previous studies in the last decade have suggested that asylum petitions with medical exam results do have a better chance of succeeding, but there is no definitive proof.

Says Scruggs: "The overwhelming response from the lawyers was that a medical exam was a necessary part of an application; that they always want it, but they don't always have the 'luxury' of getting it at all."