The forensic evaluation of torture in asylum seekers: international literature comparison and inter-rater agreement analysis

• This study reinforces the central importance of specialized forensic expertise in the medico-legal evaluation of asylum seekers reporting torture and ill-treatment. • The finding highlight the critical need for structured training, ongoing supervision, and standardized protocols to ensure the accuracy, reproducibility, and evidentiary value of forensic assessments to document human rights violations. • Investment in studies aimed at identifying and validating clinical, psychological, and forensic markers of torture and ill-treatment is urgently required. Asylum seekers often report exposure to persecution in their home countries, during transit, or while in detention. The primary purpose of a forensic medical certification is the objective documentation of physical and psychological findings associated with torture, abuse, or other forms of inhumane treatment. The study had two main objectives: (1) to analyze the demographic, clinical, and medico-legal data of individuals referred to the Specialized Outpatient Service for Survivors of Torture (SVT) at the Policlinic Hospital of the University of Palermo and (2) to evaluate how professional experience and specialized training shape the formulation of compatibility judgments according to the Istanbul Protocol, through a multicenter inter-rater analysis. This is a retrospective observational study that analyzed all consecutive forensic medical evaluations of asylum seekers at the Institute of Legal Medicine, University of Palermo, Italy, between January 1, 2018, and December 31, 2024. In total, 324 patients were examined at the institute’s outpatient clinic for survivors of torture. Our findings highlight the essential role of specialized forensic experience in the medico-legal assessment of asylum seekers reporting torture and ill-treatment. Comparative analysis across multiple international centers confirmed that physical trauma, particularly blunt injury, was the most commonly documented form of abuse. The study demonstrated high inter-rater agreement for injury identification, classification, and recognizing associated physical and psychological sequelae. However, discrepancies emerged in assigning consistency levels under the Istanbul Protocol, highlighting the need for structured training and standardized protocols to ensure the accuracy, reproducibility, and evidentiary value of forensic assessments.