16 Part I: Recognition and usage • Not consistent: the lesion could not have been caused by the trauma described. • Consistent with: the lesion could have been caused by the trauma described, but it is non-specific and there are many other possible causes. • Highly consistent: the lesion could have been caused by the trauma described, and there are few other possible causes. • Typical of: this is an appearance that is usually found with this type of trauma, but there are other possible causes. • Diagnostic of: this appearance could not have been caused other than in the way described. In practice, these conclusions need to be developed in an MLR to ensure the highest possible level of accuracy. For example, the definition of the term “highly consistent” states that there are a few other possible causes for the lesion. Relevant alternatives must be listed, and reasons given for the preference of the other option. These alternatives need not be speculative. For example, scars on the elbows and knees could be the result of military training if the person is a man known to have been conscripted into the army, but need not be discussed as a differential for a female student who has never undergone military training. The use of the term “not consistent” generally leads to the assumption that a person is fabricating or embellishing an account of torture. This may be appropriate, but there are circumstances in which an understandable mistake has been made, and this needs to be explained. For example, someone who suffers an acute rupture of the Achilles tendon when running will often feel that he or she has been hit in the ankle, although this is not the case. It should be emphasised that there is no causal link between the finding of “not consistent” and a possible fabrication of evidence. After detailing individual physical signs and an analysis of the psychological state, the Istanbul Protocol also recommends utilising the terminology above when making a conclusion of opinions on the general consistency between the person’s account of ill-treatment and the overall pattern of physical and psychological findings.