Post-migration factors will also affect the mental well-being of vulnerable asylum-seekers, including torture victims. Asylum-seekers often encounter difficulties with accessing information on asylum procedures or legal assistance, due to cultural or language barriers. This can lead to feelings of disorientation or isolation. The stress of leaving family, friends and community can be further compounded by the associated loss of status, personal identity and employment, which is experienced on arrival in the host country. For asylum-seekers who are detained while their application is outstanding, research shows that detention exacerbates their pre-existing physical and mental health conditions. These post-migration factors all increase the mental anguish and stress that many asylum-seekers may already be suffering and are further exacerbated by delays in the asylum procedure, i.e. long periods of time spent in a situation of uncertainty. The limitations on, and delays in, access to health care during this period can further exacerbate the mental and physical health of the individual. In its guidance on mental health and mental health care for migrants, the World Psychiatric Association notes that: Refugees are perhaps the most vulnerable of all migrant groups to mental and physical ill health. Lack of preparation, attitudes of the new country, poor living conditions, poor or lack of employment and variable social support all add to this vulnerability. Rates of mental disorders may be high in some refugee groups: those of common mental disorders are twice as high in refugee populations in comparison with economic migrants.10 Research studies have found that rates of post-traumatic stress disorder (PTSD) can range from 20-40 percent, and anxiety and depression rates can vary from 30-70 percent within this population sector.11 Studies have linked the incidences of depression and PTSD among asylum-seekers to traumatic events that they have suffered pre-migration, including torture.12 It is generally estimated that between 5 and 35 percent of refugees are torture survivors.13 The physical and mental health problems that many asylum-seekers suffer indicates that there is an urgent need for national asylum procedures to identify vulnerable asylum-seekers, including victims of torture and other trauma, so that they are able to access justice, health care and rehabilitation services as early as possible in the asylum procedure. Many of the physical and mental health conditions caused by torture or ill-treatment have severe and long-term debilitating effects on the individual, which are exacerbated if left untreated. The delay in treating symptoms makes it harder for the individual to reintegrate into society and resume life as a normal, functioning individual. The debilitating effects caused by suffering torture or other trauma in the past are heightened in situations where the individual has been through a difficult and stressful journey to escape persecution, and is alone in a foreign culture without family or friends on whom to rely for financial and emotional support. The Istanbul Protocol – documenting torture in asylum procedures The Istanbul Protocol,14 adopted by the United Nations in 1999, sets out international standards for states and health and legal professionals, on the investigation and documentation of allegations of torture and other ill-treatment. Although the principles in the Istanbul Protocol are not legally binding, its adoption by the United Nations gives it global authority as an instrument that should be used to guide standards for the documentation and investigation of torture.15 By detailing the process of documenting medico-legal evidence, the Istanbul Protocol’s key objective is to contribute to achieving justice and to the fight against impunity in cases of alleged torture and other ill-treatment. However, given the principle of non-refoulement of asylum-seekers, the proper investigation and documentation of allegations of torture and other forms of ill-treatment is often a key element of an asylum claim. Therefore, in asylum-seekers’ cases, the systematic documentation of allegations of torture according to the Istanbul Protocol can also provide a foundation for both the asylum claim itself and for the rehabilitation of the victim. 10 / Recognising victims of torture in national asylum procedures