Torture

The aims and goals of investigation

Torture and other ill-treatment are prohibited in international law and are likely also to be a crime under national law. International law requires not only that torture not be used, but also that any allegation of torture be investigated, and that those responsible be brought to justice.

Effective investigation, including the aspect of medical documentation, is a vital component in the struggle to eradicate the practise of torture. Legal bodies, domestic and international alike, rely on factual evidence to reach their conclusions and uphold justice.

By shedding light on cases of torture and other ill-treatment, effective investigation and documentation can assist in the achievement of a number of important goals:

  • Raising awareness of the infliction of torture and its absolute prohibition
  • Battling impunity: bringing torture into the public eye assists in calling states to account for their actions and having them fulfill their legal obligations. On a different level, torture reporting can also help to cast light on the individuals who carry out such practises, to make sure that they cannot continue to engage in such behaviour without negative consequences.
  • Redress for the survivor: there are a number of remedies and objectives that may assist the individual survivor of torture, for example:
    • Preventing and ending ongoing abuse: in certain cases, allegations of torture may be raised by a person who is still in custody of the authorities. Effective and swift investigation can help put an end to the suffering. In other cases, the individual may be seeking protection from abuse in another country, and the determination of whether the individual was a survivor of torture and is personally at risk can prevent the person being deported back into the hands of their torturers.
    • Compensation and other forms of restitution: survivors of torture may, for example, be able to claim compensation for monetary loss, physical and mental harm, and other damage caused by the torture
  • Rehabilitation: many torture survivors are in need of rehabilitation services, including medical treatment, both physical and psychological, legal assistance, and social services. Effective investigation and documentation can assist in diagnosis, treatment (including rehabilitation) and prognosis of the patient.
  • Official and public acknowledgement of their suffering can also be important in the recovery process of survivors of torture.
  • Reform: drawing attention to a situation is not just about seeking condemnation or holding a state accountable. Even more importantly, it is about seeking constructive and long-term improvements in a country, which will contribute to the ultimate elimination of torture. This will often require changes both in the legislative framework and in official attitudes to torture. The eradication of torture is a fundamental and necessary step for any society aspiring to protect human rights and care for its people.

Torture and other ill-treatment are prohibited in international law and are likely also to be a crime under national law. International law requires not only that torture not be used, but also that any allegation of torture be investigated, and … Continue reading

Preliminary Considerations

The documentation of torture and other ill-treatment depends on the gathering of detailed and accurate information from the individual on the circumstances of the alleged events, including details of any arrest, detention, conditions of detention and specific treatment while under interrogation. The interview should be structured and conducted according to the guidelines defined in “the general considerations for the interview”, “procedural safeguards” and “medical ethics” chapters of the Istanbul Protocol. These considerations apply to all persons carrying out interviews whether they are lawyers, medical doctors, psychologists, psychiatrists, human rights monitors or members of any other profession. Interview considerations that pertain specifically to the documentation of physical and psychological evidence of torure are included in Modules 5 and 6 respectively.

Torture is usually both physical and psychological in nature. It is important, therefore, for each clinician to elicit and relate physical and psychological information in their evaluations. It should be noted that, with appropriate training, physicians may become qualified to conduct psychological evaluations. Those who are not qualified, should refer the alleged victim to a qualified psychological expert (i.e. psychologist, psychiatrist, clinical social worker). Medical doctors should carefully consider the potential benefits and possible difficulties of qualifying as a psychological expert. It may be helpful to seek the advice of attorneys to better understand country-specific requirements to qualify as an expert witness on on psychological evidence of torture.

The degree of detail gathered during an interview with an alleged victim of torture depends on several factors, such as the aim of the interview/examination (producing a note in a medical record of incidental findings during a routine medical visit, versus being asked to provide a medical report for a judicial body), the location and circumstances of the interview (for example in a health clinic, in a police station or prison, or in a rehabilitation centre for survivors of torture) and the degree of access to the individual and amount of time available. This being said, the principles on interviewing can be adapted and applied to the various circumstances in which an individual alleging torture may be encountered.

Clinicians should not assume that the individual, such as the asylum applicant’s attorney, requesting a medico-legal evaluation has related all the material facts. It is the clinician’s responsibility to discover and report upon any material findings that he or she considers relevant, even if they may be considered irrelevant or adverse to the case of the party requesting the medical examination. Findings that are consistent with torture or other forms of ill-treatment must not be excluded from a medico-legal report under any circumstance.

The documentation of torture and other ill-treatment depends on the gathering of detailed and accurate information from the individual on the circumstances of the alleged events, including details of any arrest, detention, conditions of detention and specific treatment while under … Continue reading

Module 2 Answers

  1. Answer: B

    The Istanbul Protocol outlines international, legal standards on protection against torture and establishes specific guidelines for the effective investigation and documentation of torture and ill treatment. The Istanbul Protocol is a non-binding document. However, international law obliges governments to investigate and document incidents of torture and other forms of ill-treatment and to punish those responsible in a comprehensive, effective, prompt and impartial manner. The Istanbul Protocol is a tool for doing this.

  2. Answer: True

    The Istanbul Protocol outlines minimum standards for state adherence to ensure the effective documentation of torture in its Principles on the Effective Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, or “Istanbul Principles.” The Istanbul Protocol represents an elaboration of the minimum standards contained in the Istanbul Principles and should be applied in accordance with a reasonable assessment of available resources.

  3. Answer: A

    The Istanbul Protocol and its related Principles have been recognised as international standards for the effective investigation and documentation of torture and ill treatment by the UN General Assembly and the then UN Commission on Human Rights (since 2006, the UN Human Rights Council), the UN Special Rapporteur on Torture, the African Commission on Human and Peoples’ Rights, the European Union and other institutions and organizations.

  4. Answer: B

    Conducting an objective and impartial evaluation should not preclude the evaluator from being empathic. It is essential for clinicians to maintain professional boundaries and at the same time to acknowledge the pain and distress that they observe. The clinician should communicate his or her understanding of the individual’s pain and suffering and adopt a supportive, non-judgmental approach. Clinicians need to be sensitive and empathic in their questioning while remaining objective in their clinical assessment.

  5. Answer: A

    It is important to realize that the severity of psychological reactions depends on the unique cultural, social, and political meanings that torture and ill-treatment have for each individual, and significant ill effects do not require extreme physical harm. Seemingly benign forms of ill-treatment can and do have marked, long-term psychological effects. Although some survivors of torture may have few or no psychological sequelae, most individuals experience profound, long-term psychological symptoms and disabilities.

  6. Answer: B.

    Although there are a myriad of psychological issues that torture victims might have including C and D, PTSD and major depression are the two most common problems.

  7. Answer: B.

    Unfortunately, it is a common misconception among evaluators, attorneys and adjudicators that psychological evidence is of lesser legal value than “objective” physical findings. The aim and effect of torture is largely psychological. The psychological evaluation is critical in assessing the level of consistency between the alleged trauma and individual psychological responses. In some cases, the symptoms may be either attenuated or exacerbated depending on the meaning assigned to individual experiences.

  8. Answer: B

    As the Istanbul Protocol makes clear, the absence of physical and/or psychological evidence in a medical evaluation does not rule-out the possibility that torture or ill-treatment was inflicted. The Istanbul Protocol was developed to prevent torture and ill-treatment and to promote accountability. Governments must ensure that its official representatives do not engage in misuse or misrepresentation of the Istanbul Protocol to exonerate police who are accused of abuses or for any other purpose.

  9. Answer: B, D

    Each detainee must be examined in private. Police or other law enforcement officials should never be present in the examination room. This procedural safeguard may be precluded only when, in the opinion of the examining doctor, there is compelling evidence that the detainee poses a serious safety risk to health personnel. Under such circumstances, security personnel of the health facility, not the police or other law enforcement officials, should be available upon the medical examiner’s request. In such cases, security personnel should still remain out of earshot (i.e. be only within visual contact) of the patient. Prisoners should feel comfortable with where they are evaluated. In some cases, it may be best to insist on evaluation at official medical facilities and not at the place of detention. In other cases, detainees may prefer to be examined in the relative safety of their cell, if they feel the medical premises may be under surveillance, for example. The best place will be dictated by many factors, but in all cases, investigators should ensure that prisoners are not forced into accepting a place they are not comfortable with. Requests for medical evaluations by law enforcement officials are to be considered invalid unless they are requested by written orders of a public prosecutor.

  10. Answer: A

    If the forensic medical examination supports allegations of torture, the detainee should not be returned to the place of detention, but rather should appear before the prosecutor or judge to determine the detainee’s legal disposition.

  11. Answer: A

    The presence of police, soldier, warden, or other law enforcement officers in the examination room, for whatever reason, should be noted in the physician’s official medical report. Notation of police, soldier, prison officer, or other law enforcement official’s presence during the examination may be grounds for disregarding a “negative” medical report.

  12. Answer: A.

    Many of the rules and principles of medical ethics have been adopted as professional codes of conduct. While ethics must guide every action of health professionals in their work, in the process of investigating and documenting allegations of torture, there are three areas in which the health professional must be particularly cognizant of specific ethical considerations. The first is the duty to the patient, the second is the clinical independence of the health professional and the third is in the production of medical records, reports and testimony.

  13. Answer: A

    The use of hoods or blindfolds has in itself been found to be a form of ill-treatment. In the health setting hoods or blindfolds not only impair any meaningful contact with the patient; they also prevent the identification of any health professionals and may thus add to a perception of impunity in cases of ill-treatment.

  14. Answer: D

    A, B, and C are all provision under the World Medical Association’s 1975 Tokyo Declaration.

  15. Answer: F

    All of the answers represent either passive or active complicity of health professionals in torture and ill treatment. Physicians and other medical personnel have the obligation not to condone or participate in torture in any way.

  16. Answer: F

    All of the elements listed are essential to informed consent.

  17. Answer: A

    The health professional must contemplate the risks to the patient, and indeed to themselves, in disclosing such information, and the potential benefits to society as a whole (e.g. potentially avoiding further harm to others), before acting. Whatever decision is reached, the health professional should endeavour to gain consent. In such cases, the fundamental ethical obligations to respect autonomy and to act in the best interests of the patient are more important than other considerations.

  18. Answer: B

    In an ideal situation, an independent doctor will have explained the risks of a prolonged hunger strike, and taken instructions on what the person wants to happen if he or she ceases to be capable of rational thought. This should happen in an environment where the patient’s confidentiality can be respected, and where he or she can be protected from undue pressure from political colleagues. In cases where prison doctors have been following hunger strikers before and during the fast, and know what the patients’ positions and convictions are, physicians should respect the principles stated in the Declaration of Malta. If a physician is called upon to take care of a hunger striker already in a comatose state, he or she will have no choice and will have to provide reanimation. A physician should not rely on what amounts to “hearsay” in such cases. The opinions of the immediate family should be taken into consideration, but are not paramount. Neither the opinions of the authorities nor those of the patient’s political colleagues should be given any weight.

  19. Answer: B

    The Declaration of Tokyo was revised in 2006 to include the following provision: “The physician shall not use nor allow to be used, as far as he or she can, medical knowledge or skills, or health information specific to individuals, to facilitate or otherwise aid any interrogation, legal or illegal, of those individuals.”

  20. Answer: G

    The primary goal of documenting allegations of human rights violations is to create an accurate, reliable and precise record of events. All of the forms of information listed are essential to the effective medical and legal investigations of torture and ill treatment.

Answer: B The Istanbul Protocol outlines international, legal standards on protection against torture and establishes specific guidelines for the effective investigation and documentation of torture and ill treatment. The Istanbul Protocol is a non-binding document. However, international law obliges governments … Continue reading

Introduction

The term, ‘medical ethics,’ broadly describes the moral framework in which health professionals are bound to carry out their work. Many of the rules and principles of medical ethics have been adopted as professional codes of conduct. While ethics must guide every action of health professionals in their work, in the process of investigating and documenting allegations of torture, there are three areas in which the health professional must be particularly cognizant of specific ethical considerations. The first is the duty to the patient, the second is the clinical independence of the health professional and the third is in the production of medical records, reports and testimony.

There are certain ethical issues which are more likely to come to the fore depending on the various situations in which health professionals may encounter those alleging or showing signs of torture. This section points out the particular ethical considerations raised by situations such as the examination of an individual who is brought to a hospital or clinic still in the custody of the police, military or other security forces, and difficulties encountered by health professionals employed by the police, military or prison authorities.

The term, ‘medical ethics,’ broadly describes the moral framework in which health professionals are bound to carry out their work. Many of the rules and principles of medical ethics have been adopted as professional codes of conduct. While ethics must … Continue reading

Purpose of Medical Evaluations

According to the Istanbul Protocol, the broad purpose of the medical evaluation is to establish the facts related to alleged incidents of torture (IP, §120). The purpose of the written or oral testimony of the physician is to provide expert opinion on the degree to which medical findings correlate with the patient’s allegation of abuse and to communicate effectively the physician’s medical findings and interpretations to the judiciary or other appropriate authorities. In addition, medical testimony often serves to educate the judiciary, other government officials and the local and international communities on the physical and psychological sequelae of torture. The examiner should be prepared to do the following (IP, §121):

  • Assess possible injury and abuse, even in the absence of specific allegations by individuals, law enforcement or judicial officials;
  • Document physical and psychological evidence of injury and abuse;
  • Correlate the degree of consistency between examination findings and specific allegations of abuse by the patient;
  • Correlate the degree of consistency between individual examination findings with the knowledge of torture methods used in a particular region and their common after-effects;
  • Render expert interpretation of the findings of medico-legal evaluations and provide expert opinion regarding possible causes of abuse in asylum hearings, criminal trials and civil proceedings;
  • Use information obtained in an appropriate manner to enhance fact-finding and further documentation of torture.

According to the Istanbul Protocol, the broad purpose of the medical evaluation is to establish the facts related to alleged incidents of torture (IP, §120). The purpose of the written or oral testimony of the physician is to provide expert … Continue reading

Module 3 Answers

  1. Answer: A

    The primary purpose of a medical evaluation of torture and ill treatment is to assess the degree to which physical and psychological findings correlate with the individual allegations of abuse and to communicate effectively the clinician’s medical findings and interpretations to the judiciary or other appropriate authorities.

  2. Answer: F

    Clinicians must have the capacity to create a climate of trust in which disclosure of crucial, though perhaps very painful or shameful, facts can occur. All of the considerations listed will aid clinicians in earning the trust of survivors of torture.

  3. Answer: C

    Medical evaluations, whether for physical or psychological evidence, usually require considerable time, about 2 to 4 hours. If more time is required, it is advisable to schedule a second interview. Interviews lasting 6 hours or more may be particularly difficult for the individual being interviewed.

  4. Answer: D

    Forensic medical services should be under judicial or an independent authority and not under the same governmental authority as the police or prison system.

  5. Answer: A

    Physical and psychological examinations by their very nature may re-traumatise an individual by provoking and/or exacerbating psychological distress and symptoms by eliciting painful memories. The interview must be structured to minimise the risk of re-traumatisation by balancing the need to obtain detailed accurate account of events and the importance of respecting the needs of the person being interviewed.

  6. Answer: B

    The preferred gender of the examining clinician should not be presumed. Ideally, an investigation team should contain specialists of both genders, permitting the alleged torture victim to choose the gender of the investigator and, where necessary, the interpreter.

  7. Answer: C

    All of the statements about the use of interpreters are accurate with the exception of C. The age of the interpreter may be relevant. A young male individual may be able to discuss sexual torture with an older woman to whom he may relate as to an aunt, but not to a woman of his own age. Similarly, a young female individual may find an older man easier to talk to than one who is of a similar age to her torturer.

  8. Answer: A

    Transference refers to the feelings a survivor has towards the clinician that relate to past experiences but which are misunderstood as directed towards the clinician personally. Fear and mistrust may be particularly strong in cases where physicians or other health workers were participants in the torture.

  9. Answer: F

    All of the emotional reactions listed are common counter-transference reactions that an interviewer is likely experience while listening to the interview with Sr. Diana Ortiz.

  10. Answer: A, B

    The interviewer did not attempt to relocate the interview to a more comfortable and private location; Sr. Diana suggested that they move out of the cold weather into a nearby hotel. While the interviewer was empathetic to some extent, he maintained a somewhat detached demeanor and did not acknowledge the difficulty of recounting highly traumatic experiences.

  11. Answer: A

    Before beginning any medical evaluation, forensic clinicians must explain their role to the individual and make clear any limits on medical confidentiality.

  12. Answer: A, C, D

    All of the strategies listed may help to manage and limit secondary trauma with the exception of B. Discussing your emotional reactions with the survivor/alleged victim would be inappropriate and likely harmful to the individual.

  13. Answer: A

    Inquiries should be structured to elicit an open-ended, chronological account of events experienced during detention with minimal interruptions. Closed questions are often used to add clarity to a narrative account or to carefully redirect the interview if the individual wanders off the subject. Leading questions are avoided wherever possible, because individuals may answer with what they think the health professional wants to hear.

  14. Answer: E

    All of the techniques listed may help to improve the accuracy of information obtained in a medical evaluation.

  15. Answer: H

    Inconsistencies may result from a number of factors that may be directly related to the torture and ill treatment or to the psychological and/or neurological symptoms that result from torture and ill treatment. Interview conditions and cross cultural factors may be significant as well. Clinicians should be familiar with such factors to effectively explain any inconsistencies observed.

  16. Answer: F

    All of the steps listed may help clinicians to assess inconsistencies that may be identified in the course of a medical evaluation of torture and ill treatment.

  17. Answer: B

    Inquiries into prior political activities and beliefs and opinions are relevant insofar as they help to explain why the person was detained and/or tortured, but such inquiries are best made indirectly by asking the person what accusations were made, or why they think they were detained and tortured. The psychosocial history is particularly important in understanding the meaning that individuals assign to traumatic experiences.

  18. Answer: A

    Correlations between specific allegations of abuse and subsequent physical evidence require clinicians to obtain detailed information for each form of abuse alleged as stated in the question.

  19. Answer: B

    A medico-legal report should not be falsified under any circumstance. The ethical obligation of beneficence demands uncompromising accuracy and impartiality in order to establish and maintain professional credibility which, in turn, benefits survivors of torture. A medico-legal report should not be falsified under any circumstance.

  20. Answer: A

    Wherever possible, examinations to document torture for medico-legal purposes should be combined with an assessment for other needs, whether referral to specialist physicians, psychologists, physiotherapists or those who can offer social advice and support. Investigators should be aware of local rehabilitation and support services. Those who appear to be in need of further medical or psychological care should be referred to the appropriate services.

Answer: A The primary purpose of a medical evaluation of torture and ill treatment is to assess the degree to which physical and psychological findings correlate with the individual allegations of abuse and to communicate effectively the clinician’s medical findings … Continue reading

Psychological Evaluation #1

(based on an asylum evaluation conducted by Dr. Kathleen Allden, M.D. in November 2000, Boston, MA, USA)

I. Case Information

Name: Mr. __

Birth Date: x/xx/68

Birth Place: __

Gender: male

Clinician’s Name: Kathleen Allden, MD

Dates of Evaluation: August 23, 2000 (2 hours), September 6, 2000 (1 hour), September 13, 2000 (2 hours)

Interpreter: Not needed as client speaks English

Exam Requested by: Attorney Jane Doe

Subject Accompanied by: Attorney Jane Doe (first appointment only)

II. Clinician’s Qualifications [deleted]

Attached is my curriculum vitae.

I have personally examined this individual and have examined the facts recited in this written report. I believe all statements to be true. I would be prepared to testify to these statements based on my personal knowledge and belief.

III. Psychological / Psychiatric Evaluation

Background Information

Mr. __ is a 35 year old married man from [country A]. He came to the United States seeking asylum in February 2000. His wife and three children, ages 14, 10 and 5 years, are in a refugee camp in [country B], along with his mother and sister.

Summary of Collateral Sources

Draft Application for Asylum and Withholding of Removal supplied by his attorneys

Methods of Assessment Utilized

Clinical interviews

History of Torture and Ill-treatment

Mr. __ reports that he came to the United States in February 2000. He is seeking asylum because he feels it is not safe for him to return to [country A]. He says that in 1990 he was at his parents’ home when __ rebel forces attacked the house. He believes that his family was targeted because of his father’s job in the government, and because they are of the __ ethnic group. He was at home with his father, mother and sister when the house was attacked. Mr. __ and his family were taken to a rebel camp. He reports that the rebels forced him to hold his sister down while they gang raped her. Also, he was forced to watch as rebels tortured his father and cut off his limbs one at a time. He reports he was forced at gunpoint to hold his father down while they did this. He believes the rebels killed his father because at the time he was an officer in the government.

After a period of time, his mother and sister were able to leave the camp but Mr. __ says he was taken to another camp where he was burned and cut on the right arm and put in a pit. While in pit, the rebels urinated on him, threw dirty water on him and beat him. He remained in the pit for a long period of time. Conditions were filthy in the pit and his right arm became very infected. Mr. __ recalls becoming ill and coughing up brown sputum. While he was still in the pit, [country A] soldiers overtook the camp and freed him. He said that they could tell that he was not one of the __ rebel forces soldiers because it was obvious that he had been severely mistreated by them. For this reason, his life was spared at that time. He reports then being taken to the border where he escaped to [country B] and was able to reunite with his mother and sister.

During the years 1990-96, Mr. __ reports that there were many factions fighting in [country A]. He did not go back to [country A] until 1996 when there was a cease-fire. He went to check on the family’s property but found that the family’s house had been burned. He remained in [country A] where he participated in the presidential campaign of __, and was physically beaten by opposing political forces that were on the same side that had originally attacked his home and killed his father. The soldiers took him to a prison. Mr. __ and his family are members of the __ tribe. He reports that he and other __ tribe prisoners were taken away to the forest to be killed. The soldiers shot at the group of prisoners as the prisoners ran away. An unknown number were killed but Mr. __ escaped.

He went to live in barracks in an area where other __ tribe people were staying because they felt they might be safe there. In 1998, when __ rebel forces attacked this area, many people were killed. Soldiers attempted to arrest Mr. __. He believed they would take him away and kill him. He managed to escape and ran to __ peacekeeping base where other __ tribe people as well as other civilians had fled. __ peacekeeping base personnel helped Mr. __ and others flee the country by arranging for flights from an airbase. Mr. __ was flown to [country B] where he joined his mother and sister in a refugee camp.

In describing these events, Mr. __ reports that he witnessed many horrible atrocities. He said he saw soldiers ask people if they wanted a “long sleeve” or a “short sleeve” and then would chop off the arm accordingly. He also saw soldiers kill infants by bashing their heads until the brains came out. He reports seeing a group of children thrown in a well to die. While describing these experiences he said he felt ashamed to be telling me about these events. He said he felt ashamed of what had happened in his country and in other nearby countries such as [country C]. He said of the war and violence that he has experienced and witnessed, “It’s part of me now.” He describes feeling permanently changed, altered by these terrible things.

Current Psychological Complaints

Mr. __ reports that when he first arrived in the United States he was afraid to go out of the house. He lives with friends who reassured him that the United States is not like [country A] and that people are safe when they go out of their houses. He felt he might be attacked if he went out. With his friends’ encouragement, he gradually tried going out of the house and now is able to travel without significant difficulty. He has learned how to use public transportation and feels comfortable enough to use the bus.

He describes other symptoms and fears that were particularly bothersome when he first arrived in the United States but that have gradually diminished. For example, he would sleep in his clothes. He did this because in the past he felt he always had to be ready to run, ready to escape. When he came here he continued this habit until, gradually with friends’ encouragement, he was able to undress for sleep. He reports previously having difficulty falling asleep and staying asleep. He says that now he is able to sleep several hours per night but that he has nightmares of terrible past experiences during the war. His sleep disturbance and the frequency of his nightmares have improved slowly over the months since his arrival in the United States. He describes experiencing intrusive memories of the past and finds that he constantly worries about what would happen if he were sent back to [country A]. He describes being very sensitive to loud sounds and easily startled. During July 4 celebrations this summer, neighbor children were lighting firecrackers. This caused him to be very fearful and anxious as it reminded him of being in the war. His nightmares also worsened during that time period.

Mr. __ reports avoiding being reminded of the war and violence that he has experienced. For example, he avoids speaking about it. He also avoids television programmes that have violent scenes, or reports and news clips about war in [country C]. He says he avoids becoming angry or annoyed. He says he knows what people can do when they lose control and act on their anger. He says he tries to keep himself numb. He offers the example that if someone slapped him on the face, he would not feel it because he would be numb. He describes trying to push bad memories out of his mind and trying to distance himself from the past. He avoids going out on the street or in public and tries to stay indoors away from people he does not know. He says it is hard for him to see injustice or someone being mistreated. Because he becomes very angry when he witnesses injustices, he keeps himself isolated in order not to be exposed to situations that would anger him. He also feels that the cultural differences between the United States and his home are many and it is hard for him to cope with the differences. He says he only wants to be around people who encourage him and reassure him that things will turn out all right in the long run.

He worries about his family living as refugees in [country B]. His main goals are to bring his wife and children here and to work to send money to his mother and sister. (He has been told he will not be able to bring his mother and sister to the United States.) He says that having these goals helps him survive. He says that now that his father is dead it is his responsibility to look after the needs of his mother and the rest of the family. If it were not for these responsibilities, Mr. __ says he would prefer to be dead. He says he has seen too much suffering and cruelty. The past seems like a dream, the happy times in the past seem unreal. Although he contemplates suicide, he says all is not lost because if he is granted asylum, he may be able to bring his wife children to the United States so they can have a better future. He does not have confidence that there will be peace in his country for a long time.

Mr. __ says that his religious beliefs help him cope with his life. He reads the Bible every day. He speaks of his devotion to Jesus Christ and his faith in God.

Post-Torture History

Mr. __ was a refugee in [country B] before coming to the United States. He said that life in [country B] is very harsh. Food is scare, infectious diseases are common, and it is very hard to make a living. Also, people in the region do not trust people from [country A], according to Mr. __, fearing they are members of rebel groups. His family encouraged him to leave __ and go to the United States. He traveled to the United States via [country A] with the assistance of a close friend of the family. His mother, sister, wife and children are living in [country B] in a refugee camp. Currently, Mr. __ lives with friends in Massachusetts. He feels welcomed and supported by them. He has been staying with these friends since his arrival in the United States. His hosts are friends of his late father. Mr. __ does not work because he is not legally permitted to work. He feels he is able to work and he would like to work in order to earn money for his family.

Pre-Torture History

Family history: Mr. __ is one of two siblings; he has one sister. He grew up in the home of his mother and father, who were Baptists. His father was a government official in the former government. According to Mr. __, his father was able to earn a good living and the family was well provided for. Mr. __ met his wife when they were both in school; they were married around 1985. After they were married they lived with Mr. __’s parents. They have three children ages 14, 10, and 5. He describes a happy childhood and family life until the time that war broke out in his country in 1990.

Educational history: Mr. __ reports he has a high school education and completed a junior college programme in computer science.

Occupational history: Mr. __ is trained in computer science. He has not practiced that profession. While a refugee in [country A], he supported his family as a vendor.

Cultural and religious background: Mr. __ was raised as a Baptist and continues to practice his religion in the United States. He is from the __ tribe.

Medical History

Prior to the war, Mr. __’s had several episodes of malaria. Otherwise his health was good. During the time he was kept in the pit he developed a severe respiratory illness which he describes as bronchitis with a productive cough and vomiting that required long-term treatment with antibiotics after he was finally released. He says he still has right-sided chest pain and that when he takes a deep breath, he hears wheezes in his chest. He still coughs up phlegm. His chest pain is worse during rainy weather. Also, he complains of right arm pain where his arm was cut by his torturers. He has not had a physical exam since coming to the United States.

Past Psychiatric History

There is no past history of mental illness.

Substance Use and Abuse History

Prior to coming to the United States, Mr. __ reports that he had great difficulty falling asleep. He would drink alcohol to help fall asleep. He does not do this now. He denies using illicit drugs.

Mental Status Examination

  1. General appearance – Mr. __ is a neatly dressed man who was very polite and cooperative during the interviews. He was clearly distressed by having to retell his history of trauma. He was tearful and moderately agitated especially during our first meeting.
  2. Motor activity – No obvious psychomotor retardation. He was somewhat agitated and frustrated at times but able to tolerate the long interviews.
  3. Speech – His English is fluent but his accent is very heavy and I had difficulty understanding him at times. His speech was logical and goal directed. He was able to express his emotions and ideas very well.
  4. Mood and affect – Frequently during the interviews, he was clearly overwhelmed with feelings of loss and sadness. He also expressed horror at witnessing extreme cruelty and violence. He appeared frustrated at not being able to communicate to me how extremely awful the atrocities that he witnessed were. His affect was labile. He was often tearful. He was able to smile on occasion.
  5. Thought content – His thoughts centered on two main themes, his worries for his family and the horrors he has witnessed and experienced. These worries and memories seem to occupy his thought much of the time.
  6. Thought process – There is no evidence of paranoia, delusions, referential ideation or other disturbance of thought. There is no evidence of hallucinations.
  7. Suicidal and homicidal ideation – There is no evidence of homicidal ideation but he has thoughts of suicide. He says that he would prefer to be dead and that the only reason that he stays alive is that his family is his responsibility and he hopes to be able to help them have a better life.
  8. Cognitive exam – He is oriented and alert. He gives the proper date and place. He does not seem to have difficulty with long term recall but admits that giving precise dates of events is very hard for him. His immediate recall is impaired as evidenced by is ability to recall only 4 of 6 digits when asked to do so. His intermediate recall is similarly impaired as evidenced by his ability to recall only 2 of 3 objects that he is asked to recall after a 3-minute time lapse. His overall global cognitive function may also be impaired as evidenced by is inability to spell a five-letter word backwards.

Clinical Impression (Interpretation of Findings)












Conclusion and Recommendations












(based on an asylum evaluation conducted by Dr. Kathleen Allden, M.D. in November 2000, Boston, MA, USA) I. Case Information Name: Mr. __ Birth Date: x/xx/68 Birth Place: __ Gender: male Clinician’s Name: Kathleen Allden, MD Dates of Evaluation: August … Continue reading

Module 4 Answers

  1. Answer: B, C, D

    It is important to realize that torturers often attempt to conceal their deeds. For example, physical evidence of beating may be limited when wide, blunt objects are used for beatings. Similarly, victims are sometimes covered by a rug, or shoes in the case of falanga, to distribute the force of individual blows. For the same reason, wet towels may be used with electric shocks. Also, torture victims may be intentionally detained until obvious signs of abuse have resolved.

  2. Answer: A

    The improvement in the methods of detecting and providing evidence of physical torture has paradoxically led to more sophisticated methods of torture that do not to leave visible evidence on the victim’s body.

  3. Answer: A, B, C

    While the symptoms and conditions listed in A, B and C may be associated with falanga, they are not considered pathognomonic.

  4. Answer: A

    Small tympanic membrane ruptures (less than 2 mm in diameter) usually heal within 10 days.

  5. Answer: D, E

    “Palestinian” suspension results in traction on the lower roots of the brachial plexus and is therefore most likely to result in a sensory deficit in the ulnar distribution. A “winged” scapula can be observed on physical examination as a prominent vertebral border when hands are pressed against a wall with outstretched arms.

  6. Answer: A

    Various forms of positional torture are commonly associated with musculoskeletal symptoms and disabilities, but usually do not result in specific or permanent dermatologic or radiographic findings.

  7. Answer: A, C, D E

    Crushing and stretch injuries commonly cause contusions and may cause abrasions depending on the nature of the objects used and the forces applied. Rough objects and tangential forces may result in abrasions. Incisions are unlikely as they result from sharp, penetrating objects. Extensive muscle necrosis can result in the release of myoglobin which can cause acute renal failure and death unless dialysis is initiated.

  8. Answer: E

    All of the statements regarding burn injuries are accurate.

  9. Answer: E

    Electric shocks have been commonly used by torturers for many years because they cause exquisite pain, but rarely leave identifiable physical signs. Depending on the path of the current, electric shocks can result in dislocation of joints, arrhythmias, urination and defecation.

  10. Answer: A

    Occasionally the electrodes can leave small burns, probably from sparking. Lesions tend to be circular, hyperpigmented and less than 0.5 cm in diameter. Although non-specific, they can corroborate allegations of electric shock torture, especially if they are in certain parts of the body.

  11. Answer: E

    Hypoxia can cause permanent brain injury and exposure to contaminated water or other caustic liquids may result in acute broncho-pulmonary infections, conjunctivitis and otitis media.

  12. Answer: B

    Waterboarding is a form of asphyxiation torture that dates back to the Middle Ages and, recently, has been practised by the United States. Victims are strapped to a board or made to lie in a supine position with their heads lower than the rest of their bodies. The face is covered with cloth, and water is poured over the victim’s mouth to create the sensation of drowning. This deliberate infliction of severe physical and mental pain constitutes torture.

  13. Answer: E

    Violent shaking can result in all of the problems listed.

  14. Answer: B, C, D

    Rape is only one of many forms of sexual assault including forced nudity, groping, molestation and forced sexual acts. Often, sexual assaults will be accompanied by direct or implied threats. In the case of women, the threat may be one of becoming pregnant. For men, those inflicting the torture may also threaten (incorrectly but usually deliberately) that the victim will become impotent or sterile. For men or women there may be the threat of contracting HIV or other sexually transmitted infections (STIs) and often the threat or fear that sexual humiliation, assault or rape will lead to ostracism from the community and being prevented from ever marrying or starting a family. Rape is always associated with the risk of developing sexually transmitted diseases, including HIV. Ideally, medical evaluations of alleged sexual assault should include a team of experienced clinical experts.

  15. Answer: G

    All of the methods listed have been determined to constitute torture by the UN Committee Against Torture and/or the Special Rapporteur on Torture.

  16. Answer: B, C, D

    Despite the fact that torture is an extraordinary life experience capable of causing a wide range of psychological suffering, extreme trauma such as torture does not always produce psychological problems. Therefore, if an individual does not have mental problems, it does not mean that he/she was not tortured. When there are no physical or psychological findings, this does not refute or support whether torture had actually occurred. Major Depression and PTSD are the most common diagnoses among survivors of torture and ill treatment. The course of Major Depression and PTSD varies over time. There can be asymptomatic intervals, recurrent episodes, and episodes during which an individual is extremely symptomatic.

  17. Answer: A

    The psychological consequences of torture and ill treatment develop in the context of personal meaning and personality development. They also may vary over time and can be shaped by cultural, social, political, interpersonal, biological and intrapsychic factors that are unique to each individual.

  18. Answer: B

    Descriptive methods of evaluating psychological evidence of torture are best when attempting to evaluate psychological or psychiatric reactions and disorders because what is considered disordered behaviour or a disease in one culture may not be viewed as pathological in another. While some psychological symptoms may be present across differing cultures, they may not be the symptoms that concern the individual the most. Therefore, the clinician’s inquiry has to include the individual’s beliefs about their experiences and meanings of their symptoms, as well as an evaluating the presence or absence of symptoms of trauma-related mental disorders.

  19. Answer: I

    All of the factors listed can affect psychological outcomes following torture and ill treatment.

  20. Answer: G

    All of the risk factors listed can contribute to the possibility of developing mental illness among refugee survivors of torture.

Answer: B, C, D It is important to realize that torturers often attempt to conceal their deeds. For example, physical evidence of beating may be limited when wide, blunt objects are used for beatings. Similarly, victims are sometimes covered by … Continue reading

Istanbul Protocol Model Medical Curriculum

Model Curriculum on the Effective Medical Documentation
of Torture and Ill-treatment

Educational Resources for Health Professional Students
Prevention through Documentation Project, 2006-2009

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Downloadable version:

Model Curriculum on the Effective Medical Documentation of Torture and Ill-treatment Educational Resources for Health Professional Students Prevention through Documentation Project, 2006-2009 Downloadable version: Istanbul Protocol Model Medical Curriculum (pdf)

The Human Rights Committee

The Human Rights Committee is established as a monitoring body by the International Covenant on Civil and Political Rights (ICCPR). The Committee comprises 18 independent experts elected by the states parties to the Covenant. It examines reports which states parties are obliged to submit periodically and issues concluding observations that draw attention to points of concern and make specific recommendations to the state. The Committee can also consider communications from individuals who claim to have been the victims of violations of the Covenant by a state party. For this procedure to apply to individuals, the state must also have become a party to the first Optional Protocol to the Covenant. The Committee has also issued a series of General Comments, to elaborate on the meaning of various Articles of the Covenant and the requirements that these place on states parties. The General Comment regarding Article 7 is contained in Appendix One of this manual.

The Human Rights Committee is established as a monitoring body by the International Covenant on Civil and Political Rights (ICCPR). The Committee comprises 18 independent experts elected by the states parties to the Covenant. It examines reports which states parties … Continue reading