Torture

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

IRCT logo [1]

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

Physical Evidence of Torture

Witness and survivor testimony are necessary components in the documentation of torture. To the extent that physical evidence of torture exists, it may provide important confirmatory evidence that a person was tortured. Torture victims may have injuries that are substantially different from other forms of trauma. Although acute lesions may be characteristic of the alleged injuries, most lesions heal within about six weeks of torture, leaving no scars or, at the most, non-specific scars. This is often the case when torturers use techniques that prevent or limit detectable signs of injury. Under such circumstances, the physical examination may be within normal limits, but this in no way negates allegations of torture. As the Istanbul Protocol makes clearly, the absence of such physical evidence should not be construed to suggest that torture did not occur, since such acts of violence against persons frequently leave no marks or permanent scars. A detailed account of the patient’s observations of acute lesions and the subsequent healing process often represent an important source of evidence in corroborating specific allegations of torture or ill-treatment.

A medical evaluation for legal purposes should be conducted with objectivity and impartiality. The evaluation should be based on the physician’s clinical expertise and professional experience. The ethical obligation of beneficence demands uncompromising accuracy and impartiality in order to establish and maintain professional credibility. When possible, clinicians who conduct evaluations of detainees should have specific essential training in forensic documentation of torture and other forms of physical and psychological abuse. They should have knowledge of prison conditions and torture methods used in the particular region where the patient was imprisoned and the common after-effects of torture. The medical report should be factual and carefully worded. Jargon should be avoided. All medical terminology should be defined so that it is understandable to lay persons.

In addition, the physician should not assume that the official requesting a medico-legal evaluation has related all the material facts. It is the physician’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.

Witness and survivor testimony are necessary components in the documentation of torture. To the extent that physical evidence of torture exists, it may provide important confirmatory evidence that a person was tortured. Torture victims may have injuries that are substantially … Continue reading

Module 5 Answers

  1. Answer: B

    Although acute lesions may be characteristic of the alleged injuries, most lesions heal within about six weeks of torture, leaving no scars or, at the most, non-specific scars.

  2. Answer: C

    A complete physical examination is recommended unless the allegations of torture are limited and there is no history of loss of consciousness or neurological or psychological symptoms that may affect recall of torture allegations. Under such circumstances, a directed examination may be appropriate in which only pertinent positive and negative evidence is pursued on examination.

  3. Answer: F

    All of the forms of historical information listed may be useful in correlating regional practices of torture with individual allegations of abuse.

  4. Answer: C

    Inquiries should be structured to elicit an open-ended, chronological account of events experienced during detention.

  5. Answer: E

    In addition to location, size, shape and color, each of the factors listed above should be included in clinical descriptions of skin lesions.

  6. Answer: B

    Lacerations are caused by a tangential force such as a blow or a fall and produce tears of the skin. The wound edges tend to be irregular, and often any may be bruised and/or abraded. Tissue bridges may be present. Incisions are caused by sharp objects like a knife, bayonet, or broken glass that produce a more or less deep, sharp and well-demarcated skin wound.

  7. Answer: C or D

    The photograph shows a large 4 cm x 6 cm contusion with underlying edema and/or hematoma formation. There are a series of parallel linear abrasions that correspond to the ridges of a police baton (see photo below). These physical findings should be considered “highly consistent” with or “virtually diagnostic” of the alleged injury since it is very unlikely they were caused by any other mode of injury or pathophysiological process. “Proof” of torture implies 100% certainty and should be avoided unless it can be supported by the evidence. In this case the injury may have been inflicted in the context of “resisting arrest.”
    [Courtesy of Amnesty International, The Netherlands.]

  8. Answer: A, B, D

    Contusions cause blood to leak from small vessels. If the skin and subcutaneous tissues are thin, the bruise becomes apparent relatively quickly and may take the shape of the weapon used. The extent and severity of a contusion are related to the amount of force applied, but more importantly vascular structures affected. Elderly people and children who have loosely supported vascular structure will bruise more easily than young adults. Many medical conditions are associated with easy bruising. As the extravasated red cells are destroyed, the aging bruise goes through variable colour changes. Speculative judgments should be avoided in the evaluation of the nature and age of blunt traumatic lesions.

  9. Answer: B, C, D

    Full thickness wounds heal in one of two ways. When the wound is small and the edges are opposed, it heals from the top down (by primary intention). This tends to leave a small, tidy scar. If this process cannot occur, especially if the wound gapes, it heals from below (by secondary intention). This is a slow process and prone to infection, and will leave a wide scar. Scars related to self-inflicted injuries are generally superficial and within easy reach of the dominant hand. Contusions and abrasions may cause hyperpigmented scars, especially in darker skins, due to post-inflammatory hyperpigmentation. Also scars of distinctive shape and if in multiples suggest intentional injuries rather than those caused accidentally.

  10. Answer: B

    The photograph shows an oval scar above the left hip that is approximately 7 cm x 4 cm. It is a macular lesion with a depigmented, atrophic center, lacking normal skin accessories (hair). The periphery shows a hyperpigmented zone about 1 cm. wide. This scar is most consistent with a 2nd degree burn from a heated instrument.

  11. Answer: A

    This scar is the result of an abrasion injury as the individual was dragged across a rough surface.

  12. Answer: C

    This man sustained blunt trauma to the right supraorbital region which resulted in a typical laceration scar. The appearance of the scar is the result of the healing of irregular wound edges and tissue bridges.

  13. Answer: B

    The photograph shows 2 linear incisions resulting from slashes with a knife. The biconvex appearance of the scars suggest that they healed by secondary intention. These scars are most consistent with incisions because of the sharp, well-demarcated appearance of the scars.

  14. Answer: C

    The multiple linear, scars are most consistent with lacerations from whipping with an electrical wire.

  15. Answer: D

    The photograph shows evidence of multiple cigarette burns 7 days following the injury.

  16. Answer: A, B, C

    Whenever possible, the examination of women alleging rape should be performed by an expert in documenting sexual assault. Otherwise, the examining physician should speak to an expert or consult a standard text on clinical forensic medicine. A thorough physical examination should be performed, including meticulous documentation of all physical findings. It is rare to find any physical evidence when examining female genitalia more than one week after an assault. Even during examination of the female genitalia immediately after rape, there is identifiable damage in less than 50 per cent of the cases. It is unwise to draw conclusions about a refusal to consent to genital examination. If the alleged victim refuses consent, the doctor should record any relevant observations on the alleged victim’s demeanour, such as embarrassment or fear, or cultural considerations.

  17. Answer: F

    All of the statements listed are true.

  18. Answer: A

    Rectal tears with or without bleeding may be noted. Disruption of the rugal pattern may manifest as smooth fan-shaped scarring. When these scars are seen out of midline (i.e. not at 12 or 6 o’clock), they can be an indication of penetrating trauma.

  19. Answer: A

    Poor quality photographs are better than none, but they should be followed up with professional photographs as soon as possible.

  20. Answer: E

    In some cases, the use of diagnostic tests may aid in corroborating allegations of torture. Before obtaining such tests, however, clinicians should carefully consider the potential value of such tests and their inherent limitations in light of the level of “proof” needed in a particular case, the potential adverse consequences for the individual, and any resource limitations. Generally, diagnostic tests are not warranted unless they are likely to make a significant difference to a medico-legal case.

Answer: B Although acute lesions may be characteristic of the alleged injuries, most lesions heal within about six weeks of torture, leaving no scars or, at the most, non-specific scars. Answer: C A complete physical examination is recommended unless the … Continue reading

Types of questions

If possible, the individual should be asked to give a chronological account of the incident(s) in question. Generally, open-ended questions should be used, for example: ‘Can you tell me what happened?’ or ‘Tell me more about that.’ The individual should be allowed to tell his or her story with as few interruptions as possible. Further details can be elicited with appropriate follow-up questions, such as: ‘How big was the cell?’, ‘Was there any lighting?’ and ‘How could you go to the toilet?’ Asking too many questions too quickly might confuse the individual, or even remind him or her of being interrogated.

Leading questions are avoided wherever possible, because individuals may answer with what they think the health professional wants to hear. This is especially important when interviewing for medico-legal purposes, where the testimony may be challenged in court. Closed questions, which provide the interviewee with a limited number of options and, particularly, list questions, can cause confusion in the individual and might create unnecessary inconsistencies. For example, an individual might be asked, ‘Were you arrested by the police or the army?’ limiting the answer to a choice between the two. If he or she was arrested by a special task force of soldiers and policemen working together, it would be difficult to give an accurate answer without appearing to contradict the health professional. This could in turn create inconsistencies between statements.

The pace of the interview must be dictated by the individual. Even if there is limited time for the interview (such as in a police station or prison), the interviewee should not feel rushed. It is better to focus on a few specific points than to try to cover too much ground in too little time. If there are many interviewees to be seen over several days, each should be seen once or twice for a substantial period of time, rather than several shorter sessions.

In a clinical setting, the interviewer should allow enough time between appointments to allow for this and for sufficient time to write up his or her notes. It is good practise to write up the notes of each interview at the end of that session, as various aspects of the individuals’ accounts may become confused if the interviewer attempts to write up all the interviews in a later single session, and details may be forgotten.

If possible, the individual should be asked to give a chronological account of the incident(s) in question. Generally, open-ended questions should be used, for example: ‘Can you tell me what happened?’ or ‘Tell me more about that.’ The individual should … Continue reading

Medical history

As stated in Module 3 [1], the pysician should obtain a complete medical history, including information about prior medical, surgical or psychiatric problems. S/he should:

  • Be sure to document any history of injuries, medical conditions and surgery before the period of detention and any possible after­effects;
  • Avoid leading questions;
  • Structure inquiries to elicit an open-ended, chronological account of the events experienced during detention.

Specific historical information may be useful in correlating regional practices of torture with individual allegations of abuse. Examples of useful information include descriptions of torture devices, body positions, methods of restraint, descriptions of acute or chronic wounds and disabilities and identifying information about perpetrators and places of detention. While it is essential to obtain accurate information regarding a torture survivor’s experiences, open-ended interviewing methods require that a patient disclose these experiences in their own words using free recall. An individual who has survived torture may have trouble expressing in words his or her experiences and symptoms. In some cases, it may be helpful to use trauma event and symptom checklists or questionnaires. If the interviewer believes it may be helpful to use trauma event and symptom checklists, there are numerous questionnaires available; however, none are specific to torture victims. All complaints of a torture survivor are significant. Although there may be no correlation with the physical findings, they should be reported. Acute and chronic symptoms and disabilities associated with specific forms of abuse and the subsequent healing processes should be documented.

Acute Symptoms

The individual should be asked to describe any injuries that may have resulted from the specific methods of alleged abuse. For example, bleeding, bruising, swelling, open wounds, lacerations, fractures, dislocations, joint stress, haemoptysis (coughing up blood), pneumothorax (lung puncture), tympanic membrane perforation, genitourinary system injuries, burns (including colour, bulla or necrosis according to the degree of burn), electrical injuries (size and number of lesions, their colour and surface characteristics), chemical injuries (colour, signs of necrosis), pain, numbness, constipation and vomiting. The intensity, frequency and duration of each symptom should be noted. The development of any subsequent skin lesions should be described and whether or not they left scars. Ask about health on release; was he or she able to walk, confined to bed? If confined, for how long? How long did wounds take to heal? Were they infected? What treatment was received? Was it a physician or a traditional healer? Be aware that the detainee’s ability to make such observations may have been compromised by the torture itself or its after-effects and should be documented. It is important to note that acute lesions are often characteristic since they may show a pattern of inflicted injury that differs from non-inflicted injuries, for example by their shape, repetitiveness, and distribution on the body.

Chronic Symptoms

Elicit information of physical ailments that the individual believes were associated with torture or ill-treatment. Note the severity, frequency and duration of each symptom and any associated disability or need for medical or psychological care. Even if the after-effects of acute lesions are not observed months or years later, some physical findings may still remain, such as electrical current or thermal burn scars, skeletal deformities, incorrect healing of fractures, dental injuries, loss of hair and myofibrosis. Common somatic complaints include headache, back pain, gastrointestinal symptoms, sexual dysfunction and muscle pain. Common psychological symptoms include depressive affect, anxiety, insomnia, nightmares, flashbacks and memory difficulties (see Module 6 [2]).

As stated in Module 3, the pysician should obtain a complete medical history, including information about prior medical, surgical or psychiatric problems. S/he should: Be sure to document any history of injuries, medical conditions and surgery before the period of … Continue reading

Module 6 Answers

  1. Answer: E

    Detailed psychological evaluations should be included in all medical evaluations for all of the reasons listed.

  2. Answer: E

    All of the items listed are true about psychological sequelae of torture and ill treatment.

  3. Answer: B

    Torture may not only have profound effects on individuals, but on families and society as well. It can terrorize entire populations and create an atmosphere of pervasive fear, terror, inhibition, and hopelessness. It can break or damage the will and coherence of entire communities. It often results in disruptions in family dynamics and may be associated with considerable family dysfunction.

  4. Answer: E

    All of the items listed may explain why survivors of torture and ill treatment may not trust examining clinicians.

  5. Answer: H

    When listening to individuals speak of their torture, clinicians should expect to have personal reactions and emotional responses themselves including avoidance and defensive indifference in reaction to being exposed to disturbing material, disillusionment, helplessness, hopelessness that may lead to symptoms of depression or “vicarious traumatisation,” grandiosity or feeling that one is the last hope for the survivor’s recovery and well-being, feelings of insecurity in one’s professional skills in the face of extreme suffering, guilt over not sharing the torture survivor’s experience, or even anger when the clinician experiences doubt about the truth of the alleged torture history and the individual stands to benefit from an evaluation.

  6. Answer: B, C, E

    According to DSM IV criteria, the diagnosis of PTSD requires that:

    A) A person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others; and the person’s response involved intense fear, helplessness, or horror.

    B) One or more re-experiencing symptoms are present following the trauma.

    C) Three or more avoidance symptoms are present following the trauma.

    D) Two or more hyperarousal symptoms are present following the trauma.
    E) The duration of symptoms in Criteria B, C, and D) is more than 1 month.

    F) The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  7. Answer: E

    PTSD symptoms commonly occur under all of the circumstances listed above. Anniversary dates and interactions with police or security forces often serve as direct reminders of past traumatic experiences. Recalling traumatic experiences prior to, during, and following a medical evaluation often results in re-traumatisation. In gaining asylum, survivors of torture are often reminded of the loss of family, friends, job, language, etc. and/or may experience feelings of guilt in “abandoning” others who may still be detained.

  8. Answer: L

    Symptoms of Major Depression include all of the symptoms listed above. Depressive states are very common among survivors of torture. Depressive disorders may occur as a single episode or be recurrent. They can be present with or without psychotic features.

  9. Answer: G

    In addition to all of the items listed, other possible diagnoses include: generalized anxiety disorder, panic disorder, acute stress disorder, bipolar disorder, delusional disorder, disorders due to a general medical condition, (possibly in the form of brain impairment with resultant fluctuations or deficits in level of consciousness, orientation, attention, concentration, memory and executive functioning), and phobias such as social phobia and agoraphobia.

  10. Answer: B

    Somatiform disorders manifest as repeated presentations of physical symptoms in the absence of physical findings. If any physical disorders are present, they do not explain the nature and extent of the symptoms or the distress and preoccupation of the patient.

  11. Answer: A

    Neuropsychology has long been recognised as useful in discriminating between neurological and psychological conditions and in guiding treatment and rehabilitation of patients suffering from the consequences of various levels of brain damage. Neuropsychological evaluations of torture survivors are performed infrequently, but may be useful in evaluating individuals suspected of having brain injury and in distinguishing brain injury from PTSD. Neuropsychological assessment may also be used to evaluate specific symptoms, such as problems with memory that occur in PTSD and related disorders.

  12. Answer: G

    All topics listed are components of the mental status examination with the exception of G, cranial nerve assessment.

  13. Answer: B

    Significant psychological symptoms may not be present among survivors of torture for a number of reasons. Clinicians may fail to consider diagnostic possibilities especially if they simply focus on the most common psychological diagnoses. Survivors may not have significant psychological symptoms due to effective coping strategies, social supports and/or a positive meaning assigned to their experiences (i.e. suffering for an important cause). Under such circumstances the reasons for symptom mitigation can and should be explained in the clinician’s medical evaluation.

  14. Answer: A

    The first step in addressing inconsistencies is to ask the individual for further clarification.

  15. Answer: B

    Pre-torture psycho-social information is highly relevant to the interpretation of psychological evidence as it is provides a context for understanding individual behaviour and the meaning assigned to torture experiences.

  16. Answer: D

    The administration of psychological instruments is up the discretion of the examining clinician. There are numerous questionnaires available. Though they may add complementary value to a clinical evaluation, routine use is not recommended. Caution must be exercised in the interpretation of responses and scores because established norms do not exist for many countries. The Istanbul Protocol makes clear that psychological instruments should not be given more weight than the clinical evaluation.

  17. Answer: A

    The clinician should attempt to understand mental suffering in the context of the survivor’s circumstances, beliefs, and cultural norms rather than rush to diagnose and classify. Awareness of culture specific syndromes and native language-bound idioms of distress is of paramount importance for conducting the interview and formulating the clinical impression and conclusion. When the interviewer has little or no knowledge about the alleged victim’s language and culture, the assistance of an interpreter is essential.

  18. Answer: G

    Interpretation of the clinical findings is a complex task. According to the Istanbul Protocol, all of the concerns listed should be included in clinical interpretations of psychological evidence of torture and ill treatment.

  19. Answer: A

    In the course of documenting psychological evidence of torture clinicians are not absolved of their ethical obligations. Those who appear to be in need of further medical and/or psychological care should be referred to appropriate services. Clinicians should be aware of local rehabilitation and support services.

  20. Answer: F

    All of the considerations listed are true about the effects of torture on children.

Answer: E Detailed psychological evaluations should be included in all medical evaluations for all of the reasons listed. Answer: E All of the items listed are true about psychological sequelae of torture and ill treatment. Answer: B Torture may not … Continue reading

Copyright and Acknowledgements

Copyright

© International Rehabilitation Council for Torture Victims

This Model Curriculum was developed by Physicians for Human Rights USA (PHR USA) as part of the Prevention through Documentation (PtD) Project, an initiative of the International Rehabilitation Council for Torture Victims (IRCT), Human Rights Foundation of Turkey (HRFT), REDRESS, and Physicians for Human Rights.

All rights reserved. This work may be reproduced for distribution on a not-for-profit basis for training, educational and reference purposes provided that the International Rehabilitation Council for Torture Victims is acknowledged. All materials distributed must contain this copyright notice: “© International Rehabilitation Council for Torture Victims.”

ADDRESS
International Rehabilitation Council for Torture Victims (IRCT)
Borgergade 13
P.O. Box 9049
DK-1022 Copenhagen K
DENMARK

ISBN: 978-87-88882-23-0

Acknowledgements

The Model Curriculum was developed by Vincent Iacopino MD, PhD, Senior Medical Advisor, Physicians for Human Rights using the resources listed below. The Model Curriculum was edited by Madhavi Dandu, MD, MPH, University of California, San Francisco and copy edited by Gregory Wong, Wesleyan University. Editorial comments and suggestions were kindly provided by Önder Özkalıpçı MD, International Rehabilitation Council for Torture Victims; Alejandro Moreno, MD, JD, Boston Center for Refugee Health and Human Rights

Many of the materials used for the preparation of the Model Curriculum were developed through the Preventing Torture through Investigation and Documentation (PtD) Project, a collaboration between the Human Rights Foundation of Turkey, REDRESS, Physicians for Human Rights, and the International Rehabilitation Council for Torture Victims. The contributors of those materials included: Hülya Üçcpınar, Türkcan Baykal and Şebnem Korur Fincancı, with comments and contributions provided by Lutz Oette, Anna-Lena Svensson-McCarthy, Nieves Molina Clemente, Ole Vedel Rasmussen, Thomas Wenzel and Vincent Iacopino.

The PowerPoint files that were developed for each of the nine Modules in the Model Curriculum were based on contributions from a number of individuals:

  • Module 1: Vincent Iacopino, Physicians for Human Rights; Bent Sorensen, International Rehabilitation Council for Torture Victims
  • Module 2: Vincent Iacopino, Physicians for Human Rights; Önder Özkalıpçı MD, International Rehabilitation Council for Torture Victims; Caroline Schlar, Action for Torture Survivors (HRFT), Geneva; Jon Snaedal, Istanbul Protocol Implementation Project Training, Tbilisi, Georgia
  • Module 3: Türkcan Baykal MD, Human Rights Foundation of Turkey; Allen Keller MD Bellevue/NYU Program for Survivors of Torture; Uwe Jacobs PhD, Survivors International; Kathleen Allden, MD, Indochinese Psychiatric Clinic; Vincent Iacopino, Physicians for Human Rights
  • Module 4: Vincent Iacopino, Physicians for Human Rights; Önder Özkalıpçı MD, International Rehabilitation Council for Torture Victims; Alejandro Moreno, MD, JD, Boston Center for Refugee Health and Human Rights; Ole Vedel Rasmussen, MD, DMSc, International Rehabilitation Council for Torture Victims; Türkcan Baykal MD, Human Rights Foundation of Turkey; Caroline Schlar, PhD, Human Rights Foundation of Turkey, Emre Kapnın, Human Rights Foundation of Turkey; Kathleen Allden, MD, Indochinese Psychiatric Clinic
  • Module 5: Vincent Iacopino, Physicians for Human Rights; Önder Özkalıpçı MD, International Rehabilitation Council for Torture Victims; Alejandro Moreno, MD, JD, Boston Center for Refugee Health and Human Rights; Ole Vedel Rasmussen, MD, DMSc, International Rehabilitation Council for Torture Victims; Lis Danielsen, MD, DMSc, International Rehabilitation Council for Torture Victims
  • Module 6: Türkcan Baykal MD, Human Rights Foundation of Turkey, Caroline Schlar, PhD, Human Rights Foundation of Turkey, Emre Kapnın, Human Rights Foundation of Turkey; Kathleen Allden, MD, Indochinese Psychiatric Clinic; Vincent Iacopino, Physicians for Human Rights
  • Module 7: Vincent Iacopino, Physicians for Human Rights; Alejandro Moreno, MD, JD, Boston Center for Refugee Health and Human Rights; Önder Özkalıpçı MD, International Rehabilitation Council for Torture Victims
  • Module 8: Vincent Iacopino, Physicians for Human Rights; Alejandro Moreno, MD, JD, Boston Center for Refugee Health and Human Rights; Önder Özkalıpçı MD, International Rehabilitation Council for Torture Victims
  • Module 9: Vincent Iacopino, Physicians for Human Rights; Alejandro Moreno, MD, JD, Boston Center for Refugee Health and Human Rights; Önder Özkalıpçı MD, International Rehabilitation Council for Torture Victims

The two Case Examples included in Modules 7 and 8 were developed by: Vincent Iacopino, Physicians for Human Rights; Alejandro Moreno, MD, JD, Boston Center for Refugee Health and Human Rights; Önder Özkalıpçı MD, International Rehabilitation Council for Torture Victims. The PowerPoint presentations were edited by Madhavi Dandu, MD, MPH, University of California, San Francisco and copy edited by Gregory Wong, Wesleyan University.

The two Psychological Evaluations used in Module 6 were provided by: Uwe Jacobs PhD, Survivors International; Kathleen Allden, MD, Indochinese Psychiatric Clinic.

All Self-Assessment files were developed by Vincent Iacopino, Physicians for Human Rights with editorial comments and suggestions provided by Madhavi Dandu, MD, MPH, University of California, San Francisco and copy edited by Gregory Wong, Wesleyan University.

Copyright © International Rehabilitation Council for Torture Victims This Model Curriculum was developed by Physicians for Human Rights USA (PHR USA) as part of the Prevention through Documentation (PtD) Project, an initiative of the International Rehabilitation Council for Torture Victims … Continue reading