Torture

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)
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P.O. Box 9049
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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

Assessment for Referral

The clinician should not hesitate to seek any further consultation and examination that he or she considers necessary for the evaluation. Those who need further medical and/or psychological care should be referred to appropriate services as discussed in Module 3. During ongoing care, further evidence may be detected that may not have been foreseen. If there is a rehabilitation centre for torture survivors in the region, the clinician may contact them for further support and advice.

In countries with there is a tradition of systematic torture, and pressure on health care professionals, the examining clinician may also prefer to refer patients to specialists to increase the number of medical witnesses to the torture (e.g. consulting with a dermatologist for a simple contusion).

The clinician should not hesitate to seek any further consultation and examination that he or she considers necessary for the evaluation. Those who need further medical and/or psychological care should be referred to appropriate services as discussed in Module 3. … Continue reading

Module 7 Answers

  1. Answer: A, B, D

    All of the considerations listed are important for effective interviews with the exception of C. All individuals alleging torture, including those in custody, should be informed that they are not required to answer any question that they choose not to.

  2. Answer: B, C

    Informed consent is required before all medical evaluations and explaining the potential benefits and risks of the evaluation is part of the consent process.

  3. Answer: D

    Given the possibility of intense shame and ongoing fear, it would be prudent to select a translator who is not related to Mrs. Yousif and is not a member of the refugee community. The clinician should reassure Mrs. Yousif of the measures you will take to ensure confidentiality of the information she provides.

  4. Answer: C

    Initially, questions should be open-ended, allowing a narration of the trauma 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.

  5. Answer: A

    Other traumatic experiences may contribute to the psychological symptoms of survivors of torture. In Mrs. Yousif’s case, the killing of her husband and burning of her home and village likely contributed to her psychological symptoms.

  6. Answer: C

    Inability to protect the ones we love from extreme harm often results in severe and prolonged emotional reactions such as guilt, shame and rage. Mrs. Yousif indicated that she has a profound sense of guilt over what happened to her daughter and is often preoccupied with thoughts of what she should have done differently.

  7. Answer: E, F, G

    Mrs. Yousif’s trauma history did not included allegations of blindfolding. Although she reported being stuck in the head with the butt of a handgun and kicked in the side of her face, she did not have any lapses in consciousness. The abuses that she described do not suggest significant disorientation that is often associated with prolonged isolation and sleep deprivation. She does have marked symptoms of PTSD, however, and both fear of reprisals and lack of trust in the examining clinician should be anticipated given her previous interactions with police and medical personnel.

  8. Answer: A

    The content of perpetrators’ verbal remarks often refers to the intent of the abuse and is often relevant to the individual meaning assigned to the torture experience.

  9. Answer: E

    Moving on with the interview would certainly be appropriate, but the other options listed (B, C and D) also may help to inform the alleged victim’s decision on whether to discuss the allegation of sexual assault further. The option of offering to limit reporting to a judge, only, may depend on the acceptability of this option within the domestic legal system and/or the extent to which absolute confidentiality can be maintained.

  10. Answer: H

    All of the indirect questions listed may be helpful in assessing the possibility of rape and other forms of sexual assault.

  11. Answer: A, C

    Mrs. Yousif’s history is highly consistent with a Bell’s Palsy after being kicked on the right side of her face with subsequent swelling, temporarily affecting the right Facial Nerve. Her observation of “tram-track” lines following beating with a hose is also highly consistent with the alleged abuse as it indicates first-hand knowledge of the alleged experience.

  12. Answer: F

    Mrs. Yousif presented to Nyala Hospital 2 days after the alleged assault. In the acute setting for rape allegations, all of the measures listed should be taken. For CDC recommendations on antiretroviral postexposure prophylaxis after sexual exposure to HIV, see: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5402a1.htm.

  13. Answer: A

    Mrs. Yousif meets diagnostic criteria for PTSD: She was exposed to multiple traumatic events or experiences involving intense fear, horror, or helplessness and the events or experiences involved threats of death, serious injury, or physical integrity. She has at least one re-experiencing symptom, at least 3 avoidance symptoms, and at least 2 persistent indicators of increased arousal. Since her symptoms have persisted for longer than 3 months, her PTSD should be considered “chronic.”

  14. Answer: B

    While the content of PTSD symptoms may be consistent or highly consistent with allegations of torture and ill treatment, the diagnosis of PTSD, in and of itself, is not specific for torture and/or ill treatment. On the other hand, there is often a strong relationship between an individual’s psychological symptoms and the individual meaning of torture experiences.

  15. Answer: E

    All of the traumatic experiences listed likely contribute to Mrs. Yousif’s psychological symptoms.

  16. Answer: E

    All of the factors listed may help to distinguish cause-specific psychological symptoms.

  17. Answer: B

    It is rare to find any physical evidence when examining female genitalia more than one week after an assault. For this reason, and the risk re-traumatizing Mrs. Yousif unnecessarily, a pelvic examination is not recommended. The most significant component of a medical evaluation in the chronic phase of rape allegations is the psychological assessment and other, non-gynecologic, physical findings.

  18. Answer: E

    All of the symptoms of sexual dysfunction listed may be observed following rape.

  19. Answer: B

    While Mrs. Yousif’s physical findings are consistent with the alleged trauma, they may be the result of other injuries. [Note, the description of the complex, atrophic scar over the dorsum of the left hand is consistent with the history of a laceration that healed by secondary intention; it apparently became infected, formed an abscess and required incision and drainage.]

  20. Answer: C

    Mrs. Yousif’s psychological symptoms are highly consistent with the torture and ill treatment that she alleged. The severity of her symptoms is consistent with the multiple traumas she reported. In addition to meeting diagnostic criteria for PTSD and Major Depressive Disorder, the content of some of her psychological symptoms refer specifically to the alleged abuse. Her intense feelings of guilt over her daughter’s rape and the consistency between her observed affect during the interview and the content of the evaluation are also highly consistent with the torture and ill treatment she alleged.

Answer: A, B, D All of the considerations listed are important for effective interviews with the exception of C. All individuals alleging torture, including those in custody, should be informed that they are not required to answer any question that … Continue reading

What is Torture

Torture, as understood in international law, involves several elements: the infliction of severe pain (whether physical or psychological) by a perpetrator who acts purposefully and on behalf of the state. The United Nations Convention against Torture defines torture this way:

For the purposes of [the] Convention, the term “torture” means any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity. It does not include pain or suffering arising only from, inherent in or incidental to lawful sanctions.

— [Article 1.]

Torture, as understood in international law, involves several elements: the infliction of severe pain (whether physical or psychological) by a perpetrator who acts purposefully and on behalf of the state. The United Nations Convention against Torture defines torture this way: … Continue reading