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Psychological evaluations can provide critical evidence of abuse among torture victims. It has a central role in the medical investigation and documentation of torture allegations. All medical investigations and documentation of torture should include a detailed psychological evaluation because:
- One of the main aims of torture is to destroy the psychological, social integrity and functioning of the victim.
Perpetrators often attempt to justify their acts of torture and ill-treatment by the need to gather information. Such conceptualisations obscure the purpose of torture and its intended consequences. One of the central aims of torture is to reduce an individual to a position of extreme helplessness and distress that can lead to a deterioration of cognitive, emotional and behavioural functions. Torture is a means of attacking the individual’s fundamental modes of psychological and social functioning. The torturer strives not only to incapacitate a victim physically, but also to disintegrate the individual’s personality: The torturer attempts to destroy a victim’s sense of being grounded in a family and society as a human being with dreams, hopes and aspirations for the future.— (IP, §235)
Internationally accepted definitions of torture acknowledge that provoking mental suffering is often the intention of the torturer.
- All kinds of torture inevitably comprise psychological processes.
- Torture often causes psychological/psychiatric symptoms at various levels.
- Torture methods are often designed not to leave physical lesions, and physical methods of torture may result in physical findings that either disappear quickly or lack specificity.
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. Most physical symptoms and signs of torture, if there are any, rapidly disappear.
It is important to realise that torturers may attempt to conceal their acts. To avoid physical evidence of torture, precautions are taken with the intention of producing maximal pain and suffering with minimal evidence. Especially under conditions of raised awareness in society, torture applied with these precautions and sophisticated methods may leave almost no physical signs.
Torturers know that by not leaving permanent physical scars, they help their cause and make the work of their counterparts in the human rights arena more difficult. For this reason, in the Istanbul Protocol it is underscored that, “the absence of such physical evidence should not be construed to suggest that torture did not occur.”
- Psychological symptoms are often more prevalent and long-lasting than physical symptoms.
Contrary to the physical effects of torture, the psychological consequences of torture are often more persistent and troublesome than physical disability. Several aspects of psychological functioning may continue to be impaired long-term. If not treated, victims may still suffer from the psychological consequences of torture even months or years following the event, sometimes for life, with varying degrees of severity.
Psychological evaluations can provide critical evidence of abuse among torture victims. It has a central role in the medical investigation and documentation of torture allegations. All medical investigations and documentation of torture should include a detailed psychological evaluation because: One … Continue reading
- Answer: A, B, D
Torture as defined by CAT, involves the intentional infliction of severe mental or physical pain or suffering, by or with the consent or acquiescence of the state authorities, for a specific purpose, such as gaining information, punishment or intimidation or for any other reason. It does not include pain or suffering arising only from, inherent in or incidental to lawful sanctions.
- Answer: B, C, D
Ill-treatment does not have to be inflicted for a specific purpose, but there does have to be an intent to expose individuals to the conditions which amount to or result in the ill-treatment. Like torture, ill-treatment is perpetrated by or with the consent or acquiescence of the state authorities.
- Answer: C
Amnesty International documented cases of torture and other cruel, inhuman or degrading treatment in 81 countries in 2007.
- Answer: B
Torture has been practiced throughout history, but universal prohibition against torture was codified in international law only in the aftermath of WWII in 1948. The UN Convention on Torture Against Torture was adopted by the UN General Assembly considerably later in 1984.
- Answer: E
Torture commonly serves the purpose of suppressing and punishing political opponents and alleged criminals and to achieve social control by inducing a sense of terror in a population, but it is also frequently used in interrogations to force confessions. Moreover, torture can occur where there is no obvious purpose.
- Answer: D
The prohibition of torture and ill-treatment is absolute; such acts cannot be justified under any circumstances including, national security, states of emergency, the need to counter terrorism, or following orders from one’s superiors.
- Answer: B
Non-refoulment in the Convention against Torture refers to the forcible return or extradition of a person to another country where he or she is at risk of torture.
- Answer: True
States are responsible for safeguarding the rights of everyone within their jurisdiction and may under some circumstances be held accountable for acts carried out by private individuals if it supports or tolerates them, or fails in other ways to provide effective protection in law and in practice against them.
- Answer: True
Torture and ill treatment are often perpetrated in the process of criminal investigations in order to obtain false confessions to alleged crimes and in the context of claims of national security.
- Answer: False
The prohibition of torture is not limited to a negative obligation to refrain from causing suffering, but also contains wider obligations: including the obligation to investigate allegations, even if there has not been a formal complaint about it, and to bring the perpetrators to justice. The UN Convention Against Torture states clearly in article 12: “Each State Party shall ensure that its competent authorities proceed to a prompt and impartial investigation, wherever there is reasonable ground to believe that an act of torture has been committed in any territory under its jurisdiction.”
- Answer: D
The ICRC’s findings are communicated and discussed on a confidential basis with the concerned authorities and are not made available to the public. The ICRC undertakes visits under nonnegotiable modalities which include: access to all places of detention and all people detained and to make a register of all those who wish to have their details recorded; the possibility to select individual detainees to talk with in private, and the possibility to repeat the visits as often as is deemed necessary. During visits, the ICRC takes the humane treatment of detainees to encompass not only freedom from torture and other ill-treatment, but also general conditions of detention that maintain both the physical and mental integrity of the individuals.
- Answer: False
The prohibition of torture is the concern not only of those countries which have ratified particular treaties, but is also a rule of general or customary international law, which binds all states even in the absence of treaty ratification. In fact, the prohibition of torture is generally regarded as having the special status of a ‘peremptory norm’ of international law, and states cannot choose to disregard or derogate from it.
- Answer: True
The Convention Against Torture (Article 14) indicates that victims of torture have a right to redress and adequate compensation.
- Answer: E
People are particularly at risk when they are deprived of their liberty, held in pre-trial detention or subject to interrogation. The greatest risk is in the first phase of arrest and detention, before the person has access to a lawyer or court. People being held in incommunicado detention – without access to anyone in the outside world – are particularly vulnerable.
- Answer: True
Optional Protocol to the UN Convention Against Torture established a complementary dual system of regular visits by independent international and national bodies to places of detention in order to prevent torture and ill-treatment.
- Answer: E
The Human Rights Committee has stated that the protection of detainees requires that each person detained be afforded prompt and regular access to doctors. The Body of Principles for the Protection of All Persons under Any Form of Detention or Imprisonment state that ‘a proper medical examination shall be offered to a detained or imprisoned person as promptly as possible after his admission to the place of detention or imprisonment, and thereafter medical care and treatment shall be provided whenever necessary. This care and treatment shall be provided free of charge. Detainees have the right to request a second medical opinion by a doctor of their choice, and to have access to their medical records.
- Answer: True
Rule 22(2) of the UN Standard Minimum Rules for the Treatment of Prisoners states that detainees or prisoners needing special treatment must be transferred to specialised institutions or civil hospitals for that treatment.
- Answer: E
All of the measures listed above are important in the prevention of torture and ill treatment. Additional prevention measures include non-refoulement or no transfer to a country where torture is likely, providing detainees access to family members and friends, and the training of state officials, including medical personnel, on torture prohibition.
- Answer: A, C, D
Effective investigation of alleged torture and ill treatment and criminal prosecution of alleged perpetrators are essential for accountability. Adequate victim and witness protection is a critical component of such prosecutions. Allowing torture to be prosecuted as a lesser crime such as “abuse of police duty” would likely have a permissive effect on torture and ill treatment practices.
- Answer: False
All detained people have the right to equal treatment without discrimination on the grounds of race, colour, sex, sexual orientation, language, religion, political or other opinion, national or social origin, property, birth or other status. Particular allowances should, however, be made for the rights and needs of special categories of detainees including women, juveniles, elderly people, foreigners, ethnic minorities, people with different sexual orientation, people who are sick, people with mental health problems or learning disabilities, and other groups or individuals who may be particularly vulnerable during detention.
Answer: A, B, D Torture as defined by CAT, involves the intentional infliction of severe mental or physical pain or suffering, by or with the consent or acquiescence of the state authorities, for a specific purpose, such as gaining information, … Continue reading
According to the Istanbul Protocol, investigations into torture should seek to establish the facts of alleged incidents in an effort to identify and facilitate the prosecution of perpetrators and/or secure redress for the victims. When possible, forensic experts should obtain detailed information on the following topics: 1) the circumstances leading up to the torture; 2) the approximate dates and times when the torture occurred; 3) detailed physical descriptions about the people involved in the arrest, detention and torture; 4) the contents of what was asked of or told to the victim; 5) a description of the usual routine in the place of detention; 6) details about the methods of torture and/or ill-treatment used; 7) any instances of sexual assault; 8 ) resulting physical injuries; 9) weapons or physical objects used; and 10) the identity of any witnesses.
When designing commissions of inquiry, states or organisations should be very clear in defining the scope of the investigation. By framing the inquiries in a neutral manner (without predetermined outcomes), allowing for flexibility, and being clear about which events and/or issues are under investigation, the proceedings can achieve greater legitimacy among both commission members and the general public.
Commissions should be given the authority to obtain information by compelling testimonies under legal sanction, ordering the production of State documents, including medical records, and protecting witnesses. In addition, the commissions should be granted the power to conduct on-site visits and issue a public report.
Perhaps most crucial to the legitimacy of any medico-legal investigation is their impartiality. According to the Istanbul Protocol, “…[c]ommission members should not be closely associated with any individual, State entity, political party or other organisation potentially implicated in the torture. They should not be too closely connected to an organisation or group of which the victim is a member, as this may damage the commission’s credibility.”
In addition, commissions should, whenever possible, rely on their own investigators and expert advisers, especially when examining misconduct by members of the government.
Following the inquiry, the commission should issue a public report, with minority members filing a dissenting opinion. These reports should include: the scope of inquiry and terms of reference, as described above; the procedures and methods of evaluation; a list of all testifying witnesses—except for those whose identities are protected—with their age and gender; the time and place that each sitting occurred; all relevant political, social and economic conditions that may have influenced the inquiry; the specific events that occurred and supporting evidence; the commissions’ conclusions; and finally, a set of recommendations. In response to these reports, the State should issue a public statement describing how it plans to heed the commission’s recommendations.
The Istanbul Protocol also includes obligations of governments to ensure minimum standards for the effective investigation and documentation of torture and ill-treatment as stipulated in the Istanbul Principles as mentioned above.
According to the Istanbul Protocol, investigations into torture should seek to establish the facts of alleged incidents in an effort to identify and facilitate the prosecution of perpetrators and/or secure redress for the victims. When possible, forensic experts should obtain … Continue reading
Clinicians should carefully consider the context in which they are working, take necessary precautions and provide safeguards accordingly. If interviewing people who are still imprisoned or in similar situations in which reprisals are possible, all precautions should be taken to ensure that they do not place the detainee in danger (or in additional difficulty). Promises must not be made, for example, to provide security for the witness or for relatives who might be at risk, unless the interviewer is certain that they can be fulfilled. Witnesses might believe that international organisations or others investigating allegations of torture have more power to protect them than is the case. It is part of the informed consent process that individuals are aware of all the issues before they agree for a clinician to make a formal report. If the risk of harm from reprisals is a virtual certainty, conducting a medical evaluation may be considered unethical even if informed consent is obtained. This may be the case in the context of documenting human rights violations in places of ongoing conflict.
Whether or not certain questions can be asked safely will vary considerably and depends on the degree to which confidentiality and security can be ensured. When necessary, questions about forbidden activities should be avoided.
If the forensic medical examination supports allegations of torture, the detainee should not be returned to the place of detention, but rather should appear before the prosecutor or judge to determine the detainee’s legal disposition (see Procedural Safeguards below).
An interviewer will make notes of the interview, and may use other recording devices. The reasons for this should be explained to the interviewee who should be reassured as to how the notes and other records will be used and asked for consent. The way in which any records of such interviews are stored can be important in protecting the security of the interviewer and the interviewee. In many countries where torture is prevalent, the police have been known to raid clinics and search or confiscate medical records. In order to protect patients, therefore, in such conditions records should have no obvious identifying information on any document inside (such as initials or date of birth), and the files themselves being numbered with a register kept in a secure place elsewhere. Patients can be given cards with the identifying number so that treatment can be continued even if the register is not available. In some circumstances it may be necessary to hold records at a different location or even in a third country to ensure their security.
If information about an individual needs to be transmitted to another body, fax transmission is generally safer than e-mail as a copy of the latter may be stored on the sending computer or held on the server of the internet service provider. In some countries the authorities routinely screen all outgoing messages.
Clinicians should carefully consider the context in which they are working, take necessary precautions and provide safeguards accordingly. If interviewing people who are still imprisoned or in similar situations in which reprisals are possible, all precautions should be taken to … Continue reading
Psychological evaluations may take place in a variety of settings and contexts; as a result, there are important differences in the manner in which evaluations should be conducted and how symptoms will be interpreted. For example, whether or not certain sensitive questions can be asked safely will depend on the degree to which confidentiality and security can be assured. An evaluation by a clinician visiting a prison or detention centre may be very brief and not allow for as detailed an evaluation as one performed in a clinic or private office that may take place over several sessions and last for several hours. At times some symptoms and behaviours typically viewed as pathological may be viewed as adaptive or predictable, depending on the context. For example, diminished interest in activities, feelings of detachment and estrangement would be understandable findings in a person in solitary confinement. Likewise, hypervigilance and avoidance behaviours may be necessary for those living under threat in repressive societies.
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. An interpreter from the alleged victim’s country of origin will facilitate an understanding of the language, customs, religious traditions, and other beliefs that will need to be considered during the evaluation.
Clinicians should be aware of the potential emotional reactions that evaluations may elicit in survivors (see Transference and Counter-transference   in Module 3). Fear, shame, rage and guilt are typical reactions. A clinical interview may induce mistrust on the part of the torture survivor and possibly remind him or her of previous interrogations thereby “re-traumatizing” him or her. To reduce the effects of re-traumatisation, the clinician should communicate a sense of empathy and understanding. A torture survivor may suspect the clinician of having voyeuristic and sadistic motivations or may have prejudices towards the clinician because he/she hasn’t been tortured. The clinician is a person in a position of authority and, for that reason, may not be trusted with certain aspects of the trauma history. Alternatively, individuals still in custody may be too trusting in situations where the clinician cannot guarantee that there will be no reprisals for speaking about torture. Torture victims may fear that information that is revealed in the context of an evaluation cannot be safely kept from being accessed by persecuting governments. Fear and mistrust may be particularly strong in cases where physicians or other health workers were participants in the torture. In the context of evaluations conducted for legal purposes, the necessary attention to details and the precise questioning about history is easily perceived as a sign of doubt on the part of the examiner. Under these pressures, survivors may feel overwhelmed with memories and affect or mobilize strong defences such as withdrawal, affective flattening or numbing during evaluations.
As mentioned in Module 3 , if the gender of the clinician and the torturer is the same, the interview situation may be perceived as resembling the torture more than if the genders were different. For example, a woman who was raped and tortured in prison by a male guard is likely to experience more distress, mistrust, and fear when facing a male clinician than she might experience with a female. On the other hand, it may be much more important to the survivor that the interviewer is a physician regardless of gender so as to ask specific medical questions about possible pregnancy, ability to conceive later, and future of sexual relations between spouses.
When listening to individuals speak of their torture, clinicians should expect to have personal reactions and emotional responses themselves (see Transference and Counter-transference   in Module 3). Understanding these personal reactions is crucial because they can have an impact on one’s ability to evaluate and address the physical and psychological consequences of torture. Reactions may include 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.
Psychological evaluations may take place in a variety of settings and contexts; as a result, there are important differences in the manner in which evaluations should be conducted and how symptoms will be interpreted. For example, whether or not certain … Continue reading
Everyone deprived of liberty has the right to be given a reason for the arrest and detention. Article 9(1) of the ICCPR states that: ‘Everyone has the right to liberty and security of person. No one shall be subjected to arbitrary arrest or detention. No one shall be deprived of his liberty except on such grounds and in accordance with such procedures as are established by law.’
Everyone deprived of liberty has the right to be given a reason for the arrest and detention. Article 9(1) of the ICCPR states that: ‘Everyone has the right to liberty and security of person. No one shall be subjected to … Continue reading
Interviews for medical evaluations usually begin with the clinician introducing himself or herself followed by:
- Explanation of the purpose of the evaluation
- Reviewing the conditions of the evaluation, i.e.
- Independence of the evaluator
- Confidentiality of the clinician’s findings and limits thereof
- Right to refuse answering questions
- Importance of detail and accuracy of information
- Acknowledge likely difficulty of recalling certain events
- Ability to take breaks
- Access to refreshments and toilet facilities
- Statement on the overall content of the interview including: detailed questions on events before during and after the alleged torture, followed by a physical examination, should this be the case, and the possibility of photographs
- Discussing the likely benefits and risks of the evaluation
- Addressing any questions or concerns that the individual may have
- Obtaining consent to proceed with the evaluation.
For forensic evaluations, the clinician should establish the identity of the subject. As previously mentioned, law enforcement officials should not be present during the evaluation. If such officials refuse to leave the examination room, it should be noted in the clinician’s report or and/or the evaluation may be cancelled.
When the medical evaluation is being conducted by more than one clinician, i.e. one for physical evidence and another for psychological evidence, the content of the interview should focus on the information most relevant to their expertise.
Interviews for medical evaluations usually begin with the clinician introducing himself or herself followed by: Explanation of the purpose of the evaluation Reviewing the conditions of the evaluation, i.e. Independence of the evaluator Confidentiality of the clinician’s findings and limits … Continue reading
Beating is the most common form of physical torture. When the aim is to disguise its effects, beating may be performed with heavy, flexible implements such as sandbags or lead-filled plastic pipes, which may leave short-lived bruising but no permanent scarring. Sometimes the torturers perform the beating over clothing or folded towels. The impact of the blows is still severe and such beating may cause deep muscle bruising (which may take several days to reach the surface) or internal bleeding. This has been reported to lead to acute renal failure due to release of myoglobin (see Module 5). In many countries, severe beatings, which cause widespread bruising, are discontinued after the first few days of detention so that when the victim is produced to court or released after days or weeks later, all obvious signs of beating will have faded.
Falanga, also referred to as falaka, can be defined as the applications of blunt trauma to the soles of the feet. The technique has been practised throughout history. It is still very common, particularly in the Middle East, but also in the Indian subcontinent and, according to Amnesty International, in over thirty countries worldwide. In some countries, such as Turkey, it is applied almost as a routine at the time of detention and many torture survivors report having suffered it on numerous occasions.
It may be applied by batons, whips or canes to the bare feet or with shoes still on, and the immediate effect will depend on these variables. Often the victim is made to walk round on rough paving afterwards, sometimes carrying another on his back. This last detail is clearly intended to add to the humiliation as well as the pain.
As with most forms of physical torture, the physical findings associated with falanga change over time. These changes can be summarised as follows:
Acute Symptoms and Signs
The immediate effect of falanga is bleeding and oedema in the soft tissues of the feet, as well as severe pain. At clinical examination, changes are also confined to the soft tissues. Swelling of the feet, discoloration of the soles due to haematoma formation and various degrees of skin lesions are typical and diagnostic findings. Extensive ulcerations and gangrene of toes due to ischaemia have been described, but are not common. Fractures of tarsals, metatarsals and phalanxes are described as occurring occasionally. The acute changes disappear spontaneously within weeks, as the oedema and extravasation of blood resolve, but the induced soft tissue lesions may be permanent.
Symptoms and Signs in the Chronic Phase
The majority of torture victims submitted to falanga complain of pain and impaired walking. The cardinal symptom is pain in the feet and calves, and two types of pain are usually present:
- A deep, dull cramping pain in the feet, which intensifies with weight bearing and muscle activity spreading up the lower legs
- A superficial burning, stinging pain in the soles, often accompanied by sensory disturbances and frequently also a tendency for the feet to alternate between being hot and cold, suggestive of autonomic instability
Because of the pain, walking is impaired in most falanga victims. Walking speed and walking distance are reduced. Typically, the torture victim is only able to walk a limited distance, during which the pain will increase and make continued muscle activity impossible. At rest, the pain subsides and the victim can resume walking.
Theories Explaining the Persistent Pain and Foot Dysfunction After Falanga
The aetiology and pathogenesis of the persistent pain and disability after falanga is not fully understood. Several theories have been put forward, and most likely a combination of trauma mechanisms are responsible.
Reduced Shock Absorbency in the Heel Pads
The footpads are situated under the weight-bearing bony structures, at which in particular the heel pads act as the first in a series of shock absorbers. The heel pad is normally a firm elastic structure covering the calcaneus. It has a complex internal architecture consisting of closely packed fat cells surrounded by septa of connective tissue, which also contain the nerve and vessel supply to the tissues. Because of its structure, the heel pad is under constant hydraulic pressure and maintains its shape during weight load in the standing position.
After falanga, the heel pad may appear flat and wide, with displacement of the tissues laterally during weight loading. This is observed at inspection from behind, with the torture victim in the standing position. At palpation, the elasticity in the heel pad is reduced and the underlying bony structures are easily felt through the tissues. The pathophysiology of the reduced elasticity in the heel pad is thought to be tearing of the connective tissue septa, leading to deprivation of blood supply and secondary atrophy of fat cells with loss of the shock absorbing ability.
Damaged footpads are not pathognomonic of falanga, but are also described in connection with other conditions unrelated to torture, e.g. lesions in long-distance runners and patient with fractures of the heel bone. It should also be stressed that normal footpads at clinical examination does not rule out exposure to falanga.
Changes in the Plantar Fascia
The plantar fascia springs from the calcaneus and proceeds to the forefoot. It is tightened during foot of supporting the longitudinal arches of the foot, assisting the foot muscles during walking. Changes in the plantar fascia are present in some torture victims after falanga and are probably due to the repeated direct traumas to this superficial structure. After falanga, the fascia may appear thickened with an uneven surface at palpation, and tenderness may be found throughout the whole length of the fascia, from its spring to the insertion. Disruption of the plantar fascia has been reported, based on the finding of increased passive dorsiflexion in the toes at clinical examination.
Closed Compartment Syndrome
The plantar muscles of the foot are arranged in tight compartments—an anatomical arrangement which makes it possible for a closed compartment syndrome to develop. A closed compartment syndrome is defined as a painful ischaemic, circulatory disturbance in connection with an increase in pressure and volume inside a well-defined muscle compartment. In the acute form, with a rapidly increasing pressure, e.g. caused by bleeding inside the compartment, the symptoms are alarming and the consequences severe with necrosis of involved tissues if left untreated.
Chronic compartment syndromes may occur as a result of an increase in the muscle bulk and/or a narrowing of the compartment. Clinically, this condition presents itself with pain that intensifies with load and which finally makes continued muscle activity impossible. The pain subsides after a short period of rest, but recurs if muscle activity is resumed—a picture not unlike that seen in impaired walking after falanga.
In a MRI study comparing torture victims exposed to falanga with healthy volunteers, significant thickening of the plantar fascia was found in all victims. Apart from this, morphological changes were present in the fascia, possibly representing scar tissue formation. No signs of detachment of the plantar fascia, closed compartment syndrome or changes in the heel pads were shown in this study.
The skin of the soles in the normal foot is apart from the arch area, very thick and firmly tied to the underlying tissues. It is very rich in sensory nerve endings, which register touch and pressure. Peripheral nerve lesion affecting the small nerves of the soles is a very possible consequence of falanga. Neurogenic pain due to nerve lesion is therefore a possible contributing pain mechanism.
Deviations from the normal gait pattern are very frequent after exposure to falanga. Many torture victims develop a compensatory altered gait with loading of the lateral border (supinating the foot) or loading of the medial border (pronating the foot) to avoid pain at heel strike. The unwinding of the foot is likewise abnormal. Maximal extension and weight loading of the first toe is typically avoided at take-off.
Stride and walking speed are reduced. The gait is broad, stiff and insecure as seen in patients with peripheral neuropathy from other causes. Postural reflexes are elicited from the soles, and, together with the ability to register distribution of pressure, these reflexes are essential for balance and walking. Nerve lesion influencing the proprioception may therefore also contribute to the overall picture. As a consequence of the altered function of the foot, altered gait and frequently concurrent exposure to other forms of torture involving the lower extremities, a chain reaction of muscular imbalance occurs. The various muscle groups of the lower legs are often painful due to increased muscle tone, tight muscles and fasciae, tender and trigger points, and musculo-tendinous inflammation.
Clinical Examination for Falanga
The clinical examination of torture victims exposed to falanga should include:
- Inspection and palpation of the soft tissues of the feet: heel pads, plantar fascia, skin
- Assessment of foot function and gait
- Examination of soft tissues and joints in the lower extremities
- Neurological examination
It should be stressed once again that none of the findings at clinical examination in the late phases after falanga are pathognomonic, and that a normal examination of the feet does not rule out the possibility of this specific torture method. Special investigations that may aid in correlating allegations of falanga include x-rays, scintography and MRI (see Module 5). Treatment in the chronic phase often includes gentle massage to the muscles of the feet, calves and thighs, re-education of the walking pattern and supportive footwear, especially designed to offer cushioning of the heels.
Beating Beating is the most common form of physical torture. When the aim is to disguise its effects, beating may be performed with heavy, flexible implements such as sandbags or lead-filled plastic pipes, which may leave short-lived bruising but no … Continue reading
Toolkit: Istanbul Protocol Model Medical Curriculum
Subject: Module 4: Torture Methods and their Medical Consequences
Subject: Module 4: Torture Methods and their Medical Consequences
Modules 7 and 8 each include a case example of alleged torture and ill-treatment. The Modules are designed for students to develop the clinical skills necessary for the effective documentation of medical evidence torture, including both physical and psychological evidence. These cases were used extensively in Istanbul Protocol trainings in Mexico and also, with some modifications, in Sudan. The content of each was specifically designed to represent common evaluation scenarios and to include a wide range of challenges related to the documentation of physical and psychological evidence of torture. The cases are complementary, i.e. one with “strong psychological and weak physical evidence” (Case #01) and the other with “strong physical and minimal psychological evidence” (Case #02) and reflect composite imformation of actual cases. Each case consists of 1) a brief Case Summary/Refferal that the students read before the evaluation, 2) a Case Narrative to guide role-players in acting their part as an alleged torture victim, and 3) a detailed set of Guidelines for Instructors (and/or individual student users if that is the case) which outline learning objectives, relevant case information, and points for discussion for each of the 8 primary components of medical evaluation:
- Introduction/Conditions of Interview & Identification Information
- Past Medical and Surgical History & Psychosocial History – Pre-Arrest
- Trauma History
- Review of Torture Methods
- Physical Symptoms (acute and chronic) and Disabilities
- Psychological Assessment and Mental Status Examination
- Physical Examination
- Interpretation of Findings & Conclusions
It is highly recommended for the instructors to contact local treatment centers for survivors of torture, and/or other experienced clincians or providers who may be available to participate in the case examples.
Modules 7 and 8 each include a case example of alleged torture and ill-treatment. The Modules are designed for students to develop the clinical skills necessary for the effective documentation of medical evidence torture, including both physical and psychological evidence. … Continue reading