Introduction

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

Curriculum Materials

Model Curriculum

Consisting of 9 Modules (see Summary of Content below). The Modules serve as the overall knowledge base for the Model Curriculum.

Istanbul Protocol

Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment

PowerPoint (PPT) Presentations

There is a PPT Presentation to accompany each of the 9 Modules. The Presentations were designed primarily for instructors who prefer to use a lecture format. The content of the PPT presentations closely parallels that of the Modules.

Case Examples #01 and #02

Two case examples have been incorporated into Modules 7 and 8. They are designed to give students practical experience interviewing alleged victims of torture and documenting physical and psychological evidence. The medical evaluations that students develop from these case examples should be applied to Mock Court Proceedings in Module 9.

Psychological Evaluations 1 and 2

Two Psychological Evaluations are included in Module 6 to provide students with an opportunity to develop clinical impression from information contained in actual asylum cases.

Self-Assessments (quizzes)

For each Module, there is a related Self-Assessment that is designed specifically for individual student users to assess their knowledge of curriculum content. The Self-Assessments may be applied to other teaching formats as well.

Audio File

In Module 3, students will listen to an audiotape of an interview with a torture survivor, Sr Diana Ortiz, to better understand the challenges of interviewing survivors, particularly the emotional reactions of survivors and clinicians.

Model Curriculum Consisting of 9 Modules (see Summary of Content below). The Modules serve as the overall knowledge base for the Model Curriculum. Istanbul Protocol Model Medical Curriculum (pdf) Istanbul Protocol Manual on the Effective Investigation and Documentation of Torture … Continue reading

Summary of Content

Module 1: International Legal Standards

The first Module [3] provides students with a foundation for understanding how torture is defined in international law, and the duties of States to prohibit torture and ill-treatment. It reviews common torture practises in the world today. As mentioned above, instructors should add country-specific information such as national norms and regional practise. A number of resources are suggested for this purpose. Module 1 also discusses international and regional monitoring mechanisms that health professionals should be aware of and specific safeguards for individuals deprived of their liberty. Module 1 should provide students with a foundation for understanding country-specific challenges to torture prevention and accountability and help them identify effective remedial measures.

Module 2: Istanbul Protocol Standards for Medical Documentation of Torture and Medical Ethics

Module 2 [2] introduces students to the Istanbul Protocol, its purpose, history, content, applications and limitations. It reviews procedural safeguards relevant to medico-legal evaluations of torture and ill-treatment. Module 2 also provides a review of medical ethics relevant to torture documentation and outlines the duties of clinicians working with alleged torture victims and detainees in general. Instructors should include additional information on country-specific rules and regulations regarding medical documentation of torture and ill-treatment. This will aid students in addressing country-specific challenges. Module 2 also reviews general guidelines for gathering evidence.

Module 3: Interview Considerations

Module 3 [1] provides a detailed review of interviewing considerations that is relevant not only for clinicians, but lawyers, adjudicators and human rights investigators/monitors. The Module first reviews a wide range of preliminary considerations (interview settings, trust, informed consent, privacy, empathy, safety and security, re-traumatisation, gender considerations, cultural and religious awareness, working with interpreters, and transference and counter-transference reactions, among others) and then discusses how to conduct interivews and the content of the interviews. Students will be asked to listen to an audiotape of a radio interview with a torture survivor and apply what they have learned in Module 3 to their experience of listening to a survivor. This practical exercise will help students to understand the emotions reactions of survivors (transference) and common reactions of clinicians (counter-transference).

Module 4: Torture Methods and their Medical Consequences

Module 4 [4] provides students with a detailed review of the relationship between specific methods of torture and their physical and psychological health consequences. It reviews specific torture methods and ill-treatment, how they are applied, and the possible acute and chronic physical findings associated with them. This information will help students to correlate medical findings and specific allegations of torture and ill-treatment. The Module also provides a review of common psychosocial consequences of torture and ill-treatment and factors that may affect the variability of psychological evidence.

Module 5: Physical Evidence of Torture and Ill Treatment

Module 5 [5] provides a detailed review of physical examination methods used to evaluate physical evidence of torture and ill-treatment. It begins with a review relevant questions for the medical history, then provides a systematic organ system review of physical evidence, and concludes with information on medical photography and relevant diagnostic tests. Module 5 will help students assimilate the information needed to evaluate and effectively document physical evidence of torture and ill-treatment. The Self-Assessment quizzes for Modules 4 and 5 will also help students to recognise common physical evidence of torture, provide accurate interpretations of their findings, and understand indications for diagnostic test.

Module 6: Psychological Evidence of Torture and Ill Treatment

Module 6 [8] addresses psychological evidence of torture. It provide clinicians with understanding of the central role of the psychological evaluation, how to conduct and psychological evaluation and how to interpret relevant findings. It reviews the value and limitations of using diagnostic classifications and the use of psychometric instruments. It also includes information on evaluating children who have been directly or indirectly exposed to torture. Case information for two Psychological Evaluations are included at the end of Module 6 to provide students an opportunity to formulate their own clinical impressions and review them with other students and the instructor.

Module 7 & 8: Case Examples

Modules 7 [7] and 8 [6] are designed to help students develop interview and examination skills that are essential to the effective documentation of torture and ill-treatment. Modules 7 and 8 each consist of a Case Example for a role-play interview of an alleged torture victim. Each Module contains Case Summary/Referral infomation that the students review prior to conducting an interview. Role-players act the part of an alleged torture victim using a Case Narrative file, which the students do not have access to. The physical examination findings are limited to photographic images. Each Module contains suggestions for instructors on how to implement the Case Examples and detailed guidelines for instructors to assist with the analysis of the cases.

Module 9: Writing Reports and Testifying in Court

Module 9 [9] provides information on how to write a medical report and provide court testimony. The Module reviews a number of general considerations for report writing, the content of medical reports, how to formulate appropriate interpretations and conclusions, and how to convey them to adjudicators. The Module also discusses how to address the problem of inconsistencies in an individual’s case. Students may be asked to bring their written reports from the Case Examples in Modules 7 and 8 and participate in a Mock Judicial Proceeding, wherein they have an opportunity to present their evidence in “court” and play the role of a cross-examining lawyer. Instructors should consider adding course evaluation component to the end of Module 9.

Module 1: International Legal Standards The first Module provides students with a foundation for understanding how torture is defined in international law, and the duties of States to prohibit torture and ill-treatment. It reviews common torture practises in the world … Continue reading

Introduction

Purpose of the Model Medical Curriculum

The primary purpose of Model Curriculum is to provide health professional students with essential knowledge and skills to prevent torture and ill-treatment through effective investigation and documentation of these practises using Istanbul Protocol standards. The Curriculum was developed specifically for health professional students. Practicing clinicians interested in training other clinicians on the effective investigation and documentation of torture and ill-treatment should consider additional educational material developed through the PtD Project (see generic and country-specific Training of Trainers and Training of Users materials available at: http://www.irct.org/Purpose—principles-2715.aspx [2] [1]). Health professional students should seek to complement this curriculum with other educational materials that address the broader context of health and human rights, in an effort to promote health and human dignity through the protection and promotion of human rights.

Who Are These Educational Resources For?

Medical evaluations of physical and psychological evidence of torture and ill-treatment require students to have some basic scientific knowledge and clinical experience. The Model Curriculum is most appropriate for health professional students who have already learned anatomy, physiology, pathology, physical examination techniques, and have had some exposure to clinical medicine and psychiatry or clinical psychology.

The Model Curriculum was designed to be used by instructors who wish to teach a 10 to 20 hour course and by individual students or student groups. The Modules may be applied to a number of teaching formats including, seminars, lectures, and self-study. Instructors should contact the IRCT to access materials for instructor use only.

As mentioned above, clinicians and legal experts who are already in practise and have some familiarity with the investigation and documentation of torture and wish to implement Istanbul Protocol standards using a multiple-day symposium format should access PtD materials available at: http://www.irct.org/Purpose—principles-2715.aspx [2] [1].

The overall objective of the PtD Project is to make a substantial and tangible contribution to the prevention of torture and ill-treatment worldwide by conveying knowledge and skills to health and legal professionals about systematised and high quality investigation and documentation of these unlawful acts. The PtD training format includes national adaptation of generic, international material for the training of trainers and subsequent training of clinicians and legal experts. The PtD educational materials also may be helpful to train health professional instructors who intend to teach the Model Curriculum on the Effective Medical Documentation of Torture and Ill-treatment.

Purpose of the Model Medical Curriculum The primary purpose of Model Curriculum is to provide health professional students with essential knowledge and skills to prevent torture and ill-treatment through effective investigation and documentation of these practises using Istanbul Protocol standards. … Continue reading

Resources

As mentioned above, the content of the Model Curriculum is based on the Istanbul Protocol and a number of manuals and resources that were subsequently developed by Istanbul Protocol authors and editors, and their colleagues, to supplement the Istanbul Protocol, including extensive training materials developed by the IRCT and partner organisations, the Human Rights Foundation of Turkey (HRFT) and Physicians for Human Rights (PHR) for the Prevention through Documentation (PtD) Project. Selected materials were excerpted and adapted from these resources to develop a comprehensive curriculum for health professionals in the course of their training. The primary resources used for the development of the Model Curriculum include:

Each Module contains a list of the primary resources used for its development. It is important to note that clinicians who conduct forensic medical evaluations of alleged victims of torture and ill-treatment should be familiar with the entire content of the Istanbul Protocol, especially if they refer to the application of Istanbul Protocol standards in their medico-legal report(s).

As mentioned above, the content of the Model Curriculum is based on the Istanbul Protocol and a number of manuals and resources that were subsequently developed by Istanbul Protocol authors and editors, and their colleagues, to supplement the Istanbul Protocol, … Continue reading

How to Use These Educational Resources

Teaching Formats

Each Module includes a summary of Objectives, Content, Discussion Questions, Teaching Formats, and Primary References. This information can be applied to several different teaching formats including:

Didactic Lectures

Instructors with limited course time (i.e. 10-12 hours) may prefer to use a lecture format, in which case, PPT presentations can be used as the primary tool for knowledge transfer. The Discussion Questions contained in each module may be used for subsequent class participation. Though the practical applications in Modules 3 (interview analysis), 6 (clinical impressions of Psychological Evaluations) 7 and 8 (medical evaluations of Case Examples) and 9 (mock court proceedings) were designed primarily as group activites, PPT presentions for these Modules can be used as case demonstrations for the entire class.

Self-Assessment quizzes are available for each Module and instructors may use these as the basis for knowledge assessments. Suggestions for individual research or assignments are included in each Module and may be used for knowledge assessments. Another option would be to ask students to keep a journal and make entries throughout the course. Suggestions for journal entries are included in the Teaching Format section at the beginning of each Module. They should consist of several paragraphs (no more than a page) that are shared only with the instructor or with the entire class. Reflections in student journals could be a formal or an informal tool to assess student progress.

Seminars

Seminars are an ideal teaching format as they provide more time for student interactions and for practical applications and group activities that are suggested for each Module. In the seminar format, it would be advisable for the students to read the content of each module in advance of attending class. PPT Presentations are not as useful as they are redundant with the content of the Modules. Seminar classes may be structured to address the Discussion Questions listed for each of the Module or to work on a Group Activity. Suggestions for group activities are also included in each Module. The process for group activities is as follows:

  • Divide theclass into several groups and assign each group with one or more tasks
  • A facilitator should be identified to moderate the discussion and rapporteur should be identified to record the group’s findings and report them when the class reconvenes
  • After 20-30 minutes of group discussion, the entire class should reconvene
  • Rapporteurs should briefly report on their group’s findings
  • Open class discussion

Knowledge assessment may be based on participation and performance in seminar discussions and group activities. Student also may be required to submit their written reports for Modules 7 and 8. Another option would be to ask students to make journal entries throughout the course as described above. The Self-Assessment quizzes would likely not be used in the seminar format.

Student Groups

Health professional students may initiate their own course if instructors are not available and/or there is no time alloted for such electives in the students’ curriculum A seminar format would be advisable for such student groups, but any combination of the teaching formats could be applied for such purposes.

Individual Students

Individual students may access the Model Curriculum online and take the course at their own pace. This would be a very effective way of learning how to document torture and ill-treatment when there are no courses/instructors/student groups available. While individual, self-programmed studies may be convenient for students, the practical applications component of the Model curriculum would be limited.

Individual students should focus on the Modules rather than PPT Presentations. They should read through the Discussion Questions and give them careful consideration. The Self-Assessment quizzes for each Module would be useful for students to assess their progress. They also may consider keeping a journal as described above.

National Adaptation of the Model Curriculum

Torture practises vary, to some extent, in different regions of the world, as do national legal standards, and the extent of human rights monitoring and documentation of such practises. A systematic, country-specific review of legal standards and torture practises is beyond the scope of this Curriculum. It is highly recommended that instructors and students research and include relevant country-specific materials for effective national adaptation of the modules contained in this curriculum.

The Prevention through Documentation Project has included 10 target countries (Georgia, Mexico, Morocco, Sri Lanka Uganda, Ecuador, Egypt, Kenya, the Philippines, and Serbia). Country assessment reports by the IRCT are availabe (see: http://www.irct.org/Target-countries-2709.aspx [1]) and may serve as a model for national adaptation efforts. A series of national adaptation resources have been developed to relate generic, international materials to local settings (see: http://www.irct.org/Purpose—principles-2715.aspx [2] or contact the IRCT for additional information)

Guest Speakers

It is highly recommended for Model Curriculum 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 the Model Curriculum course, especially in supervising the practise interviews for the cases included in Modules 7 and 8.

Teaching Formats Each Module includes a summary of Objectives, Content, Discussion Questions, Teaching Formats, and Primary References. This information can be applied to several different teaching formats including: Didactic Lectures Instructors with limited course time (i.e. 10-12 hours) may prefer … Continue reading

Glossary

Medical Terms

Axilla
Armpit.
Brachial plexus
The nerves running from the spine into the arm.
Callus
An area of thickening of bone at the place of healing.
Cerebral oedema (edema)
Swelling of the brain.
Cognitive impairment
Partial impairment of memory, thinking, perception or mood.
Counter-transference
Potential emotional reaction of the clinical evaluator toward the alleged torture victim.
Depigmentation
Complete loss of pigment from a patch of skin.
DSM
Diagnostic and Statistical Manual (American Psychiatric Association).
Haematuria
Blood in the urine.
Hyperpigmentation
Increase in pigmentation of an area of skin.
Hypopigmentation
Partial loss of pigment from an area of skin.
Intrusive memories
Involuntary, unpleasant and recurrent memories of an incident.
Ischemia
Decreased blood flow.
Laceration
A wound in which the skin is torn by blunt force.
Medical Evaluation
An assessment of physical and/or psychological evidence by a clinician.
Medical history
An individual’s personal account of a health problem.
Medico-legal
Relating to that branch of medicine that assists the courts.
Necrotic
Devitalized (death of) body tissues.
Neuropathy
Nerve damage.
Oedematous (edematous)
Swollen.
Parasthesias
A skin sensation such as burning, itching, tingling, with no apparent casuse.
Pathognomonic
A pathological finding that has only one cause.
Perianal
Around the anus.
Petechiae
Clusters of very small bruises.
Psychosomatic symptoms
Apparently physical symptoms that have a psychological cause.
Retinal haemorrhage
Bleeding into the back of the eye.
Sequelae
The consequences of a medical problem.
Striae distensae
Stretch marks of the skin.
Subdural bleeding
Bleeding between certain layers of fibrous tissue covering the brain.
Tonic-clonic fits
The common form of epileptic convulsions or seizures.
Transference
Feelings that a survivor of torture has towards the clinician that relate to past experiences, but which are misunerstood and towards the clinician personally.
Urethral meatus
The aperture at the end of the penis through which urine is voided.

Legal Terms

Allegation
A claim (as yet neither proved nor disproved) that an incident of torture has occurred.
Applicant
Person making an application under an individual complaint procedure.
Application
Submission asking a judicial body to consider a case under an individual complaint procedure.
Arrest
The act of apprehending a person for the alleged commission of an offence or by the action of an authority.
Asylum
Asylum is sought by individuals who do not wish to return to a country, usually their own, where they are at risk. If granted, it means being allowed to remain in a country which is not their own. It may be temporary or permanent.
Corroboration
Evidence which supports or confirms the truth of an allegation.
CPT
Council of Europe’s Committee for the Prevention of Torture.
Declaration
A particularly formed resolution, usually of the United Nations General Assembly, which is not as such legally-binding, but sets out standards which states undertake to respect.
Derogate
To temporarily suspend or limit.
Detention
Depriving a person of personal liberty except as a result of conviction for an offence.
Domestic law or legal system
National law or legal system; law or legal system which is specific to a particular country.
Enforcement (of obligations)
Making the obligations effective; ensuring that they are respected.
Fact-finding
Carrying out an investigation to discover the facts.
Incommunicado detention
Being held by the authorities without being allowed any contact with the outside world.
Individual complaint
A complaint relating to a specific set of facts affecting an individual or individuals.
Instrument
A general term to refer to international law documents, whether legally binding or not.
Judicial procedure
A procedure before a judicial body.
NGO
Non-governmental organisation.
Perpetrator
The person who has carried out an act.
Reparation
Measures to repair damage caused, eg. compensation.
Sanction
A penalty imposed for a state’s failure to respect its legal obligation.
State responsibility
Holding a state accountable under international law.
Treaty
International law document which sents out legally-binding obligations for states.
War Crimes
Grave breaches of the Geneva Conventions 1949, committed in the course of an armed conflict against persons or property protected by the Conventions, and other criminal violations of the rules of war.

Clarifications of Terms

Use of the term “patient”
Individuals who allege torture and ill treatment are sometimes referred to as “patients” even in the context of medico-legal evaluations.
Physicians/Clinicians
The terms “physician” and “clincician” are often used interchangably in this Curriculum. Keep in mind that psychological evidence may be evaluated by physicians, psychologists and clinical social workers. Physical evidence, however, is evaluated by physicians (medical doctors) only.

Medical Terms AxillaArmpit.Brachial plexusThe nerves running from the spine into the arm.CallusAn area of thickening of bone at the place of healing.Cerebral oedema (edema)Swelling of the brain.Cognitive impairmentPartial impairment of memory, thinking, perception or mood.Counter-transferencePotential emotional reaction of the clinical … Continue reading