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Module 4: Torture Methods and their Medical Consequences
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
Psychological reactions to torture present physicians, clinicians and social scientists with the challenge of evaluating and assisting individuals who have survived crises of life-threatening proportions. For many that have survived torture, the experience can cause profound effects at a deeply personal level that may persist and fluctuate for many years. Psychological consequences develop in the context of personal meaning and personality development. They will vary over time and are shaped by cultural, social, political, interpersonal, biological and intrapsychic factors that are unique to each individual. One should not assume that all forms of torture have the same outcome. However, over the past two decades much has been learned about psychological, biological and neuropsychiatric responses to extreme stress, including torture, and clusters of typical symptoms have emerged that are recognised across cultures.
Psychological reactions to torture present physicians, clinicians and social scientists with the challenge of evaluating and assisting individuals who have survived crises of life-threatening proportions. For many that have survived torture, the experience can cause profound effects at a deeply … Continue reading
- Answer: B, C, D
It is important to realize that torturers often attempt to conceal their deeds. For example, physical evidence of beating may be limited when wide, blunt objects are used for beatings. Similarly, victims are sometimes covered by a rug, or shoes in the case of falanga, to distribute the force of individual blows. For the same reason, wet towels may be used with electric shocks. Also, torture victims may be intentionally detained until obvious signs of abuse have resolved.
- Answer: A
The improvement in the methods of detecting and providing evidence of physical torture has paradoxically led to more sophisticated methods of torture that do not to leave visible evidence on the victim’s body.
- Answer: A, B, C
While the symptoms and conditions listed in A, B and C may be associated with falanga, they are not considered pathognomonic.
- Answer: A
Small tympanic membrane ruptures (less than 2 mm in diameter) usually heal within 10 days.
- Answer: D, E
“Palestinian” suspension results in traction on the lower roots of the brachial plexus and is therefore most likely to result in a sensory deficit in the ulnar distribution. A “winged” scapula can be observed on physical examination as a prominent vertebral border when hands are pressed against a wall with outstretched arms.
- Answer: A
Various forms of positional torture are commonly associated with musculoskeletal symptoms and disabilities, but usually do not result in specific or permanent dermatologic or radiographic findings.
- Answer: A, C, D E
Crushing and stretch injuries commonly cause contusions and may cause abrasions depending on the nature of the objects used and the forces applied. Rough objects and tangential forces may result in abrasions. Incisions are unlikely as they result from sharp, penetrating objects. Extensive muscle necrosis can result in the release of myoglobin which can cause acute renal failure and death unless dialysis is initiated.
- Answer: E
All of the statements regarding burn injuries are accurate.
- Answer: E
Electric shocks have been commonly used by torturers for many years because they cause exquisite pain, but rarely leave identifiable physical signs. Depending on the path of the current, electric shocks can result in dislocation of joints, arrhythmias, urination and defecation.
- Answer: A
Occasionally the electrodes can leave small burns, probably from sparking. Lesions tend to be circular, hyperpigmented and less than 0.5 cm in diameter. Although non-specific, they can corroborate allegations of electric shock torture, especially if they are in certain parts of the body.
- Answer: E
Hypoxia can cause permanent brain injury and exposure to contaminated water or other caustic liquids may result in acute broncho-pulmonary infections, conjunctivitis and otitis media.
- Answer: B
Waterboarding is a form of asphyxiation torture that dates back to the Middle Ages and, recently, has been practised by the United States. Victims are strapped to a board or made to lie in a supine position with their heads lower than the rest of their bodies. The face is covered with cloth, and water is poured over the victim’s mouth to create the sensation of drowning. This deliberate infliction of severe physical and mental pain constitutes torture.
- Answer: E
Violent shaking can result in all of the problems listed.
- Answer: B, C, D
Rape is only one of many forms of sexual assault including forced nudity, groping, molestation and forced sexual acts. Often, sexual assaults will be accompanied by direct or implied threats. In the case of women, the threat may be one of becoming pregnant. For men, those inflicting the torture may also threaten (incorrectly but usually deliberately) that the victim will become impotent or sterile. For men or women there may be the threat of contracting HIV or other sexually transmitted infections (STIs) and often the threat or fear that sexual humiliation, assault or rape will lead to ostracism from the community and being prevented from ever marrying or starting a family. Rape is always associated with the risk of developing sexually transmitted diseases, including HIV. Ideally, medical evaluations of alleged sexual assault should include a team of experienced clinical experts.
- Answer: G
All of the methods listed have been determined to constitute torture by the UN Committee Against Torture and/or the Special Rapporteur on Torture.
- Answer: B, C, D
Despite the fact that torture is an extraordinary life experience capable of causing a wide range of psychological suffering, extreme trauma such as torture does not always produce psychological problems. Therefore, if an individual does not have mental problems, it does not mean that he/she was not tortured. When there are no physical or psychological findings, this does not refute or support whether torture had actually occurred. Major Depression and PTSD are the most common diagnoses among survivors of torture and ill treatment. The course of Major Depression and PTSD varies over time. There can be asymptomatic intervals, recurrent episodes, and episodes during which an individual is extremely symptomatic.
- Answer: A
The psychological consequences of torture and ill treatment develop in the context of personal meaning and personality development. They also may vary over time and can be shaped by cultural, social, political, interpersonal, biological and intrapsychic factors that are unique to each individual.
- Answer: B
Descriptive methods of evaluating psychological evidence of torture are best when attempting to evaluate psychological or psychiatric reactions and disorders because what is considered disordered behaviour or a disease in one culture may not be viewed as pathological in another. While some psychological symptoms may be present across differing cultures, they may not be the symptoms that concern the individual the most. Therefore, the clinician’s inquiry has to include the individual’s beliefs about their experiences and meanings of their symptoms, as well as an evaluating the presence or absence of symptoms of trauma-related mental disorders.
- Answer: I
All of the factors listed can affect psychological outcomes following torture and ill treatment.
- Answer: G
All of the risk factors listed can contribute to the possibility of developing mental illness among refugee survivors of torture.
Answer: B, C, D It is important to realize that torturers often attempt to conceal their deeds. For example, physical evidence of beating may be limited when wide, blunt objects are used for beatings. Similarly, victims are sometimes covered by … Continue reading
Effective medical investigation and documentation of torture and ill-treatment require clinicians to have a detailed understanding of torture methods and their physical and psychological sequelae. This Module provides a review of common torture methods and their medical consequences. It is important to keep in mind that it is difficult to separate physical from psychological torture, as each has a component of the other; for example, hooding not only impedes normal breathing, but also produces disorientation and fear. In addition, physical forms of torture and ill treatment will generally produce both physical and psychological sequelae, and psychological forms of torture and ill-treatment often result in psychological sequelae, but may also produce physical sequelae as well.
The methods of torture and ill-treatment included in this module are not exhaustive. The actual methods that a survivor experiences are only limited by the imagination and cruelty of his or her torturers. As mentioned in Module 1, it is important to realize that, although there is much similarity of torture methods around the world, there can be regional and country-specific variations. Instructors and students who use this Model Curriculum should be aware of regional, country-specific, and local practises and adapt them to the Model Curriculum materials accordingly with relable and current human rights reports.
Although physical torture as practised around the world has many features in common, almost invariably including beating, slapping and kicking, more sophisticated techniques have been developed in many areas. In countries whose authorities wish to disguise the fact that torture takes place, methods are devised, sometimes with the help of doctors, that produce maximum pain with minimum external evidence. This must be recognised by the examiner if the after-effects of these techniques are not to be missed, especially after the passage of time. Documentation of special methods of torture alleged by an individual requires that the examiner has a detailed knowledge of torture techniques used in the country where the torture was alleged to have taken place. With this knowledge the interviewer can take an informed and detailed history (taking care to avoid using leading questions). This helps to give a precise picture of such details of torture as the victim’s posture, clothing, blindfolding or hooding, the implements used, duration of assault and his or her condition at the end of the session – whether he or she could walk or whether there were any bleeding wounds. It cannot be emphasised too strongly that such a detailed history is essential to ensure that, during the subsequent physical examination, signs in the relevant areas of the body are not missed and that a correct differentiation from accidental or self-inflicted injury is made. For this reason it is necessary to review, at length, some of the techniques employed in different countries before outlining the symptoms and signs to be expected during history-taking and physical examination. Of particular value in assessing the severity of the attack is a history of loss of consciousness, though this should be elaborated by questions aimed at finding out whether unconsciousness was caused by blows to the head, asphyxiation, unbearable pain or exhaustion.
As discussed in Module 3, survivors may be unable to describe exactly what happened to them because they may have been blindfolded, lost consciousness, sustained head injury, or have difficulty recalling or revealing the especially traumatic components of their experience. It is important to realize that torturers often attempt to conceal their deeds. For example, physical evidence of beating may be limited when a wide, blunt objects are used for beatings. Similarly, victims are sometimes covered by a rug, or shoes in the case of falaka, to distribute the force of individual blows. For the same reason, wet towels may be used with electric shocks. In other cases, torturers use methods with the intent of producing maximal pain and suffering with minimal evidence, for example, forced positioning, near asphyxiation, mock executions, temperature manipulation, sensory deprivation, prolonged isolation, threats of harm to the individual and his or her family, and sexual humiliations, among many others.
It is important to understand that some methods on their own may amount to torture; in other cases significance is attached to the use of a combination of methods, which may collectively amount to torture. Also, the length of time over which the individual is subjected to the methods may be decisive. Again, for this reason, it is important to document as accurately and completely as possible all the events to which an individual was exposed and their consequences.
It is important to keep in mind that, when assessing the degree of suffering involved, one should take into account the identity and background of the alleged victim. For example, certain situations that might be relatively bearable for some people could be degrading and humiliating to those of a particular gender, culture or religious faith. Torture and other ill-treatment can also often go hand-in-hand with discrimination, based on race, religion, gender or other factors, which may exacerbate the distress. In addition, physical and mental suffering can differ amongst categories of victims, for example some tortures may exacerbate pre-existing health problems, and children may experience a higher degree of suffering than adults undergoing similar ill-treatment. All these factors should be taken into account in documenting the alleged victim’s experience.
Effective medical investigation and documentation of torture and ill-treatment require clinicians to have a detailed understanding of torture methods and their physical and psychological sequelae. This Module provides a review of common torture methods and their medical consequences. It is … Continue reading
Trauma to the ears, especially rupture of the tympanic membrane (eardrum), is a frequent consequence of harsh beatings. The ear canals and tympanic membranes should be examined with an otoscope and injuries described. A common form of torture, known in Latin America as telefono, is a hard slap of the palm to one or both ears, rapidly increasing pressure in the ear canal, thus rupturing the drum. There is often tinnitus for a while. Attacks of otitis media may supervene. Deafness usually gradually improves as the drum repairs itself. Very occasionally there is dislocation of the ossicles which will cause permanent loss of hearing. Even more rarely, a perilymph fistula may lead to vertigo. Few of the long-term signs are specific to torture, but a careful history may make the differentiation from disease possible and an expert may be able to differentiate a perforation resulting from trauma from one caused by infection.
Prompt examination is necessary to detect tympanic membrane ruptures less than 2 millimetres in diameter, which may heal within 10 days. Fluid may be observed in the middle or external ear. If otorrhea (leaking middle ear fluid) is confirmed by laboratory analysis, MRI or CT should be performed to determine the fracture site. The presence of hearing loss should be investigated, using simple screening methods. If necessary, audiometric tests should be conducted by a qualified audiometric technician. The radiographic examination of fractures of the temporal bone or disruption of the ossicular chain is best determined by CT, then hypocycloidal tomography and, lastly, linear tomography.
Trauma to the ears, especially rupture of the tympanic membrane (eardrum), is a frequent consequence of harsh beatings. The ear canals and tympanic membranes should be examined with an otoscope and injuries described. A common form of torture, known in … Continue reading
The psychological consequences of torture present two paradoxes. First, psychological wounds are the most personal, intimate, and enduring consequences of torture and can affect not only the victim but also his/her family and community. Yet these scars are invisible; there are no objective signs, measurable parameters, lab tests or x-rays that are able to document psychological wounds. The goal of torture is not to simply physically incapacitate the victim, but to reduce the individual to a position of extreme helplessness and distress and break his/her will. At the same time, torture sets horrific examples to those that come in contact with the victim and can profoundly damage intimate relationships between spouses, parents and children, and other family members, as well as relationships between the victims and their communities. In this way, torture can break or damage the will and coherence of entire communities.
The second paradox is that despite the fact that torture is an extraordinary life experience capable of causing a wide range of psychological suffering, extreme trauma such as torture does not always produce psychological problems. Therefore, if an individual does not have mental problems, it does not mean that he/she was not tortured. When there are no physical or psychological findings, this does not refute or support whether torture had actually occurred.
The psychological consequences of torture present two paradoxes. First, psychological wounds are the most personal, intimate, and enduring consequences of torture and can affect not only the victim but also his/her family and community. Yet these scars are invisible; there … Continue reading
Direct trauma to the eye is very common, either incidental to general beating about the head or else intentionally aimed. There may be conjunctival or retinal haemorrhage, dislocation of the lens or detachment of the retina. Torturers may force their victims to look at the sun or bright lights for long periods. Conversely, detainees may be kept for months or years in total darkness. Survivors often complain long afterwards of lacrimation (tearing) and photophobia (light sensitivity). However, such cases do not show any detectable physical abnormality and treatment is purely symptomatic.
Direct trauma to the eye is very common, either incidental to general beating about the head or else intentionally aimed. There may be conjunctival or retinal haemorrhage, dislocation of the lens or detachment of the retina. Torturers may force their … Continue reading
The potential effects of torture include cumulative traumatic experiences on individual, family and community levels.
On the individual level
Torture is a dynamic process that begins at the moment of losing liberty, and involves a sequence of traumatic events that may take place at different times and places, ending with the release or demise of the victim. Sometimes this cascade of events may start again within a short time-frame, without leaving any time for the individual to recover. The person experiences complete lack of control, inability to escape, and is also challenged by the unpredictability of the torturer.
Generally torture has an extremely threatening and painful character, and can induce immediate reactions of panic and fear, including significant fear of death, with a very high level of tension and, sometimes subsequently, of emotional numbness. These feelings may be accompanied by a sense of complete confusion, powerlessness, and loss of control which can bring about a shattered understanding of one’s self, of any meaningful existential system and of the predictability of the world. Torture can damage individuals on a number of levels:
- physical and psychological integrity and entity,
- cognitive, emotional, behavioural, social well-being,
- self-respect or self-esteem ,
- sense of safety and survival,
- dreams, hopes, aspirations for the future,
- belief system,
- system of meaning about him/herself and the world,
- connectedness, and
The aim of torture is often not only the intentional destruction of the victim, but of his or her economic, social, and cultural worlds of the victims. Torture also may profoundly affect an individual’s sense of being grounded in a family and in society. It may also cause secondary problems which compromise social, educational and occupational functioning.
On the family level
Torture can profoundly damage intimate relationships between spouses, parents, children and other family members, and relationships between the victims and their communities. Such trauma can lead to various forms of family dysfunction and disruptions including:
- Other members of the family may also be detained, tortured and ill treated.
- Other members of the family may suffer from the secondary traumatisation.
- The repercussions of the physical and psychological suffering of the tortured person within the family can cause an increased level of stress as well as fear, worry, feelings of being terrorised and threatened, and loss of sense of safety and security, affecting the family system and the other members of the family.
- Torture may change the roles and relationship patterns in the family; it may result in deterioration in the ability to care for children and loved ones, and in parenting capacity.
- Torture experiences may also cause substantial disruption of the quality of life in the family due to health problems, forced change of living place, loss of work and diminished social support.
The potential effects of torture include cumulative traumatic experiences on individual, family and community levels. On the individual level Torture is a dynamic process that begins at the moment of losing liberty, and involves a sequence of traumatic events that … Continue reading