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Module 5: Physical Evidence of Torture and Ill-Treatment
Lesions on the face are particularly distressing for survivors of torture because they are a frequent reminder of the episode. Most traumatic scars on the face tend to be relatively small, and scars from acne and chickenpox, and tribal markings, must not be mistaken for them.
Lesions are common over bony points, especially the eyebrows and the cheekbones. These may be associated with a fracture of the malar bone (cheekbone). Bruises and scars in the scalp can be difficult to find, especially if the hair is thick. Bruises will normally be tender to touch. Broken or missing teeth are often shown by individuals as evidence of assault, but where the general oral hygiene is poor this usually makes this sign unhelpful. Petechiae of the palate may be evidence of forced oral intercourse. Slaps to the ear can sometimes damage the eardrum. However, the finding of scars of the tympanic membrane (eardrum) does not exclude childhood infections.
Conjunctival hemorrhage, lens dislocation, subhyeloid hemorrhage, retrobulbar hemorrhage, retinal hemorrhage, and visual field loss may all be observed following torture. Referral to an ophthalmologist is recommended whenever there is a suspicion of ocular trauma or disease.
Blunt trauma to the external ear may result in haematoma. Cartilage necrosis and infection are likely sequelae if the ear is left untreated. Lacerations of the pinna vary from those of minor significance to complete amputation. Rupture of the tympanic membrane is a frequent consequence of harsh beatings. Prompt examination is necessary to detect tympanic membrane ruptures less than 2 mm in diameter, as they can heal within 10 days. About 80% of traumatic tympanic membrane perforations diagnosed within 14 days of injury will have healed spontaneously.
The short and long term sequelae of significant injury to the middle and inner ear are hearing loss, vertigo, tinnitus, unsteadiness and, less commonly, facial nerve paralysis. An audiogram should be performed to assess injury to the ossicles and inner ear. A conductive hearing loss is usually due to a tear in the tympanic membrane and blood in the middle ear. A hearing loss of less than 40 dB suggests an ossicular chain dislocation. Sensorineural loss indicates cochlear or retrocochlear damage.
Fluid may be observed in the middle and/or external ear. If otorrhea is confirmed by laboratory analysis to be CSF (cerebrospinal fluid), then MRI or CT should be performed, if possible, to determine the fracture site. 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.
The nose should be evaluated for alignment, crepitation, and deviation of the nasal septum. Initially soft tissue swelling may make interpretation difficult and it may be necessary to re-examine nose after 48 hours when this has subsided. Frequently there is an associated deviation of nasal septum which may result in nasal obstruction. For simple nasal fractures, standard nasal radiographs should be sufficient. Sometimes the fracture of the nasal bone includes the frontal process of the maxilla, and sometimes it extends to include ethmoid labyrinth. For complex nasal fractures and when the cartilaginous septum is displaced, and when rhinorrhea is present, CT and/or MRI are recommended.
Jaw, Oropharynx and Teeth
The oral cavity must be carefully examined. During the application of electric current to the mouth, the tongue, gingiva or lips may be bitten. Lesions might also be produced by forcing objects or materials into the mouth. Temporomandibular joint syndrome can be caused by electric current and blows to the face. It will produce pain in the temporomandibular joint, limitation of jaw movement, and in some cases subluxation of this joint.
A careful dental history should be taken and, if dental records exist, these should be requested. The patient should be referred to a dentist if there is any damage to the teeth. Mandibular fractures, avulsions or fractures of the teeth, broken prostheses, swelling of the gums, bleeding, pain, or loss of fillings from teeth can all result from direct trauma or electric shock torture. Dental caries and gingivitis should also be noted. Poor quality dentition may be due to conditions in detention, or may have preceded it. X-rays and MRI are suggested for determining the extent of soft tissue, mandibular and dental trauma.
Lesions on the face are particularly distressing for survivors of torture because they are a frequent reminder of the episode. Most traumatic scars on the face tend to be relatively small, and scars from acne and chickenpox, and tribal markings, … Continue reading
Many infectious diseases can be transmitted by sexual assault, including sexually transmitted diseases such as gonorrhoea, chlamydia, syphilis, HIV, hepatitis B and C, herpes simplex and Condyloma acuminatum (venereal warts), vulvovaginitis associated with sexual abuse, such as trichomoniasis, Moniliasis vaginitis, Gardnerella vaginitis and Enterobius vermicularis (pinworms), as well as urinary tract infections.
Appropriate laboratory tests and treatment should be prescribed in all cases of sexual abuse. In the case of gonorrhoea and chlamydia, concomitant infection of the anus or oropharynx should be considered at least for examination purposes. Initial cultures and serologic tests should be obtained in cases of sexual assault, and appropriate therapy initiated. Sexual dysfunction is common among survivors of torture, particularly among victims who have suffered sexual torture or rape, but not exclusively. Symptoms may be physical or psychological in origin or a combination of both and include:
- Aversion to members of the opposite sex or decreased interest in sexual activity;
- Fear of sexual activity because a sexual partner will know that the victim has been sexually abused or fear of having been damaged sexually. Torturers may have threatened this and instilled fear of homosexuality in men who have been anally abused. Some heterosexual men have had an erection and, on occasion, have ejaculated during non-consensual anal intercourse. They should be reassured that this is a physiological response;
- Inability to trust a sexual partner;
- Disturbance in sexual arousal and erectile dysfunction;
- Dyspareunia (painful sexual intercourse in women) or infertility due to acquired sexually transmitted disease, direct trauma to reproductive organs or poorly performed abortions of pregnancies following rape.
Many infectious diseases can be transmitted by sexual assault, including sexually transmitted diseases such as gonorrhoea, chlamydia, syphilis, HIV, hepatitis B and C, herpes simplex and Condyloma acuminatum (venereal warts), vulvovaginitis associated with sexual abuse, such as trichomoniasis, Moniliasis vaginitis, … Continue reading
Examination of the trunk, in addition to noting lesions of the skin, should be directed toward detecting regions of pain, tenderness or discomfort that would reflect underlying injuries of the musculature, ribs or abdominal organs. The examiner must consider the possibility of intramuscular, retroperitoneal and intra-abdominal hematomas, as well as laceration or rupture of an internal organ. Ultrasonography, CT scans and bone scintigraphy should be used, when realistically available, to confirm such injuries. Routine examination of the cardiovascular system, lungs and abdomen should be performed in the usual manner. Pre-existing respiratory disorders are likely to be aggravated in custody, and new ones may develop. Near asphyxiation often leaves no marks and may cause acute and chronic respiratory problems as well as other complications.
Victims can be exposed in a confined space to smoke or tear gas. Many survivors will give an account of a persistent dry cough for a few days or weeks afterwards, probably as a result of inhalation pneumonitis (inflammation of the lungs). Some survivors say that they have been asthmatic since such an incident, but it would be very difficult to demonstrate causation. Examination of the lungs, and respiratory function tests are usually normal.
Rib fractures are a frequent consequence of beatings to the chest. If displaced, they may be associated with lacerations of the lung and possible pneumothorax. Fractures of the vertebral pedicles may result from direct blunt force. Fractures of the lower right ribs carry approximately a 10% risk of hepatic injury.
Following acute abdominal trauma, the physical examination must seek evidence of damage to abdominal organs or the urinary tract, but this examination is often negative. Gross haematuria is the most significant indication of kidney contusion. Organ injury may present on investigation as free air, extraluminal fluid, and areas of low attenuation, which may represent oedema, contusion, haemorrhage or a laceration. Peripancreatic edema is one of the signs of acute traumatic and non-traumatic pancreatitis. Ultrasound is particularly useful in detecting subcapsular hematomas of the spleen. Peritoneal lavage may detect occult abdominal haemorrhage, but free abdominal fluid detected subsequently on CT scan might be from the lavage or haemorrhage; thus invalidating the finding. Acute renal failure due to crush syndrome may be seen acutely following severe beatings.
Examination of the trunk, in addition to noting lesions of the skin, should be directed toward detecting regions of pain, tenderness or discomfort that would reflect underlying injuries of the musculature, ribs or abdominal organs. The examiner must consider the … Continue reading
The neurological examination should include both the central and peripheral nervous systems. Particular attention should be paid to assessment of both motor and sensory neuropathies and cranial nerves. Performing examination of reflexes is important. Radiculopathies, other neuropathies, cranial nerve deficits, hyperalgesia, parasthesiae, hyperaesthesia, change in position and temperature sensation, motor function, gait and coordination may all result from trauma associated with torture. In patients with a history of dizziness and vomiting, vestibular examination should be conducted, and evidence of nystagmus noted.
The neurological examination should include both the central and peripheral nervous systems. Particular attention should be paid to assessment of both motor and sensory neuropathies and cranial nerves. Performing examination of reflexes is important. Radiculopathies, other neuropathies, cranial nerve deficits, … Continue reading
Genital examination is generally the last part of the physical examination. The doctor must seek specific consent prior to a genital examination, even if consent for the physical examination has already been given. Prior notice of an intention to conduct a detailed physical examination that may include a genital examination could be reassuring to the person and help her to give informed consent. A clear, unambiguous explanation of the reason for the genital examination should be given while the alleged victim is fully clothed. Rape victims in particular may feel disempowered, and may feel that they cannot refuse a request from the doctor, who should make every effort to ensure that any consent given is real and informed.
If the alleged victim refuses consent, the doctor should record any relevant observations on the alleged victim’s demeanour, such as embarrassment or fear. It is unwise to draw conclusions about a refusal to consent to genital examination. Lying prone on an examination table, exposed and with legs apart in front of a relative stranger, can trigger powerful recall of the rape. The individual may be anxious, and shame can be profound, making genital examination unacceptable to her.
If informed consent is obtained, the woman should be made at ease, reassured and explained the procedures that are going to be performed. The genitals should be inspected for the presence of a hymen, the likelihood of having been pregnant, and evidence of genital mutilation. Is there vaginal discharge or tenderness, or spasm of the vaginal muscles?
Genital examination is generally the last part of the physical examination. The doctor must seek specific consent prior to a genital examination, even if consent for the physical examination has already been given. Prior notice of an intention to conduct … Continue reading
In many cultures, it is completely unacceptable to penetrate the vagina of a woman who is a virgin with anything, including a speculum, finger or swab. If the woman demonstrates clear evidence of rape on external inspection, it may be unnecessary to conduct an internal pelvic examination. Genital examination findings may include:
- Small lacerations or tears of the vulva. These may be acute and are caused by excessive stretching. They normally heal completely, but, if repeatedly traumatised, there may be scarring;
- Abrasions of the female genitalia. Abrasions can be caused by contact with rough objects such as fingernails or rings;
- Vaginal lacerations. These are rare, but, if present, may be associated with atrophy of the tissues or previous surgery. They cannot be differentiated from incisions caused by inserted sharp objects.
It is rare to find any physical evidence when examining female genitalia more than one week after an assault. Later on, when the woman may have had subsequent sexual activity, whether consensual or not, or given birth, it may be almost impossible to attribute any findings to a specific incident of alleged abuse. Therefore, the most significant component of a medical evaluation may be the examiner’s assessment of background information (for example, correlation between allegations of abuse and acute injuries observed by the individual) and demeanour of the individual, bearing in mind the cultural context of the woman’s experience.
In many cultures, it is completely unacceptable to penetrate the vagina of a woman who is a virgin with anything, including a speculum, finger or swab. If the woman demonstrates clear evidence of rape on external inspection, it may be … Continue reading
Complaints of musculoskeletal aches and pains are very common in survivors of torture. They may be the result of repeated beatings, of suspension, or of other positional torture. They may also be somatic. They are non-specific, but should be documented. In accordance with the characteristics of torture, complaints are characterized as pain in the respective region of the body, limitation of joint movement, swelling, parasthesiae, numbness, loss of sensation to touch, and tendon reflex loss.
Physical examination of the skeleton should include testing for mobility of joints, the spine and the extremities. Pain with motion, contractures, strength, evidence of compartment syndrome, fractures with or without deformity, and dislocations should all be noted after documenting visible signs such as contusions, abrasions, and lacerations as described above. Trauma to muscle should be checked for, such as muscle rupture and muscle tearing. Specific clinical signs of ligament tear include swelling, bruising, muscle spasm, and painful stress test, often with joint laxity. There may be a palpable gap in the ligament. If it is completely torn, then considerable swelling and bruising occurs. Tendon ruptures, avulsions from the insertion of the bone, and dislocation of a tendon from its groove may all be observed.
Back pain is also common in survivors of torture, and there may be some local tenderness in the lumbar spine. However, these findings are non-specific and common in the general population. Fractures of the vertebral pedicles (the parts of the vertebra going away from the main body) may result from direct blunt force and, in some instances, radiography of the vertebrae may indicate recent or healed fractures.
Fractures are caused by a loss of bone integrity due to the effect of a blunt mechanical force on various vector planes. Fractures can be caused by a direct blow, in which case the fracture is at the site of the impact, or by twisting or crushing, in which case the fracture tends to be at the weakest part of the bone. In the acute phase, local swelling, bony deformity, tenderness and loss of function will be typical findings on clinical examination. In the chronic phase, various degrees of bony deformity, pain with activity and loss of function may be found. A direct fracture occurs at the site of impact or at the site where the force was applied. In an indirect fracture, the location, contours, and other characteristics of a fracture reflect the nature and direction of the applied force. The most frequent fractures seen in survivors of torture are of the nasal bones, the ribs, the radius, ulna and small bones of the hand, the transverse process of vertebrae, and those of the coccyx. The hyoid bone and laryngeal cartilage may be fractured in partial strangulation or from blows to the neck.
If a person alleges that a bone was fractured during torture and a callus is palpable, that should normally be sufficient to document. X-rays are unlikely to add anything. Generally, even with an X-ray, it is only possible to say that a bone was fractured within a wide time-frame, but very rarely that the fracture was caused by torture. Mal-united fractures are highly supportive of a history of torture with no immediate medical treatment.
Routine radiographs are recommended at the initial examination, if facilities are available. Injuries to tendons, ligaments, and muscles are best evaluated with MRI, but arthrography (arthroscopy) can also be performed. In the acute stage, MRI can detect hemorrhage and possible muscle tears. Muscles usually heal completely without scarring, so later imaging studies will be negative. MRI or scintigraphy may detect bone injury such as a subperiosteal haematoma, which may not be detected on routine radiographs or CT. Radiographic aging of relatively recent fractures should be performed by an experienced trauma radiologist.
Complaints of musculoskeletal aches and pains are very common in survivors of torture. They may be the result of repeated beatings, of suspension, or of other positional torture. They may also be somatic. They are non-specific, but should be documented. … Continue reading
Men who have been subjected to torture of the genital region, including the crushing, wringing or pulling of the scrotum or direct trauma to that region, usually complain of pain and sensitivity in the acute period. Hyperaemia, marked swelling and ecchymosis can be observed. The urine may contain a large number of erythrocytes and leucocytes. If a mass is detected, it should be determined whether it is a hydrocele, haematocele or inguinal hernia. In the case of an inguinal hernia, the examiner cannot palpate the spermatic cord above the mass. With a hydrocele or a haematocele, normal spermatic cord structures are usually palpable above the mass. A hydrocele results from excessive accumulation of fluid within the tunica vaginalis due to inflammation of the testis and its appendages or to diminished drainage secondary to lymphatic or venous obstruction in the cord or retroperitoneal space. A haematocele is an accumulation of blood within the tunica vaginalis, secondary to trauma. Unlike the hydrocele, it does not transilluminate.
Testicular torsion may also result from trauma to the scrotum. With this injury, the testis becomes twisted at its base, obstructing blood flow to the testis. This causes severe pain and swelling and constitutes a surgical emergency. Failure to reduce the torsion immediately will lead to infarction of the testis. Under conditions of detention, where medical care may be denied, late sequelae of this lesion may be observed.
Individuals who were subject to scrotal torture may suffer from chronic urinary tract infection, erectile dysfunction or atrophy of the testes. Symptoms of PTSD are not uncommon. In the chronic phase, it may be impossible to distinguish between scrotal pathology caused by torture and that caused by other disease processes. Failure to discover any physical abnormalities on full urological examination suggests that urinary symptoms, impotence or other sexual problems may be explained on psychological grounds. Scars on the skin of the scrotum and penis may be very difficult to visualize. For this reason, the absence of scarring at these specific locations does not demonstrate the absence of torture. On the other hand, the presence of scarring usually indicates that substantial trauma was sustained.
As with sexual assault of women described above, male victims of sexual violence also need to be assessed for prophylaxis of sexually transmitted diseases, Hepatitis B and HIV.
Men who have been subjected to torture of the genital region, including the crushing, wringing or pulling of the scrotum or direct trauma to that region, usually complain of pain and sensitivity in the acute period. Hyperaemia, marked swelling and … Continue reading
After anal rape or insertion of objects into the anus of either gender, pain and bleeding can occur for days or weeks. This often leads to constipation, which can be exacerbated by the poor diet in many places of detention. Gastrointestinal and urinary symptoms may also occur. Generally, visual inspection of the anogenital region is sufficient to find scarring and other lesions of the skin. The focus of the examination will depend on the history. In the acute phase, any examination beyond visual inspection may require local or general anaesthesia and should be performed by a specialist. For example, If an individual has persistent bleeding after an object was pushed through the anus, there may be scarring of the rectal mucosa and this can be looked for by proctoscopy. In the chronic phase, several symptoms may persist, and they should be investigated. There may be anal scars of unusual size or position, and these should be documented. Anal fissures may persist for many years, but it is normally impossible to differentiate between those caused by torture and those caused by other mechanisms. On examination of the anus, the following findings should be looked for and documented:
- Fissures tend to be non-specific findings as they can occur in a number of “normal” situations (constipation, poor hygiene). However, when seen in an acute situation (i.e. within 72 hours) fissures are more specific findings and can be considered evidence of penetration;
- Rectal tears with or without bleeding may be noted;
- Disruption of the rugal pattern may manifest as smooth fan-shaped scarring. When these scars are seen out of midline (i.e. not at 12 or 6 o’clock), they can be an indication of penetrating trauma;
- Skin tags, which can be the result of healing trauma;
- Purulent discharge from the anus. Cultures should be taken for gonorrhoea and chlamydia in all cases of alleged rectal penetration, regardless of whether a discharge is noted.
Following rape, the possibility of sexually transmitted diseases should be considered and local protocols followed. If there is any possibility of the perpetrator being prosecuted, air dried internal and external anal swabs can be taken up to five days after the rape, even if the survivor has defecated, and stored for DNA testing.
After anal rape or insertion of objects into the anus of either gender, pain and bleeding can occur for days or weeks. This often leads to constipation, which can be exacerbated by the poor diet in many places of detention. … Continue reading
- To provide in-depth information on physical examination methods, factors to consider during examinations, and the interpretation of findings.
- To be able to conduct a physical examination of each organ system and assess possible acute and chronic signs and symptoms of torture and ill-treatment
- To understand basic mechanisms of injury
- To be familiar with specific examination considerations for victims of sexual assault
- To understand the effective use of medical photography and the appropriate use of diagnostic tests
- Discuss the circumstances for the appropriate use of directed vs. comprehensive physical examinations
- To be familiar with the differentiation of self-inflicted injuries and those caused by torture and ill-treatment
- Physical evidence of torture
- Medical history
- Acute symptoms
- Chronic symptoms
- The physical examination
- Acute symptoms
- Chronic symptoms
- Dermatologic Evaluation
- Burns and scalds
- Complex Lesions
- Head and neck
- Jaw, Oropharynx and Teeth
- Chest and Abdomen
- Musculoskeletal System
- Neurological Examination
- Head Trauma and Post-traumatic Epilepsy
- Nerve damage
- Examination of Women
- Examination Following a Recent Assault
- Examination After the Immediate Phase
- Genital Examination of Women
- Genital Examination of Men
- Perianal Examination
- Medical Photography
- Assessment for Referral
- Diagnostic Tests
- Radiologic Imaging
- CT scans
- Biopsy of Electric Shock Injury
- Students should work in groups or individually to answer questions contained in Self-Assessment 5
- Additional Discussion Topics:
- Discuss relevant considerations to distinguish physical findings caused by torture and ill-treatment and those that may be self-inflicted or the result of other causes
- Discuss the relative value of diagnostic tests and their limitations and develop a series of country-specific recommendations for indications of using diagnostic tests in various documentation settings
- Discuss appropriate indications for a genital examination (women and men), how the examinations should, and should not, be performed, and any relevant country-specific considerations for the evaluation of allegations of sexual assault
- Group Activity:
- Divide the class into several groups and have each group work on answering questions contained in Self-Assessment 5
- 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
- Alternative Option:
- Divide the class into several groups and assign each group with one or more (or all) of the Discussion Topics
- Follow the usual sequence for conducting group activities as outlined above
- Individual Research/Assignment:
- Individual students should answer all questions contained in Self-Assessment 5
- Journal Entry: (Instructor to assign Write a few paragraphs — no more than a page)
- Respond to one or more of the Discussion Topics
- The Istanbul Protocol, Chapter V
- The Medical Documentation of Torture
- Medical Investigation and Documentation of Torture: A Handbook for Health Professionals
- Medical Physical Examination of Alleged Torture Victims: A Practical Guide to the Istanbul Protocol for Medical Doctors
- Examining Asylum Seekers
- Dermatologic Findings after Alleged Torture (PowerPoint file). Lis Danielsen and Ole Vedel Rasmussen, IRCT 2004-2005.
- Torture Methods (PowerPoint file). Ole Vedel Rasmussen, IRCT 2004-2005.
- Işkence Atlaı: Işkencenin Tibbi Olarak Belgelendirilmesinde Muayene ve Tanısal Inceleme Sonuclarının Kullanılması
- Trainers’ Guidelines for Health Professionals: Training of Users
Objectives To provide in-depth information on physical examination methods, factors to consider during examinations, and the interpretation of findings. To be able to conduct a physical examination of each organ system and assess possible acute and chronic signs and symptoms … Continue reading