Module 5: Physical Evidence of Torture and Ill-Treatment

Medical Photography

One helpful tool in the documentation of physical evidence of torture is photography. It may be possible to ask experts elsewhere to comment on photographs if there is no local expertise available to interpret them. Those interviewing in custodial settings may not be permitted to use such equipment, but it can sometimes be negotiated with the detaining authorities. If photography is not possible, drawings and diagrams can be useful.

When working with a person who is alleging recent torture, it is very helpful to be able to document the injuries as quickly as possible, before any change occurs. Any photographic equipment can be used to capture a wound in the first instance and more photographs can be taken later, with a better camera if possible.

The subject of clinical photography must consent to having the pictures taken and agree about how the photographs will be stored and used.

The first photograph should show the individual clearly with, if possible, the lesions visible to allow identification in court if necessary. The front page of a recent newspaper (or other object of verifiable age) can demonstrate that the photograph was not taken prior to that date. If there are date and time settings on the camera, these should be used correctly. There should always be an indicator of scale for close-up images. A tape measure is best but, if necessary, any well-known object of standard size can be used, such as a 35mm film canister or a coin. In photographs taken using the camera’s built-in flash, wounds tend to be obscured. It is better to work in daylight or to use background lighting.

Digital cameras allow many photographs to be taken using different angles and lighting conditions and the best produced as evidence, although every image taken should be stored securely (for example, on a secure computer, with password protection). Films can also be useful as courts have not generally agreed how digital images should be treated as evidence. Digital images and scanned prints can be useful as they can be e-mailed to experts for an opinion. If necessary they can be cropped and enlarged, but the original version must always be retained. Further interference must be avoided as allegations of manipulation are difficult to refute.

Once the photographs have been taken, the chain of custody of the images must be ensured. A ‘chain of custody’ is a detailed record showing the exact date, time and location in which a piece of evidence entered the possession of different individuals. A chain of custody aims to prevent outside interference with evidence. It may be valuable to add to a witness statement a phrase such as: ‘I took photographs of [name] on [date] using my [type] digital camera. I kept it in my possession until I transferred the images to [X] directory on [X] computer. To the best of my knowledge it has not been tampered with, and the photographs in this report were made from that file.’

One helpful tool in the documentation of physical evidence of torture is photography. It may be possible to ask experts elsewhere to comment on photographs if there is no local expertise available to interpret them. Those interviewing in custodial settings … Continue reading

Diagnostic Tests

In some cases, the use of diagnostic tests may aid in corroborating allegations of torture. Before obtaining such tests, however, clinicians should carefully consider the potential value of such tests and their inherent limitations in light of the level of “proof” needed in a particular case, the potential adverse consequences for the individual, and any resource limitations. Generally, diagnostic tests are not warranted unless they are likely to make a significant difference to a medico-legal case.

Radiologic Imaging

In the acute phase of injury, various imaging modalities may be quite useful in providing additional documentation of both skeletal and soft tissue injuries. Once the physical injuries of torture have healed, however, the residual sequelae generally are no longer detectable by these same imaging methods. This is often true even when the survivor continues to suffer significant pain or disability from his/her injuries.

References have already been made to various radiologic studies in the discussions of the examination of the patient and in the context of various forms of torture. What follows is a summary of the application of these methods, recognizing that the more sophisticated (and expensive) technology is not universally available.

Radiologic and imaging diagnostic examinations include routine radiographs (x-rays), radioisotopic scintigraphy, computerized tomography (CT), nuclear magnetic resonance imaging (MRI), and ultrasonography (USG). Each has its advantages and disadvantages. X-rays, scintigraphy, and CT scanning use ionizing radiation, which may be a concern for pregnant women and children. MRI uses a magnetic field; potential biologic effects on fetuses and children are theoretical, but thought to be minimal. Ultrasound uses sound waves; no biologic risk is known.

X-Rays

X-rays are readily available. They can be very useful when searching for fractures, fissures, deformity and foreign bodies in osseous structures. Excluding the skull, all injured areas should have routine radiographs as the initial examination. While routine radiographs will demonstrate facial fractures, CT is a superior examination as it demonstrates more fractures, fragment displacement and associated soft tissue injury and complications. When periosteal damage or minimal fractures are suspected, bone scintigraphy should be used in addition to x-rays.

The type of fracture can reveal important information on the force and its form of application. In this respect, soft tissue changes adjacent to the fracture or deformity as well as foreign bodies in the vicinity can also contribute information. The awareness of the forms of torture used can specify the cause of a lesion otherwise considered to be non-specific. Extension deformities can be followed up with these approaches during chronic stages.

A percentage of x-rays will be negative even when there is an acute fracture or early osteomyelitis. It is possible for a fracture to heal leaving no radiographic evidence of previous injury; this is especially true in children. Routine radiographs are not the ideal examination for evaluation of soft tissues.

Scintigraphy

Scintigraphy is an examination of high sensitivity but low specificity. Scintigraphy is an economic and effective examination to screen the entire skeleton for disease processes such as osteomyelitis or trauma. Testicular torsion can also be evaluated, but ultrasound is better suited to this task. Scintigraphy is not the appropriate examination to identify soft tissue trauma.

Scintigraphy can detect an acute fracture within twenty-four hours, but generally it takes two to three days and may occasionally take a week or more, particularly in the elderly. Generally the scan returns to normal after two years. However, it may remain positive in both fractures and cured osteomyelitis for years. The use of bone scintigraphy to detect fractures at the epiphysis or metadiaphysis (ends of long bones) in children is very difficult because of the normal uptake of the radiopharmaceutical at the epiphysis. Scintigraphy is often able to detect rib fractures that are not apparent on routine x-ray films.

Scintigraphy is more sensitive in the demonstration of bone tissue lesions than classical radiological techniques. It allows observation of the effects years later. It is more cost effective than MRI which can verify lesions in early stages. Fundamental events in revealing the pathology are osteoblastic activity and increased blood flow in tissues. In trauma not leading to fractures, bone metabolism and thus turnover is increased, and as trauma continues microfractures develop. The contribution of scintigraphy significantly increases in areas such as ribs, spinous processes and the scaphoid bone which are hard to evaluate by direct X-rays. Thus scintigraphy yields better results in trauma directed to thorax. Lesions such as epiphyseal separation or metaphyseal edge fractures which are easily missed can well be differentiated by the shape of epiphyseal plate and its visualisation. Scintigraphy also provides advantages as a screening procedure in multiple traumatic injuries.

Another contribution of scintigraphy is that activity of radioactive material changes in time. In acute stages, positive results are obtained in 80% of the lesions within the first 24 hours and 95% in 72 hours. Increased activity may be observed 1-2 years after the alleged injuries and may sometimes persist for 10-15 years.

Application of Bone Scintigraphy to the Diagnosis of Falanga

Bone scans may be performed either with delayed images at about three hours or as a three-phase examination. The three phases are: 1) radionucleide angiogram (arterial phase); 2) blood pool images (venous phase, which is soft tissue); and 3) delayed phase (bone phase). Patients examined soon after falanga should have two bone scans performed at one-week intervals. A negative first delayed scan and positive second scan indicates exposure to falanga within days before the first scan. In acute cases, two negative bone scans at an interval of one week do not necessarily mean that falanga did not occur, but that the severity of the falanga applied was under the sensitivity level of the scintigraphy. Initially, if three-phase scanning is done, increased uptake in the radionucleide angiogram phase and in blood pool images and no increased uptake in the bone phase indicate hyperemia compatible with soft tissue injury. Trauma in the foot bones and soft tissue can also be detected with MRI.

Ultrasound

Ultrasound is inexpensive and without biologic hazard. The quality of the examination depends on the skill of the operator. In parts of the world where CT is not available, USG is used to evaluate acute abdominal trauma. Tendonopathy can also be evaluated by USG, and it is a method of choice for testicular abnormalities.

Shoulder USG is carried out in acute and chronic periods following suspension torture. In the acute period, edema, fluid collection on and around the shoulder joint, lacerations and hematomas of the rotator cuffs can be observed by USG. The reapplication of USG and subsequent observation that findings from the acute period disappear in time strengthens the diagnosis. In such cases, EMG, scintigraphy and other radiological examinations should be carried out together and their correlation examined. Even lacking positive results from other examinations, USG findings alone are adequate to prove suspension torture.

Although ultrasound is primarily used for evaluation of muscles and joints, especially the shoulder joint, its contributions can be much wider depending on the skill of the applicator administering it. Insufficient documentation increases the possibility of mis-diagnosis as results may appear conclusive. However, results by less experienced operators can well serve as a document for more experienced specialists who evaluate the event later.

Contribution of conventional ultrasound varies according to its capacity for morphological evaluation. At present, high channel probes with multifrequencies between 8 and 15 MHz can be more sensitive than CT and MRI in showing changes in cutaneous, subcutaneous, osseous and soft tissues as well as in muscles and joints. Ultrasound sensitivity to pathology related to shoulder, knee and ankle joints and related lesions of joints, tendons and adjacent soft tissues is usually is higher than MRI. It is possible to demonstrate correctly muscle contusion and haematomas, subcutaneous contusion and haemorrhages, loss of uniformity of subcutaneous fat tissue, soft tissue micro and macro-calcifications and foreign bodies with ultrasound. Traumatic changes and contusions of soft tissue in genitals, breast and perineum can be identified in detail with high resolution probes.

A second contribution is information on the perfusion of tissues identified by Doppler studies. Focal deficits of tissue perfusion and areas of reactive hyperaemia can be identified in injuries especially caused by cold (cold water, cold air). Findings of testicular torsion or of early detorsion can also be successfully demonstrated. It is also possible to demonstrate fracture, fissure, small osseous cortical discontinuities, neovascularisation due to wound healing, or reactive periosteal callus formation in osteochondral injuries earlier and more precisely in comparison to direct X-rays or CT and MRI. However, in cases when there are no cortical injuries, verification of medullary and trabecular osseous changes is possible neither by classic nor by Doppler sonographic studies.

CT scans

CT is excellent for imaging both soft tissue and bone. MRI is better for soft tissue than bone. However, MRI may detect an occult fracture before it can be imaged by either routine radiographs or scintigraphy. Use of open scanners and/or sedation may alleviate anxiety and claustrophobia that are especially prevalent among torture survivors.

CT is also excellent for diagnosing and evaluating fractures, especially temporal bone and facial bones. Other advantages include determining alignment and displacement of fragments, especially spinal, pelvic, shoulder and acetabular fractures. CT cannot identify bone bruising.

CT with and without intravenous infusion of a contrast agent should be the initial examination for acute, subacute and chronic central nervous system (CNS) lesions. If the CT examination is negative, equivocal or does not explain the survivor’s CNS complaints or symptoms, proceed to an MRI.

CT with bone windows and a pre- and post-contrast examination should be the initial examination for temporal bone fractures. Bone windows may demonstrate fractures and ossicular disruption. The pre-contrast examination may demonstrate fluid and cholesteatoma. Contrast is recommended because of the common vascular anomalies that occur in this area. For rhinorrhea, injection of contrast into the spinal canal should follow a temporal bone. MRI may also demonstrate the tear responsible for the leakage of fluid.

When rhinorrhea is suspected, a CT of the face with soft tissue and bone windows should be performed. Then, a CT should be obtained after contrast is injected into the spinal canal.

MRI

MRI is more sensitive than CT in detecting central nervous system (CNS) abnormalities. The time course of CNS hemorrhage is divided into immediate, hyperacute, acute, subacute and chronic phases. The time course of CNS hemorrhage has ranges that correlate with imaging characteristics of the hemorrhage. Thus, the imaging findings may allow estimation of the timing of head injury and correlation to alleged incidents. CNS hemorrhage may completely resolve or produce sufficient hemosiderin deposits that the CT scan will be positive even years later. Hemorrhage in soft tissue, especially in muscle, usually completely resolves leaving no trace, but rarely can ossify. This is called heterotrophic bone formation or myositis ossificans and is detectable on CT scan.

Recently there have been significant advances in demonstration of acute and chronic lesions using MRI. MRI with Turbo STIR sequences, directed to the whole body can demonstrate general body trauma and identify lesions and areas needing detailed evaluation. Unidentified lesions and those not causing any clinical complaints can also be visualized. Early stage cortical and medullary oedema and trabecular destructions can be much more readily demonstrated than CT. Minimal changes identified as bone bruise in pre-oedema stages can also be identified in osseous tissues. New special sequences which can verify these changes within hours are being developed and administered. Small millimetric cortical destructions, minimal oedematous changes of soft tissue, especially in series with fat suppression, and muscle contusion or strain injuries can also be identified.

Biopsy of Electric Shock Injury

Electric shock injuries may, but do not necessarily, exhibit microscopic changes that are highly diagnostic and specific for electric current trauma. The absence of these specific changes in a biopsy specimen does not mitigate against a diagnosis of electric shock torture, and judicial authorities must not be permitted to make such an assumption. Unfortunately, if a court requests that a petitioner alleging electric shock torture submit to a biopsy for confirmation of the allegations, refusal to consent to the procedure or a “negative” result is bound to have a prejudicial impact upon the court. Furthermore, clinical experience with biopsy diagnosis of torture-related electrical injury is limited, and the diagnosis can usually be made with confidence from the history and physical examination alone.

This procedure is therefore one that should currently be done in a clinical research setting, and not promoted as a diagnostic standard. In giving informed consent for biopsy, the individual must be informed of the uncertainty of the results and permitted to weigh the potential benefit against the impact upon an already traumatised psyche.

Rationale for biopsy

There has been extensive laboratory research measuring the effects of electric shocks on the skin of anaesthetized pigs. This work has shown that there are histologic findings specific for electrical injury that can be established by microscopic examination of punch biopsies of the lesions. However, further discussion of this research, which may have significant clinical application, is beyond the scope of this publication. The reader is referred to the above cited references for further information.

Few cases of electric shock torture of humans have been studied histologically. Only in one case, where lesions were excised probably 7 days after the injury, were alterations in the skin believed to be diagnostic of electrical injuries observed (deposition of calcium salts on dermal fibers in viable tissue located around necrotic tissue). Lesions excised a few days after alleged electrical torture in other cases have shown segmental changes and deposits of calcium salts on cellular structures highly consistent with influence of an electrical current, but not diagnostic since deposits of calcium salts on dermal fibers were not observed. A biopsy taken one month after alleged electrical torture showed a conical scar, 1-2 mm broad, with increased number of fibroblasts and tightly packed, thin collagen fibers, arranged parallel to the surface, consistent with, but not diagnostic of, electrical injury.

Method

After receiving informed consent from the patient, and before biopsy, the lesion must be photographed according to accepted forensic methods. Under local anesthesia, a 3-4 mm punch biopsy is obtained, and placed in buffered formalin or similar fixative. Skin biopsy should be performed as soon as possible after injury. Since electrical trauma is usually confined to the epidermis and superficial dermis, the lesions may quickly disappear. Biopsies can be taken from more than one lesion, but the potential distress to the patient must be considered.

Biopsy material should be examined by a pathologist experienced in dermatopathology.

Diagnostic findings for electrical injury

  1. Vesicular nuclei in epidermis, sweat glands and vessel walls (only one differential diagnosis: injuries via basic solutions)
  2. Deposits of calcium salts distinctly located on collagen and elastic fibers (the differential diagnosis, calcinosis cutis, is a rare disorder only found in 75 of 220,000 consecutive human skin biopsies, and the calcium deposits are usually massive without distinct location on collagen and elastic fibers.

Typical, but not diagnostic, findings for electrical injury

  1. Lesions appearing in conical segments, often 1-2 mm large
  2. Deposits of iron or copper on epidermis (from the electrode)
  3. Homogenous cytoplasm in epidermis, sweat glands and vessel walls
  4. Deposits of calcium salts on cellular structures in segmental lesions
  5. No abnormal histologic observations

In some cases, the use of diagnostic tests may aid in corroborating allegations of torture. Before obtaining such tests, however, clinicians should carefully consider the potential value of such tests and their inherent limitations in light of the level of … Continue reading

Module 6: Psychological Evidence of Torture and Ill-Treatment

Objectives

  • To appreciate the central role of psychological evaluation in medical evaluations of torture and ill-treatment
  • To understand how to conduct a psychological evaluation, document psychological findings, and formulate clinical impressions and conclusions regarding torture and ill-treatment
  • To review transference, counter-transference, re-traumatisation issues
  • Using the Psychological Evaluations # 1 and #2, students will be asked to develop interpretations of the psychological findings and conclusions and recommendations using Istanbul Protocol standards
  • To understand the value and limitations of diagnostic classifications (ICD-10 and DSM) in the evaluation of psychological evidence of torture and ill-treatment
  • To understand the value and limitations of psychometric instruments (questionnaires, scales, etc) during the psychological evaluation
  • To be familiar with psychological evaluations of torture and ill-treatment in children

Content

  • The central role of the psychological evaluation
  • Conducting the psychological evaluation
  • Psychological findings and diagnostic considerations
  • Components of the psychological/psychiatric evaluation
    • Identifying Data
    • History of Torture and Ill-treatment
    • Current Psychological Complaints
    • Post-torture History
    • Pre-torture History
    • Medical History
    • Past Psychiatric History
    • Neuro-psychological Assessment
    • Mental Status Examination
    • Assessment of Social Function
    • Psychological Testing and the Use of Checklists and Questionnaires
    • Clinical Impression
    • Recommendations
    • Treatment Considerations
  • Children and Torture
    • Developmental Considerations
    • Clinical Considerations
    • Role of the Family
  • International statistical classification of diseases and related health problems, Annex

Discussion Topics

  • Students should work in groups or individually on one or both of the Psychological Evaluations (#1 and #2, see Appendix I at the end of this Module). Each group should write up their interpretation of findings and conclusions and recommendations.
  • Additional Discussion Topics:
    • Discuss the reasons why some survivors of torture have difficulties recalling and recounting their experiences
    • Discuss possible reasons for inconsistencies in the evaluation and strategies to explain inconsistencies in medico-legal reports
    • Discuss how to assess the possibility of simulation of psychological symptoms
    • Discuss who can/should conduct the psychological evaluations in your country (consider: qualifications, authority, official vs. non-official, etc)
    • Discuss current, country-specific challenges in conducting psychological evaluations of torture and ill-treatment and their validity, or lack thereof, in medico-legal contexts

Teaching Formats

  • Group Activity:
    • Students should work in groups or individually on one or both of the Psychological Evaluations (#1 and #2, see Appendix I at the end of this Module). Each group should write up their interpretation of findings and conclusions and recommendations based on Istanbul Protocol standards.
    • 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 assigned to read one or both of the Psychological Evaluations and write up their interpretation of findings and conclusions and recommendations based on Istanbul Protocol
  • Journal Entry: (Instructor to assign; Write a few paragraphs — no more than a page)
    • Respond to one or more of the Discussion Topics
    • In your opinion, what are the most significant challenges in conducting a psychological evaluation of torture and ill treatment? Explain.

Primary Resources

  • The Istanbul Protocol, Chapter VI
  • Psychological Evaluation of Torture Allegations: An International Training Manual
  • The Medical Documentation of Torture
  • Medical Investigation and Documentation of Torture: A Handbook for Health Professionals
  • Trainers’ Guidelines for Health Professionals: Training of Users

Objectives To appreciate the central role of psychological evaluation in medical evaluations of torture and ill-treatment To understand how to conduct a psychological evaluation, document psychological findings, and formulate clinical impressions and conclusions regarding torture and ill-treatment To review transference, … Continue reading

Module 5 Presentation: Physical Evidence of Torture and Ill-Treatment


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Download Module 5: Physical Evidence of Torture and Ill Treatment (PowerPoint Presentation) (ppt)

Self-Assessment and Quiz

  1. Most physical methods of torture result in characteristic, acute and chronic lesions.
    1. True
    2. False
  2. Physicians who conduct medical evaluations of physical evidence of torture should:
    1. Always conduct a complete physical examination
    2. Always conduct a directed physical examination (pursuit of pertinent positive and negative findings)
    3. Conduct a complete physical examination unless the allegations of torture are limited and there is no history of loss of consciousness or neurological or psychological symptoms that may affect recall of torture allegations.
    4. Conduct an examination which focuses on positive physical findings since pertinent negative finding are not necessary in medico-legal cases
  3. Which of the following forms of historical information may be useful in correlating practices of torture with individual allegations of abuse
    1. Descriptions of torture devices
    2. Body positions
    3. Methods of restraint
    4. Descriptions of acute or chronic wounds and disabilities
    5. Identifying information about perpetrators and places of detention
    6. All of the above
  4. A 38 year-old man alleges that he was detained on suspicion of harboring terrorists. He explains that soon after being detained he was beaten, but does not elaborate further. Which of the following questions would be most appropriate at this time?
    1. What kind of physical symptoms and injuries resulted?
    2. What were your thoughts and emotional reactions at the time?
    3. Can you tell me more about what happened?
    4. Who did this to you?
    5. Do you have any scars from the torture?
  5. In addition to location, size, shape, and color, which of the following should be included in clinical descriptions of skin lesions?
    1. Surface texture
    2. Periphery of the lesion
    3. Extent of demarcation
    4. Level in relation to surrounding skin
    5. All of the above
  6. Lacerations are caused by sharp objects like a knife, bayonet, or broken glass that produce a more or less deep, sharp and well-demarcated skin wound.
    1. True
    2. False
  7. A 32 year-old man alleges that he was beaten with a police baton. On physical examination, you observe the following:

    [Courtesy of Amnesty International, The Netherlands.]

    How would you describe the level of consistency between the allegation of abuse and the findings on physical examination?

    1. Not consistent
    2. Consistent
    3. Highly consistent
    4. Virtually diagnostic
    5. Proof of torture
  8. Which of the following are true about contusions?
    1. The extent and severity of a contusion is related to the amount of force applied, and the vascular structures affected
    2. Deep contusions should be re-examined 1 to 2 days after the alleged injury
    3. The color of the bruise can be used to determine the age of the contusion
    4. Sometimes the shape of the bruise helps to identify the shape of the blunt instrument that caused the injury
    5. All of the above
  9. Which of the following statements about scars are true?
    1. Wounds that heal by secondary intention are generally smaller than those that heal by primary intention
    2. Scars related to self-inflicted injuries are generally superficial and within easy reach of the dominant hand
    3. The location and presence of multiple scars may help to distinguish intentional vs. accidental injuries
    4. Post-inflammatory hyperpigmentation may result from contusions and abrasions
    5. All of the above
  10. A 30 year-old man states that he lost consciousness while he was suspended. When he awoke some time later in his cell, he noted a painful, red blister on his left torso which took several weeks to heal. You conduct a medical evaluation for asylum 2 years after the alleged injury. Bases on the photographic information below, what is the most likely cause of the scar?
    [Courtesy of Amnesty International, The Netherlands.]

    1. Electric shock
    2. Burn with a heated instrument
    3. Beating with a police baton
    4. Striae Distinsae
    5. None of the above
  11. Which of the following is the most likely cause of the scars in the photograph below?

    < [Courtesy of Alejandro Moreno, MD, JD.]

    1. Abrasions
    2. Incisions
    3. Lacerations
    4. Burns
    5. Electric shock
  12. Which of the following is the most likely cause of the scar in the photograph below?

    [Courtesy of Alejandro Moreno, MD, JD.]

    1. Abrasion
    2. Incision
    3. Laceration
    4. Burn
    5. Electric shock
  13. Which of the following is the most likely cause of the scars in the photograph below?

    [Courtesy of Alejandro Moreno, MD, JD.]

    1. Abrasions
    2. Incisions
    3. Lacerations
    4. Burns
    5. Electric shock
  14. Which of the following is the most likely cause of the scars in the photograph below?
    [Courtesy of the Human Rights Foundation of Turkey.]

    1. Striae Distensae
    2. Contact dermatitis
    3. Whipping with an electrical wire
    4. Shock baton
  15. What is the most likely cause of the findings in the following photograph?

    [Courtesy of the Human Rights Foundation of Turkey.]

    1. Abrasions
    2. Incisions
    3. Lacerations
    4. Burns
    5. Electric shock
  16. Which of the following statements are true about medical examinations of women alleging sexual assault?
    1. The examination should be performed by an expert in documenting sexual assault
    2. A thorough physical examination should be performed
    3. It is rare to find any physical evidence when examining female genitalia more than one week after an assault
    4. Refusal to consent to a genital examination is a strong indication of false allegations of rape
    5. All of the above
  17. Which of the following statements are true about genital examination of men?
    1. Individuals who were subjected to scrotal torture may suffer from chronic urinary tract infection, erectile dysfunction or atrophy of the testes
    2. Symptoms of PTSD are not uncommon
    3. In the chronic phase, it may be impossible to distinguish between scrotal pathology caused by torture and that caused by other disease processes
    4. 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
    5. 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
    6. All of the above
  18. Perianal examinations findings are generally non-specific. When scars are observed out of the midline (i.e. not at 12 or 6 o’clock), they may be an indication of rectal tears associated with penetrating trauma.
    1. True
    2. False
  19. If a camera is available, it is better to take poor quality photographs than to have no photographs at all.
    1. True
    2. False
  20. In general, diagnostic tests should be obtained whenever possible for medical evaluations of torture and ill treatment because:
    1. They are generally inexpensive and readily available
    2. They often provide the evidence needed to prove torture allegations
    3. Their diagnostic value nearly always outweighs their cost
    4. Their reliability and specificity for specific torture is well documented
    5. None of the above

Most physical methods of torture result in characteristic, acute and chronic lesions. True False Physicians who conduct medical evaluations of physical evidence of torture should: Always conduct a complete physical examination Always conduct a directed physical examination (pursuit of pertinent … Continue reading