Module 7: Case Example #1

Modules 7 and 8 each include a case example of alleged torture and ill-treatment. The Modules are designed for students to develop the clinical skills necessary for the effective documentation of medical evidence torture, including both physical and psychological evidence. These cases were used extensively in Istanbul Protocol trainings in Mexico and also, with some modifications, in Sudan. The content of each was specifically designed to represent common evaluation scenarios and to include a wide range of challenges related to the documentation of physical and psychological evidence of torture. The cases are complementary, i.e. one with “strong psychological and weak physical evidence” (Case #01) and the other with “strong physical and minimal psychological evidence” (Case #02) and reflect composite imformation of actual cases. Each case consists of 1) a brief Case Summary/Refferal that the students read before the evaluation, 2) a Case Narrative to guide role-players in acting their part as an alleged torture victim, and 3) a detailed set of Guidelines for Instructors (and/or individual student users if that is the case) which outline learning objectives, relevant case information, and points for discussion for each of the 8 primary components of medical evaluation:

1. Introduction/Conditions of Interview & Identification Information
2. Past Medical and Surgical History & Psychosocial History – Pre-Arrest
3. Trauma History
4. Review of Torture Methods
5. Physical Symptoms (acute and chronic) and Disabilities
6. Psychological Assessment and Mental Status Examination
7. Physical Examination
8. Interpretation of Findings & Conclusions

It is highly recommended for the instructors to contact local treatment centers for survivors of torture, and/or other experienced clincians or providers who may be available to participate in the case examples.

Modules 7 and 8 each include a case example of alleged torture and ill-treatment. The Modules are designed for students to develop the clinical skills necessary for the effective documentation of medical evidence torture, including both physical and psychological evidence. … Continue reading →

1. Answer: A, B, D

   All of the considerations listed are important for effective interviews with the exception of C. All individuals alleging torture, including those in custody, should be informed that they are not required to answer any question that they choose not to.

2. Answer: B, C

   Informed consent is required before all medical evaluations and explaining the potential benefits and risks of the evaluation is part of the consent process.

3. Answer: D

   Given the possibility of intense shame and ongoing fear, it would be prudent to select a translator who is not related to Mrs. Yousif and is not a member of the refugee community. The clinician should reassure Mrs. Yousif of the measures you will take to ensure confidentiality of the information she provides.

4. Answer: C

   Initially, questions should be open-ended, allowing a narration of the trauma with minimal interruptions. Closed questions are often used to add clarity to a narrative account or to carefully redirect the interview if the individual wanders off the subject.

5. Answer: A

   Other traumatic experiences may contribute to the psychological symptoms of survivors of torture. In Mrs. Yousif’s case, the killing of her husband and burning of her home and village likely contributed to her psychological symptoms.

6. Answer: C

   Inability to protect the ones we love from extreme harm often results in severe and prolonged emotional reactions such as guilt, shame and rage. Mrs. Yousif indicated that she has a profound sense of guilt over what happened to her daughter and is often preoccupied with thoughts of what she should have done differently.

7. Answer: E, F, G

   Mrs. Yousif’s trauma history did not included allegations of blindfolding. Although she reported being stuck in the head with the butt of a handgun and kicked in the side of her face, she did not have any lapses in consciousness. The abuses that she described do not suggest significant disorientation that is often associated with prolonged isolation and sleep deprivation. She does have marked symptoms of PTSD, however, and both fear of reprisals and lack of trust in the examining clinician should be anticipated given her previous interactions with police and medical personnel.

8. Answer: A

   The content of perpetrators’ verbal remarks often refers to the intent of the abuse and is often relevant to the individual meaning assigned to the torture experience.

9. Answer: E

   Moving on with the interview would certainly be appropriate, but the other options listed (B, C and D) also may help to inform the alleged victim’s decision on whether to discuss the allegation of sexual assault further. The option of offering to limit reporting to a judge, only, may depend on the acceptability of this option within the domestic legal system and/or the extent to which absolute confidentiality can be maintained.

10. Answer: H

    All of the indirect questions listed may be helpful in assessing the possibility of rape and other forms of sexual assault.

11. Answer: A, C

    Mrs. Yousif’s history is highly consistent with a Bell’s Palsy after being kicked on the right side of her face with subsequent swelling, temporarily affecting the right Facial Nerve. Her observation of “tram-track” lines following beating with a hose is also highly consistent with the alleged abuse as it indicates first-hand knowledge of the alleged experience.

12. Answer: F

    Mrs. Yousif presented to Nyala Hospital 2 days after the alleged assault. In the acute setting for rape allegations, all of the measures listed should be taken. For CDC recommendations on antiretroviral postexposure prophylaxis after sexual exposure to HIV, see: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5402a1.htm.

13. Answer: A

    Mrs. Yousif meets diagnostic criteria for PTSD: She was exposed to multiple traumatic events or experiences involving intense fear, horror, or helplessness and the events or experiences involved threats of death, serious injury, or physical integrity. She has at least one re-experiencing symptom, at least 3 avoidance symptoms, and at least 2 persistent indicators of increased arousal. Since her symptoms have persisted for longer than 3 months, her PTSD should be considered “chronic.”

14. Answer: B

    While the content of PTSD symptoms may be consistent or highly consistent with allegations of torture and ill treatment, the diagnosis of PTSD, in and of itself, is not specific for torture and/or ill treatment. On the other hand, there is often a strong relationship between an individual’s psychological symptoms and the individual meaning of torture experiences.

15. Answer: E

    All of the traumatic experiences listed likely contribute to Mrs. Yousif’s psychological symptoms.

16. Answer: E

    All of the factors listed may help to distinguish cause-specific psychological symptoms.

17. Answer: B

    It is rare to find any physical evidence when examining female genitalia more than one week after an assault. For this reason, and the risk re-traumatizing Mrs. Yousif unnecessarily, a pelvic examination is not recommended. The most significant component of a medical evaluation in the chronic phase of rape allegations is the psychological assessment and other, non-gynecologic, physical findings.

18. Answer: E

    All of the symptoms of sexual dysfunction listed may be observed following rape.

19. Answer: B

    While Mrs. Yousif’s physical findings are consistent with the alleged trauma, they may be the result of other injuries. [Note, the description of the complex, atrophic scar over the dorsum of the left hand is consistent with the history of a laceration that healed by secondary intention; it apparently became infected, formed an abscess and required incision and drainage.]

20. Answer: C

    Mrs. Yousif’s psychological symptoms are highly consistent with the torture and ill treatment that she alleged. The severity of her symptoms is consistent with the multiple traumas she reported. In addition to meeting diagnostic criteria for PTSD and Major Depressive Disorder, the content of some of her psychological symptoms refer specifically to the alleged abuse. Her intense feelings of guilt over her daughter’s rape and the consistency between her observed affect during the interview and the content of the evaluation are also highly consistent with the torture and ill treatment she alleged.

Answer: A, B, D All of the considerations listed are important for effective interviews with the exception of C. All individuals alleging torture, including those in custody, should be informed that they are not required to answer any question that … Continue reading →

1. There are a number of different formats to consider for the case examples contained in Module 7 and 8, depending on the time and resources available. Ideally, each student should have an opportunity to practice various components of the interview and engage in analysis of the information gathered. Options for teaching formats include but may not be limited to:
   • Student groups can be divided so that there are between 2 and 8 students per group. The instructor(s) should periodically check on each group to assess progress and address any questions or concerns that may arise. Student evaluation groups can work concurrently, with the 8 components of the interview divided up among the students. Each case example will require approximately 2 to 3 hours of time for the interview and feedback process.
   • If there is not adequate time in the course for the students to conduct Case #01 and #02 on separate days, it may be possible to have half of the students conduct Case 1 and the other half conduct Case #01 on the same day.
   • Alternatively, one demonstration evaluation may be conducted for the entire class and students asked to volunteer for various components of the interview. Several students may work together, or sequentially for each of the 8 primary components of medical evaluation so that each student has an opportunity to participate.
   • A single demonstration evaluation by one or more instructors may be another possibility, with student interaction at the end of each of the 8 components of the interviews.
   • Also, one or both Case Narratives may be assigned for students to read in advance (without role-play interviews) and followed by class discussion and/or a demonstration case.
   • Individual online users of the Model Curriculum may review all materials contained in Modules 7 and 8 and complete the related self-assessment quizzes.
2. Regarding Role-players: If interviews are conducted in class, instructors will need to use their best judgment in selecting role-players. Role-players may be individuals outside the class or the students themselves. In either case, the instuctors should provide the role-players with adequate information to convey the information contained in Narratives for Case #01 and Case #02 and review a relevant process issues, for example:
   • Discuss the role-play for police coercion. Request permission to use paper handcuffs.
   • Provide role-players with Case Narratives
   • Instructor(s) and role-players will review the cases in detail and discuss content and process issues prior to class
   • Consider the following recommendations for role-players:
     • General affect or emotion conveyed in the interviews
     • Emotional responses to specific experiences related in the interviews
     • Importance of staying in the role of the detainee/alleged victim until the debriefing
     • Imagine having experienced what is alleged in the narratives or by a friend/spouse
     • Make effective use of silence or pauses when you respond to the interviewer
     • Make effective use of body language (eye contact, body position, tone and pattern of speech)
     • Discuss gender issues
     • Discuss how the detainee’s should appear and be dressed
   • Discuss the debriefing process
     • At the end of each case interview, role-players should provide feedback on trainee performances and process issues
     • Consider relevant transference and counter-transference issues (see Module 3): Clinicians who conduct medical evaluations of detainees should be familiar with common transference reactions (i.e., potential reactions of the survivors toward the physician) that survivors experience and the potential impact of such reactions on the evaluation process. Counter-transference (i.e. the interviewer’s emotional response to the torture survivor) reactions should also be discussed.
3. Instructors should note:
   • Students may feel uncomfortable role-playing as it is likely to cause emotional stress which may or may not be associated with past experiences. Do not require or make students feel obligated to “volunteer” as role-players.
   • Remind the students of the objectives of this module before it starts and that the point of the exercise is to practice and learn rather than conduct a “perfect” interview.
   • Encourage participants to convey their emotions during their feedback.
   • During the feedback:
     • Ensure that the language is non-judgmental, but constructive and respectful.
     • Take the group dynamics into consideration.
     • Take care that the ones in the role of interviewers do not get frustrated and do not feel judged.
     • Underline positive aspects.
     • Remind the participants that the task of interviewing somebody can create tension, is difficult and doesn’t exactly reflect the real life interview experiences.
     • Show appreciation for the interviewee and interviewer.
4. Case Summaries/Referrals: A brief Case Summarie/Referral will be distributed to the trainees before each of the training sessions (Modules 7 and 8). The format is intended to approximate the information that may be contained in an official request for a forensic medical evaluation.
5. Case Narratives: The narratives provide considerable detail on the alleged trauma, subsequent symptoms and disabilities and physical and psychological assessments. The narratives will serve as background information and guidelines for the conduct of the interviews and will be used by the trainers and role-players in preparation for the training sessions. The students who conduct the interviews should not have prior access to the Case Narratives.
6. Time-outs: A break in the interview action used to make teaching points. Note: The instructor should indicate whether time-outs can be initiated only by the instructor of by the students as well. To conserve time, it may be advisable for time-outs to be reserved for instructors only. There should be time for discussion at the end of each of the 8 interview components so that all participants can ask questions and engage in relevant discussion.
7. Recommended Agenda: It is important to complete all components of the medical evaluation working sessions in the period allotted. This will help to ensure that each trainee has an opportunity to participate in the interview process and that the entire examination will be completed. The following recommended agenda is based on a 3 hour interview, but may be modified, proportionally, depending on the time available.
   • Identify sequence of participation among students (5 min)
   • Components:
     1. Introduction/Conditions of Interview & Identification Information
     2. Past Medical and Surgical History & Psychosocial History – Pre-Arrest
     3. Trauma History
     4. Review of Torture Methods
     5. Symptoms (acute and chronic) and Disabilities
     6. Psychological Assessment and Mental Status Examination
     7. Physical Examination
     8. Interpretation of Findings & Conclusions

     NOTE: For the above 8 components, a total of 120 minutes: 15 min for each component (student = 10 min + discussion = 5 min)

   • Debriefing with Role-Player (15 min)
   • Summary Discussion (40 min)
8. Assessment of Student Performance: Instructors may assess each student’s performance for the two case interviews using periodic observation. It is recommended that students be required to take notes on all components of the case interviews in which they participate and to develop a written report that can be evaluated by the instructor. Any assignment for written reports should be due at the time of the final module, Module 9, which addresses Report Writing and Testifying in Court.
9. Terminology: Please keep in mind that the subject being evaluated should not be referred to as a “victim” or “survivor.” Please use the individual’s name or “detainee,” “alleged victim,” “subject,” “individual,” or some other neutral term.
10. Interview Setting: It is important that the students understand their role in providing a private and comfortable interview setting. Arrange the chairs so that the two interview chairs are next to one another and the other chairs in the room are some distance from those of the interviewer and the detainee.
11. Optional Simulation of Police Coercion: The “alleged victim” or “detainee” (role-player) will be brought to the “examination” room (conference or class room) when the instructor indicates that he/she is ready. The instructor should consider arranging for the detainee to enter the room in paper handcuffs (assuming this is acceptable to the role-player) and in the custody of a “police officer.” The reason for this is to simulate conditions that examiners are likely to experience in evaluating alleged victims. The “police officer” should be present for the first five minutes of the examination unless asked to leave by the trainee. This activity will help each group to discuss how to handle the issue of police coercion.

There are a number of different formats to consider for the case examples contained in Module 7 and 8, depending on the time and resources available. Ideally, each student should have an opportunity to practice various components of the interview … Continue reading →

Case Summary/Referral #01

(distribute to students who conduct the interviews)

(Weak physical evidence, strong psychological evidence and strong historical evidence; medical evaluation 4 months after alleged torture)

Note: This case example is written specifically for a female role-player. All names included in the narrative are fictitious.

• Name: Mrs. Asha Ali Yousif
• Date Reporting to the Center: dd/mm/yyyy (today’s date)
• Date of Birth: dd/mm/yyyy (age 35)
• Age: 35 years-old
• Marital Status/Children: Married, widow, 13 year-old daughter
• Religion: Muslim
• Ethnic Group: Fur
• Profession: Teacher
• Political/Social Affiliation: None
• Date and Place of Detention/Assault: dd/mm/yyyy (4 months prior to the exam date) in a field 2 Km east of Kalma Camp; dd/mm/yyyy (2 days following the alleged assault) at Nyala Wasat (Central) police station.
• Period of Detention: Less than 2 hours on both occasions
• Trauma History: On dd/mm/yyyy (4 months prior to the exam date), at approximately 2:00pm, Mrs. Yousif, her 13 year-old daughter, and two other women were attacked by armed men in military uniforms whilst fetching firewood several miles from Kalma camp. They were all beaten and raped. One of the women, Fatima Ibrahim (22 yrs), was shot and killed while attempting to escape. Several days later, Mrs. Yousif reported the incident to police at Nyala Wasat (Central) Police Station. Police refused to file a case. One of the police officers, Omer Mohamed Suliman, beat and sexually assaulted her. She then went to Nyala Hospital, but was refused a medico-legal evaluation since she did not have Police Form 8 (medico-legal form for treatment of injuries caused by a criminal act), formerly a requirement under Sudanese Law. A friend in Kalma was worried about her and insisted that she get help. The friend also suggested that Mrs. Yousif and her daughter take legal action against their perpetrators.
• Alleged Perpetrators: Men in military uniform, also, police officer Omer Mohamed Suliman from Nyala Wasat (Central) Police Station.
• Reasons for visit: Mrs. Yousif indicated that she would like to get help for her daughter and herself, but she was not sure about taking legal action against their perpetrators.
• Effects of Torture: Insomnia, nightmares, inability to concentrate, profound sadness, frequent headaches and decreased appetite. She is also very troubled about her daughter’s health and future.

Case Narrative #01

(distribute to role-players only)

Note: This case example is written specifically for a female role-player. All names included in the narrative are fictitious.

Case Summary/Referral Information

• Name: Mrs. Asha Ali Yousif
• Date Reporting to the Center: dd/mm/yyyy (today’s date)
• Date of Birth: dd/mm/yyyy (age 35)
• Age: 35 years-old
• Marital Status/Children: Married, widow, 13 year-old daughter
• Religion: Muslim
• Ethnic Group: Fur
• Profession: Teacher
• Political/Social Affiliation: None
• Date and Place of Detention/Assault: dd/mm/yyyy (4 months prior to the exam date) in a field 2 Km east of Kalma Camp; dd/mm/yyyy (2 days following the alleged assault) at Nyala Wasat (Central) police station.
• Period of Detention: Less than 2 hours on both occasions
• Trauma History: On dd/mm/yyyy (4 months prior to the exam date), at approximately 2:00pm, Mrs. Yousif, her 13 year-old daughter, and two other women were attacked by armed men in military uniforms whilst fetching firewood several miles from Kalma camp. They were all beaten and raped. One of the women, Fatima Ibrahim (22 yrs), was shot and killed while attempting to escape. Several days later, Mrs. Yousif reported the incident to police at Nyala Wasat (Central) Police Station. Police refused to file a case. One of the police officers, Omer Mohamed Suliman, beat and sexually assaulted her. She then went to Nyala Hospital, but was refused a medico-legal evaluation since she did not have Police Form 8 (medico-legal form for treatment of injuries caused by a criminal act), formerly a requirement under Sudanese Law. A friend in Kalma was worried about her and insisted that she get help. The friend also suggested that Mrs. Yousif and her daughter take legal action against their perpetrators.
• Alleged Perpetrators: Men in military uniform, also, police officer Omer Mohamed Suliman from Nyala Wasat (Central) Police Station.
• Reasons for visit: Mrs. Yousif indicated that she would like to get help for her daughter and herself, but she was not sure about taking legal action against their perpetrators.
• Effects of Torture: Insomnia, nightmares, inability to concentrate, profound sadness, frequent headaches and decreased appetite. She is also very troubled about her daughter’s health and future.

Identification Information

My name is Asha Ali Yousif, and I am 35 years-old.

Additional Information:

• Date of Birth: dd/mm/yyyy (age 35)
• Citizenship: Sudanese
• Marital Status/Children: Married, widow, 13 year-old daughter
• Place of Birth: A village east of Nyala
• Place of Residence: Kalma IDP Camp, 17 Km. east of Nyala, southern Darfur state
• Highest Level of Education: completed high school
• Occupation: Former teacher, currently unemployed
• Religion: Muslim
• Identification Document Presented: None
• Ethnic Group: Darfurian, Fur Tribe
• Physician Examiner’s Name and License #: (To be filled out by the examining physician)
• Individuals Present in the Examination Room and Reason for Presence: (To be filled out by the examining physician)
• Language Spoken: Fur
• Name of Interpreter: None (To be filled out by the examining physician)
• Restrictions Noted: (To be filled out by the examining physician)
• Detainee Status: No (To be filled out by the examining physician)

Past Medical/Surgical History and Psychosocial History

Past Medical/Surgical History

Before my encounters with soldiers and police, I had no medical problems, no major illnesses or injury, no surgery, broken bones or head injury. I am not on any medications, except aspirin for headaches and pains in my body. I have never used any illegal drugs and I do not drink alcohol. I do not smoke either.

Psychosocial History

I never had any mental problems, nor has anyone in my family. I am the oldest of four children. Although my family was very poor, we were able survive with the money that my parents made working odd jobs. I was able to go to school and become a teacher. My husband was also a teacher, but he and my father were killed about a year ago, when the Sudanese Army and Janjaweed militia burned my village to the ground. After that, my daughter and I went to Kalma camp.

Prior Medical Evaluation

I went to Nyala Hospital after my daughter and I were attacked by soldiers, but the doctors refused to examine me because I did not have official papers from the police. On the same day, I visited a clinic in Kalma, and they gave me some aspirin for my headaches. I was planning to tell them about what happened to me, but I was too afraid after my experience with the police.

Trauma History

NOTE: Provide information in parentheses only if specifically asked by the interviewer.

About a year ago, the army and militia came to our village and burned it to the ground. They accused us of supporting the SLA and shot some of the men including my husband and father right in front of us. My daughter and I have been living in Kalma for about one year. Since I lost my husband, my home and my job, we don’t have enough to survive. Sometimes we cut grass in nearby fields to sell. We also have go outside the camp to wash our clothes and collect firewood. We know this is dangerous, but we do not have a choice. My daughter and I have been through a lot. When they burned our village to the ground, they threatened to rape the women. This happened to some of the women in our village, but we were lucky that day. Since then, I thought it was safer for my daughter and me to be together. Now I know this is not true.

On dd/mm/yyyy (4 months prior to the exam date), I went to fetch firewood with my daughter and two other women from Kalma. We had done this many times without any problems, but on that day, we were attacked by 10 men in military uniforms. They had guns and threatened to kill us if we tried to run away. They started insulting us, calling us slaves and saying that this land did not belong to us. I pleaded with them not to hurt my daughter, Salwa. One of them said: “Don’t worry she will soon be the mother of an Arab child.” Salwa was very frightened and began to cry. They slapped her and told her to take off her clothes, but she did not. I tried to wrap my arms around her to protect her, but they pulled her away from me. I was stuck [above my left eye] with the butt of a gun and fell to the ground They continued to punch and kick me. One of the other women, Fatima Ibrahim, who was also from our village, tried to run away, but they shot her in the back. She was not moving. One of the men walked over to her and shot her in the head. “This is what happens when you do not obey your masters,” he said. One of the men started raping me while several others threatened me with their guns. I could hear my daughter screaming, but could do nothing. After the third one had raped me, he spit on me and kicked me very hard on the right side of my face. Later I noticed it was very swollen [in front of my right ear] and I was unable to move the right side of my face [or close my right eye] for about 2 weeks. They said nothing else and left us there naked. My daughter was badly bruised on her face and there was blood running down her legs. I tried to reassure her, but we both just wept for a long time.

After 2 days, I decided to go to the police station in Nyala to make a complaint. I waited a long time and then was placed in a room with a police officer. His name was, Omer Mohamed Suliman. I told him what happened and he laughed. “I find this hard to believe,” he said. Who were the men that you say did this?” he asked. I told him that I did not know, but that they were in military uniforms. He refused to believe me and said: “You know nothing and have no witnesses. If you were raped, then show your injuries. His tone began to change and insisted I take off my clothes. He slapped my face and called me a liar. He grabbed me and started pulling off my clothes. He touched my breasts and between my legs. I yelled for help. He stopped when another police officer peered in through the door. After that, be began beating me with a hose on my back and arms. He said, “If you tell anyone, your daughter will find you dead.”

From the police station, I went to Nyala Hospital. I told the doctor what happened in the field. I was too afraid to tell him about what happened at the police station. He said there was nothing he could do, since I did not have official papers from the police requesting an examination.

A few days later, I visited a clinic in Kalma and they gave me some aspirin for my headaches and a bandage for the cuts I had above my left eye and on the back of my left hand. I was planning to tell them about what happened to me, but I was afraid to after my experience with the police.

Recently, a friend in Kalma insisted that my daughter and I get some help. She can see that we are very troubled. She also suggested we take legal action against those who hurt us.

Review of Torture Methods

The following history should be revealed only on further questioning, unless asked in the context of the trauma history:

• Sexual Assault:
  • Condoms were not used by any of the perpetrators.
  • No anal intercourse
  • No menstrual period for the past three months
  • [History of infibulation prior to marriage and reinfibulation after the birth of her child.]
• Head trauma: handgun butt to the left side of her face, just above the left eyebrow, no loss of consciousness. There was blood on my face and a cut above my left eyebrow. The area was very tender and swollen for about one to two weeks.
• Laceration injury to the dorsum (backside) of the left hand: I am not sure how or when this happened but I noticed that it had bled. The injury became infected, swollen and drained pus about a week later. I was treated as an outpatient with antibiotics. The doctors opened it and packed it with gauze. Eventually it healed.
• The review of torture methods is negative for the all other torture methods, physical and psychological.

Physical Symptoms (Acute and Chronic) and Disabilities

Acute Symptoms

• Blood in the urine for about 3 days following the incident, then it resolved completely. No vaginal discharge, no menstrual period since the assault.
• Unable to move the right side of my face [or close my right eye] for about 2 weeks.
• Observed bruises where beaten, black and blue marks that resolve after about 2 weeks. [IF ASKED, RESPOND: Some of the bruises on the back and chest were long in shape, like the hose that was used to beat her. Each of the bruises had two parallel lines about 1-2 cm wide and a clear area in the middle of the lines.]

Chronic Symptoms

• Chronic headaches [IF ASKED, RESPOND: in the front of the head, throbbing, lasts a few hours, once to a few times per day, improved with acetaminophen, similar headaches in the past with stress, but only occasionally.]
• Difficulty concentrating and irritable
• Having problems sleeping (see psychological evaluation below)

Disabilities

• None noted

Psychological Evaluation and Mental Status

Mental Status

Mrs. Yousif was appropriately dressed and groomed and looked her stated age. She was alert, fully oriented, pleasant and cooperative throughout the evaluation. There were no gross abnormalities in movement or posture on observation. She appeared to possess average intellectual ability, with good insight and judgment. Her speech was clear and fluent. There was no evidence of delusions, hallucinations or psychotic thought processes. Memory was intact. Attention and concentration appeared intact. Her mood and affect conveyed a watchfulness and some apprehension, and were congruent, but she was open enough to be able to describe her experiences willingly. At times, she wept when she was discussing emotionally painful aspects of her experience. There was no evidence of suicidal or homicidal ideation.

Psychological Findings

1. Symptoms of Post-traumatic Stress Disorder:
   • Persistent Re-experiencing of Traumatic Events and Avoidance Behaviour: Mrs. Yousif reported frequent nightmares from which she awakens in a sweat with her heart pounding. The nightmares usually refer to a grave threat to herself and her daughter. The content of her dreams includes trauma-related material to varying degrees but usually not precise repetitions of actual events. For example, the night prior to the examination she dreamt that thieves had entered her domicile carrying knives, beating her with sticks, and threatened her and her daughter. She awakens from her nightmares gripped with fear and finds it difficult to fall asleep again. She often experiences intrusive recollections of the sexual assault that she experienced. Mrs. Yousif indicated that she has a profound sense of guilt over what happened to her daughter and is often preoccupied with thoughts of what she should have done differently. Sometimes when she sees police or security forces, she feels anxious and starts thinking about what happened to them. She tries to avoid intrusive recollections through prayer. Also, she avoids talking to her daughter and others about what happened to them as it often precipitates recollections of her abuse and makes it difficult to fall asleep.
   • Persistent Symptoms of Increased Arousal: As mentioned above, Mrs. Yousif suffers from difficulties falling asleep and from poor sleep throughout the night, often waking up hourly throughout the night. In the morning, she often feels exhausted. She also startles easily, feeling very jumpy in response to any kind of sudden noise. She indicated that: “Sometimes when I am in a room like this, I feel that someone may just storm in.” She feels that her concentration is impaired since being raped. For example, she used to like to read and talk to friends, but now has difficulty following conversations and reading. Often she forgets that she has already taken her headache medicine and subsequently takes a second dose. She misplaces things and sometimes takes days to find them. She is no longer good with directions and indicated that she cannot find her way even after a second time. “I have trouble following what is said in conversation and forget names of people I know, or what I had eaten the previous night,” she said. She sometimes feels irritable and has outbursts of anger without a clear reason. Her daughter has been unable to speak since the rapes; she spends hours alone staring straight ahead and she seems to be unaware of her surroundings. Mrs. Yousif is worried that her daughter is losing her mind. She tries to coax her daughter to eat and talk with her and she tries hard to keep her own despair secret in order to reassure her daughter. Nevertheless, Mrs. Yuosif finds that she has outbursts of anger and crying that she cannot prevent. Somatic Complaints: Mrs. Yousif suffers from frequent headaches that respond well to aspirin.
2. Major Depression: Mrs. Yousif demonstrated symptoms of major depression, including depressed mood, diminished interest or pleasure in activities, decreased appetite resulting in weight loss [IF ASKED, RESPOND: about 4 Kilos], insomnia, fatigue and loss of energy, frequent crying and difficulty concentrating. She denied suicidal ideation and suicide attempts. Mrs. Yousif explained that her sadness stems largely from her inability to protect her daughter and what this means for her future. Though she wants justice for what has been done to them, she is afraid to take legal action.  In the days after she had been raped, she spent hours bathing herself to cleanse herself of the shame she felt. Mrs. Yousif blames herself for what happened. She regrets not insisting that her daughter stay in the camp. She also expressed considerable anger over the camp-related security issues. She asked, “Why do we have to go where it is dangerous to get what we need?”

Physical Examination

(All photos taken on the day of examination)

NOTE: Images of “virtual physical examination” findings will be presented in a separate room using PPT slides.

• Slide #1: Note 1 cm hyperpigmented, linear scar above left eyebrow consistent with an old laceration injury.
• Slide #2: Note complex, atrophic scar, approximately 4 x 6 cm over the dorsum of the left hand associated with hypopigmentation and subcutaneous fibrosis.

Interpretation and Conclusion

Per trainee’s assessment

Case Summary/Referral #01 (distribute to students who conduct the interviews) (Weak physical evidence, strong psychological evidence and strong historical evidence; medical evaluation 4 months after alleged torture) Note: This case example is written specifically for a female role-player. All names … Continue reading →

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Download Module 7: Case Example #01 (PowerPoint Presentation) (ppt)

1. Which of the following do you consider to be important considerations before interviewing Mrs. Asha Ali Yousif?
   1. A safe and comfortable location
   2. Privacy during the interview
   3. Understanding that she must answer all of the questions asked
   4. Understanding that she can take breaks if she wishes
   5. All of the above
2. Which of the following must be addressed before beginning all interviews?
   1. Making sure that refreshments are available
   2. Obtaining informed consent
   3. Explaining the benefits and risks of the medical evaluation
   4. Ensuring that the translator and alleged victim are the same gender
3. Who would you consider to be the most appropriate translator for your interview with Mrs. Yousif?
   1. Mrs. Yousif’s daughter
   2. A male village elder
   3. A stranger in Kalma Camp
   4. A stranger from outside Kalma Camp
4. In the process of eliciting the trauma history from Mrs. Yousif, which of the following interviewing techniques do you think is most appropriate?
   1. Asking simple questions that require brief answers to ensure a coherent and reproducible narrative
   2. Asking questions about the most significant alleged trauma first
   3. Asking open-ended questions and minimize interruptions
   4. The evaluator should use whatever interviewing technique that he or she is most comfortable with
5. What psychosocial information elicited from Mrs. Yousif’s is most likely to contribute to her to her psychological symptoms?
   1. The killing of her husband and burning of her home and village
   2. That she was poor
   3. Her occupation as a teacher
   4. That she had no prior history of mental problems
6. Mrs. Yousif’s feelings of guilt are most likely related to?
   1. Not being able to support her family
   2. Failing to fight off her attackers
   3. Failing to protect her daughter’s sexual assault
   4. Exposing herself to further abuse by reporting the torture to the police
7. In Mrs, Yousif’s case, which of the following factors may interfere with an accurate recounting of past events:
   1. Blindfolding
   2. Disorientation
   3. Lapses in consciousness
   4. Organic brain damage
   5. Psychological sequelae of abuse
   6. Fear of placing oneself or others at risk
   7. Lack of trust in the examining clinician
8. It is important to document what the perpetrators reportedly said during the alleged abuse as it may help to establish the intent of their actions and provide insight into the meaning an individual assigns to his or her experience.
   1. True
   2. False
9. If during the course of interviewing an alleged torture victim the individual acknowledges that he or she was sexually assaulted and does not feel comfortable discussing this further, which of the following would you consider appropriate?
   1. Move on with the interview
   2. Explain how common sexual assault is among torture survivors (women and men)
   3. Acknowledge relevant norms of social stigma associated sexual assault
   4. Offer to limit reporting of sexual assault information according to the alleged victim’s wishes, i.e. only to the judge
   5. All of the above
10. Which of the following questions should you consider to indirectly assess allegations of sexual assault?
    1. What was said by the alleged perpetrators
    2. Removal of clothing of the alleged victim and perpetrator(s)
    3. Duration of the encounter/assault
    4. The use of weapons
    5. Any form of physical contact or touching
    6. Subsequent vaginal pain or bleeding
    7. The possibility of pregnancy or a sexually transmitted disease
    8. All of the Above
11. Which of the following would you consider to be highly consistent with Mrs. Yousif’s allegations of torture?
    1. History of a right-sided facial droop after being kicked on the right side of her face
    2. Chronic headaches relieved by aspirin
    3. Bruises shaped in parallel lines, but clear in the middle of the lines
    4. No menstrual period since the assault
    5. All of the above
12. If you examined Mrs. Yousif when she visited Nyala Hospital for medical care, what should have been done ideally?
    1. Conduct a thorough physical examination with particular attention to cutaneous lesions that could have resulted from an assault
    2. Conduct a pelvic examination and document any evidence of sexual assault
    3. Discuss the issues of pregnancy and emergency contraception
    4. Assess for sexually transmitted diseases (i.e. gonorrhoea, chlamydia, syphilis and trichomoniasis, Hepatitis B and HIV) and consider post-exposure prophylaxis
    5. Obtain wet vaginal swabs and dry them for subsequent DNA analysis
    6. All of the above
13. Does Mrs. Yousif meet diagnostic criteria for PTSD?
    1. Yes
    2. No
14. The presence of diagnostic criteria for PTSD has greater value for the adjudication of legal cases than understanding the meaning that individuals attach to experiences of torture and ill treatment.
    1. True
    2. False
15. Which of the following factors may contribute to Mrs. Yousif’s psychological symptoms?
    1. Home and village burned
    2. Husband and father killed in front of her
    3. Difficulty surviving in Kalma Camp
    4. Rape of her daughter
    5. All of the above
16. Which of the following can help to distinguish Mrs. Yousif psychological symptoms caused by sexual assault experiences versus other traumatic experiences or losses?
    1. The onset and trend in her psychological symptoms
    2. The content of her nightmares and intrusive recollections
    3. Triggers for intrusive recollection, reliving experiences, and avoidance reactions
    4. Feeling responsible for her daughter’s rape
    5. All of the above
17. Mrs. Yousif should have a pelvic examination at the time of your evaluation to assess possible physical evidence of rape, even though the likelihood of such evidence decreases considerably after the first week of the assault.
    1. True
    2. False
18. Symptoms of sexual dysfunction following rape may be physical or psychological in origin or a combination of both and include:
    1. Aversion to members of the opposite sex or decreased interest in sexual activity
    2. Inability to trust a sexual partner
    3. Disturbance in sexual arousal and erectile dysfunction
    4. 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
    5. All of the above
19. On physical examination (see PPT Module 7, Slides 16-18) Mrs. Yousif is noted to have: 1) a 1 cm hyperpigmented, linear scar above the left eyebrow; and 2) a complex, atrophic scar, approximately 4 x 6 cm over the dorsum of the left hand associated with hypopigmentation and subcutaneous fibrosis. How would you describe the level of consistency between, Mrs. Yousif’s allegations of abuse and these physical examination findings?
    1. Not consistent
    2. Consistent with
    3. Highly consistent with
    4. Virtually diagnostic of
20. How would you describe the level of consistency between, Mrs. Yousif’s allegations of abuse and psychological evaluation findings?
    1. Not consistent
    2. Consistent with
    3. Highly consistent with
    4. Virtually diagnostic of

Which of the following do you consider to be important considerations before interviewing Mrs. Asha Ali Yousif? A safe and comfortable location Privacy during the interview Understanding that she must answer all of the questions asked Understanding that she can … Continue reading →