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Istanbul Protocol Model Medical Curriculum
Educational Resources for Health Professional Students
Effective medical investigation and documentation of torture and ill-treatment require clinicians to have a detailed understanding of torture methods and their physical and psychological sequelae. This Module provides a review of common torture methods and their medical consequences. It is important to keep in mind that it is difficult to separate physical from psychological torture, as each has a component of the other; for example, hooding not only impedes normal breathing, but also produces disorientation and fear. In addition, physical forms of torture and ill treatment will generally produce both physical and psychological sequelae, and psychological forms of torture and ill-treatment often result in psychological sequelae, but may also produce physical sequelae as well.
The methods of torture and ill-treatment included in this module are not exhaustive. The actual methods that a survivor experiences are only limited by the imagination and cruelty of his or her torturers. As mentioned in Module 1, it is important to realize that, although there is much similarity of torture methods around the world, there can be regional and country-specific variations. Instructors and students who use this Model Curriculum should be aware of regional, country-specific, and local practises and adapt them to the Model Curriculum materials accordingly with relable and current human rights reports.
Although physical torture as practised around the world has many features in common, almost invariably including beating, slapping and kicking, more sophisticated techniques have been developed in many areas. In countries whose authorities wish to disguise the fact that torture takes place, methods are devised, sometimes with the help of doctors, that produce maximum pain with minimum external evidence. This must be recognised by the examiner if the after-effects of these techniques are not to be missed, especially after the passage of time. Documentation of special methods of torture alleged by an individual requires that the examiner has a detailed knowledge of torture techniques used in the country where the torture was alleged to have taken place. With this knowledge the interviewer can take an informed and detailed history (taking care to avoid using leading questions). This helps to give a precise picture of such details of torture as the victim’s posture, clothing, blindfolding or hooding, the implements used, duration of assault and his or her condition at the end of the session – whether he or she could walk or whether there were any bleeding wounds. It cannot be emphasised too strongly that such a detailed history is essential to ensure that, during the subsequent physical examination, signs in the relevant areas of the body are not missed and that a correct differentiation from accidental or self-inflicted injury is made. For this reason it is necessary to review, at length, some of the techniques employed in different countries before outlining the symptoms and signs to be expected during history-taking and physical examination. Of particular value in assessing the severity of the attack is a history of loss of consciousness, though this should be elaborated by questions aimed at finding out whether unconsciousness was caused by blows to the head, asphyxiation, unbearable pain or exhaustion.
As discussed in Module 3, survivors may be unable to describe exactly what happened to them because they may have been blindfolded, lost consciousness, sustained head injury, or have difficulty recalling or revealing the especially traumatic components of their experience. It is important to realize that torturers often attempt to conceal their deeds. For example, physical evidence of beating may be limited when a wide, blunt objects are used for beatings. Similarly, victims are sometimes covered by a rug, or shoes in the case of falaka, to distribute the force of individual blows. For the same reason, wet towels may be used with electric shocks. In other cases, torturers use methods with the intent of producing maximal pain and suffering with minimal evidence, for example, forced positioning, near asphyxiation, mock executions, temperature manipulation, sensory deprivation, prolonged isolation, threats of harm to the individual and his or her family, and sexual humiliations, among many others.
It is important to understand that some methods on their own may amount to torture; in other cases significance is attached to the use of a combination of methods, which may collectively amount to torture. Also, the length of time over which the individual is subjected to the methods may be decisive. Again, for this reason, it is important to document as accurately and completely as possible all the events to which an individual was exposed and their consequences.
It is important to keep in mind that, when assessing the degree of suffering involved, one should take into account the identity and background of the alleged victim. For example, certain situations that might be relatively bearable for some people could be degrading and humiliating to those of a particular gender, culture or religious faith. Torture and other ill-treatment can also often go hand-in-hand with discrimination, based on race, religion, gender or other factors, which may exacerbate the distress. In addition, physical and mental suffering can differ amongst categories of victims, for example some tortures may exacerbate pre-existing health problems, and children may experience a higher degree of suffering than adults undergoing similar ill-treatment. All these factors should be taken into account in documenting the alleged victim’s experience.
Effective medical investigation and documentation of torture and ill-treatment require clinicians to have a detailed understanding of torture methods and their physical and psychological sequelae. This Module provides a review of common torture methods and their medical consequences. It is … Continue reading
Toolkit: Istanbul Protocol Model Medical Curriculum
Subject: Module 4: Torture Methods and their Medical Consequences
Subject: Module 4: Torture Methods and their Medical Consequences
Psychological evaluations can provide critical evidence of abuse among torture victims. It has a central role in the medical investigation and documentation of torture allegations. All medical investigations and documentation of torture should include a detailed psychological evaluation because:
- One of the main aims of torture is to destroy the psychological, social integrity and functioning of the victim.
Perpetrators often attempt to justify their acts of torture and ill-treatment by the need to gather information. Such conceptualisations obscure the purpose of torture and its intended consequences. One of the central aims of torture is to reduce an individual to a position of extreme helplessness and distress that can lead to a deterioration of cognitive, emotional and behavioural functions. Torture is a means of attacking the individual’s fundamental modes of psychological and social functioning. The torturer strives not only to incapacitate a victim physically, but also to disintegrate the individual’s personality: The torturer attempts to destroy a victim’s sense of being grounded in a family and society as a human being with dreams, hopes and aspirations for the future.— (IP, §235)
Internationally accepted definitions of torture acknowledge that provoking mental suffering is often the intention of the torturer.
- All kinds of torture inevitably comprise psychological processes.
- Torture often causes psychological/psychiatric symptoms at various levels.
- Torture methods are often designed not to leave physical lesions, and physical methods of torture may result in physical findings that either disappear quickly or lack specificity.
The improvement in the methods of detecting and providing evidence of physical torture has paradoxically led to more sophisticated methods of torture that do not to leave visible evidence on the victim’s body. Most physical symptoms and signs of torture, if there are any, rapidly disappear.
It is important to realise that torturers may attempt to conceal their acts. To avoid physical evidence of torture, precautions are taken with the intention of producing maximal pain and suffering with minimal evidence. Especially under conditions of raised awareness in society, torture applied with these precautions and sophisticated methods may leave almost no physical signs.
Torturers know that by not leaving permanent physical scars, they help their cause and make the work of their counterparts in the human rights arena more difficult. For this reason, in the Istanbul Protocol it is underscored that, “the absence of such physical evidence should not be construed to suggest that torture did not occur.”
- Psychological symptoms are often more prevalent and long-lasting than physical symptoms.
Contrary to the physical effects of torture, the psychological consequences of torture are often more persistent and troublesome than physical disability. Several aspects of psychological functioning may continue to be impaired long-term. If not treated, victims may still suffer from the psychological consequences of torture even months or years following the event, sometimes for life, with varying degrees of severity.
Psychological evaluations can provide critical evidence of abuse among torture victims. It has a central role in the medical investigation and documentation of torture allegations. All medical investigations and documentation of torture should include a detailed psychological evaluation because: One … Continue reading
The Manual on Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, commonly known as the Istanbul Protocol, outlines international, legal standards on protection against torture and sets out specific guidelines on how effective legal and medical investigations into allegations of torture should be conducted.
The Istanbul Protocol is an important source as it both reflects existing obligations of States under international treaty and customary international law and aids States to effectively implement relevant standards. It became a United Nations official document in 1999. The Istanbul Protocol is intended to serve as a set of international guidelines for the assessment of persons who allege torture and ill-treatment, for investigating cases of alleged torture, and for reporting such findings to the judiciary and any other investigative body. The investigation and documentation guidelines also apply to other contexts, including human rights investigations and monitoring, assessment of individuals seeking political asylum, the defence of individuals who “confess” to crimes during torture, and assessment of needs for the care of survivors of torture. In the case of health professionals who are coerced to neglect, misrepresent, or falsify evidence of torture, the manual also provides an international point of reference for health professionals and adjudicators alike.
The documentation guidelines apply to individuals who allege torture and ill-treatment, whether the individuals are in detention, applying for political asylum, refugees or internally displaced persons, or the subject of general human rights investigations. The guidelines provided cover a range of topics including:
- Relevant international legal standards
- Relevant Ethical Codes
- Legal Investigation of Torture
- General Considerations for Interviews
- Physical Evidence of Torture
- Psychological Evidence of Torture
Many procedures for a torture investigation are included in the manual, such as how to interview the alleged victim and other witnesses, selection of the investigator, safety of witnesses, how to collect alleged perpetrator’s statement, how to secure and obtain physical evidence, and detailed guidelines on how to establish a special independent commission of inquiry to investigate alleged torture and ill-treatment. The manual also includes comprehensive guidelines for clinical examinations to detect physical and psychological evidence of torture and ill-treatment.
The Istanbul Protocol also outlines minimum standards for state adherence to ensure the effective documentation of torture in its Principles on the Effective Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, or “Istanbul Principles” The guidelines contained in the Istanbul Protocol are not designed to be fixed, rather, they represent an elaboration of the minimum standards contained in the Istanbul Principles and should be applied in accordance with a reasonable assessment of available resources.
The Istanbul Protocol is a non-binding document. However, international law obliges governments to investigate and document incidents of torture and other forms of ill-treatment and to punish those responsible in a comprehensive, effective, prompt and impartial manner. The Istanbul Protocol is a tool for doing this.
The Manual on Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, commonly known as the Istanbul Protocol, outlines international, legal standards on protection against torture and sets out specific guidelines on how effective … Continue reading
Medical documentation may be critical to legal investigations of torture through the following means:
- Producing a contemporaneous record (a record as close in time as possible to the event) of signs and symptoms of ill-treatment when an individual presents to any health professional for treatment after the event – the examining health professional may not be called upon to produce a report, but in the future an expert may be asked to use this record to form an opinion of events at the time
- Providing detailed understanding of the case so that the person can be referred for the appropriate treatment and rehabilitation in a specialised centre or by other specialists
- The production of a medico-legal report for submission to a judicial or administrative body:
- for judicial enquiries or court cases aimed at the prosecution of perpetrators
- for a judicial process which decides on the responsibility of the state
- for a judicial process which decides upon compensation/reparations for survivors
- in individual cases where a medico-legal report may be used as part of a court application to end on-going abuse while the person is still in detention
- for the case of asylum seekers when medical evidence may be used as part of the evidence (e.g. in hearings) to show a history of ill-treatment in another country and the physical and psychological consequences thereof.
- The documentation of patterns of widespread abuse. Courts, NGOs, and inter-governmental mechanisms, can all have need for knowledge of the existence of widespread abuse. Assessment of the prevalence of torture and other ill-treatment, relies upon well-documented individual allegations
- The production of supporting material during visits to places of detention. Medical documentation may not necessarily lead to the production of a medico-legal report on specific cases, but the medical findings can be used more generally to support allegations of conditions and treatment amounting to torture or other ill-treatment.
Medical documentation may be critical to legal investigations of torture through the following means: Producing a contemporaneous record (a record as close in time as possible to the event) of signs and symptoms of ill-treatment when an individual presents to … Continue reading
Psychological evaluations may take place in a variety of settings and contexts; as a result, there are important differences in the manner in which evaluations should be conducted and how symptoms will be interpreted. For example, whether or not certain sensitive questions can be asked safely will depend on the degree to which confidentiality and security can be assured. An evaluation by a clinician visiting a prison or detention centre may be very brief and not allow for as detailed an evaluation as one performed in a clinic or private office that may take place over several sessions and last for several hours. At times some symptoms and behaviours typically viewed as pathological may be viewed as adaptive or predictable, depending on the context. For example, diminished interest in activities, feelings of detachment and estrangement would be understandable findings in a person in solitary confinement. Likewise, hypervigilance and avoidance behaviours may be necessary for those living under threat in repressive societies.
The clinician should attempt to understand mental suffering in the context of the survivor’s circumstances, beliefs, and cultural norms rather than rush to diagnose and classify. Awareness of culture specific syndromes and native language-bound idioms of distress is of paramount importance for conducting the interview and formulating the clinical impression and conclusion. When the interviewer has little or no knowledge about the alleged victim’s language and culture, the assistance of an interpreter is essential. An interpreter from the alleged victim’s country of origin will facilitate an understanding of the language, customs, religious traditions, and other beliefs that will need to be considered during the evaluation.
Clinicians should be aware of the potential emotional reactions that evaluations may elicit in survivors (see Transference and Counter-transference   in Module 3). Fear, shame, rage and guilt are typical reactions. A clinical interview may induce mistrust on the part of the torture survivor and possibly remind him or her of previous interrogations thereby “re-traumatizing” him or her. To reduce the effects of re-traumatisation, the clinician should communicate a sense of empathy and understanding. A torture survivor may suspect the clinician of having voyeuristic and sadistic motivations or may have prejudices towards the clinician because he/she hasn’t been tortured. The clinician is a person in a position of authority and, for that reason, may not be trusted with certain aspects of the trauma history. Alternatively, individuals still in custody may be too trusting in situations where the clinician cannot guarantee that there will be no reprisals for speaking about torture. Torture victims may fear that information that is revealed in the context of an evaluation cannot be safely kept from being accessed by persecuting governments. Fear and mistrust may be particularly strong in cases where physicians or other health workers were participants in the torture. In the context of evaluations conducted for legal purposes, the necessary attention to details and the precise questioning about history is easily perceived as a sign of doubt on the part of the examiner. Under these pressures, survivors may feel overwhelmed with memories and affect or mobilize strong defences such as withdrawal, affective flattening or numbing during evaluations.
As mentioned in Module 3 , if the gender of the clinician and the torturer is the same, the interview situation may be perceived as resembling the torture more than if the genders were different. For example, a woman who was raped and tortured in prison by a male guard is likely to experience more distress, mistrust, and fear when facing a male clinician than she might experience with a female. On the other hand, it may be much more important to the survivor that the interviewer is a physician regardless of gender so as to ask specific medical questions about possible pregnancy, ability to conceive later, and future of sexual relations between spouses.
When listening to individuals speak of their torture, clinicians should expect to have personal reactions and emotional responses themselves (see Transference and Counter-transference   in Module 3). Understanding these personal reactions is crucial because they can have an impact on one’s ability to evaluate and address the physical and psychological consequences of torture. Reactions may include avoidance and defensive indifference in reaction to being exposed to disturbing material, disillusionment, helplessness, hopelessness that may lead to symptoms of depression or “vicarious traumatisation,” grandiosity or feeling that one is the last hope for the survivor’s recovery and well-being, feelings of insecurity in one’s professional skills in the face of extreme suffering, guilt over not sharing the torture survivor’s experience, or even anger when the clinician experiences doubt about the truth of the alleged torture history and the individual stands to benefit from an evaluation.
Psychological evaluations may take place in a variety of settings and contexts; as a result, there are important differences in the manner in which evaluations should be conducted and how symptoms will be interpreted. For example, whether or not certain … Continue reading
- Answer: A, B, D
Torture as defined by CAT, involves the intentional infliction of severe mental or physical pain or suffering, by or with the consent or acquiescence of the state authorities, for a specific purpose, such as gaining information, punishment or intimidation or for any other reason. It does not include pain or suffering arising only from, inherent in or incidental to lawful sanctions.
- Answer: B, C, D
Ill-treatment does not have to be inflicted for a specific purpose, but there does have to be an intent to expose individuals to the conditions which amount to or result in the ill-treatment. Like torture, ill-treatment is perpetrated by or with the consent or acquiescence of the state authorities.
- Answer: C
Amnesty International documented cases of torture and other cruel, inhuman or degrading treatment in 81 countries in 2007.
- Answer: B
Torture has been practiced throughout history, but universal prohibition against torture was codified in international law only in the aftermath of WWII in 1948. The UN Convention on Torture Against Torture was adopted by the UN General Assembly considerably later in 1984.
- Answer: E
Torture commonly serves the purpose of suppressing and punishing political opponents and alleged criminals and to achieve social control by inducing a sense of terror in a population, but it is also frequently used in interrogations to force confessions. Moreover, torture can occur where there is no obvious purpose.
- Answer: D
The prohibition of torture and ill-treatment is absolute; such acts cannot be justified under any circumstances including, national security, states of emergency, the need to counter terrorism, or following orders from one’s superiors.
- Answer: B
Non-refoulment in the Convention against Torture refers to the forcible return or extradition of a person to another country where he or she is at risk of torture.
- Answer: True
States are responsible for safeguarding the rights of everyone within their jurisdiction and may under some circumstances be held accountable for acts carried out by private individuals if it supports or tolerates them, or fails in other ways to provide effective protection in law and in practice against them.
- Answer: True
Torture and ill treatment are often perpetrated in the process of criminal investigations in order to obtain false confessions to alleged crimes and in the context of claims of national security.
- Answer: False
The prohibition of torture is not limited to a negative obligation to refrain from causing suffering, but also contains wider obligations: including the obligation to investigate allegations, even if there has not been a formal complaint about it, and to bring the perpetrators to justice. The UN Convention Against Torture states clearly in article 12: “Each State Party shall ensure that its competent authorities proceed to a prompt and impartial investigation, wherever there is reasonable ground to believe that an act of torture has been committed in any territory under its jurisdiction.”
- Answer: D
The ICRC’s findings are communicated and discussed on a confidential basis with the concerned authorities and are not made available to the public. The ICRC undertakes visits under nonnegotiable modalities which include: access to all places of detention and all people detained and to make a register of all those who wish to have their details recorded; the possibility to select individual detainees to talk with in private, and the possibility to repeat the visits as often as is deemed necessary. During visits, the ICRC takes the humane treatment of detainees to encompass not only freedom from torture and other ill-treatment, but also general conditions of detention that maintain both the physical and mental integrity of the individuals.
- Answer: False
The prohibition of torture is the concern not only of those countries which have ratified particular treaties, but is also a rule of general or customary international law, which binds all states even in the absence of treaty ratification. In fact, the prohibition of torture is generally regarded as having the special status of a ‘peremptory norm’ of international law, and states cannot choose to disregard or derogate from it.
- Answer: True
The Convention Against Torture (Article 14) indicates that victims of torture have a right to redress and adequate compensation.
- Answer: E
People are particularly at risk when they are deprived of their liberty, held in pre-trial detention or subject to interrogation. The greatest risk is in the first phase of arrest and detention, before the person has access to a lawyer or court. People being held in incommunicado detention – without access to anyone in the outside world – are particularly vulnerable.
- Answer: True
Optional Protocol to the UN Convention Against Torture established a complementary dual system of regular visits by independent international and national bodies to places of detention in order to prevent torture and ill-treatment.
- Answer: E
The Human Rights Committee has stated that the protection of detainees requires that each person detained be afforded prompt and regular access to doctors. The Body of Principles for the Protection of All Persons under Any Form of Detention or Imprisonment state that ‘a proper medical examination shall be offered to a detained or imprisoned person as promptly as possible after his admission to the place of detention or imprisonment, and thereafter medical care and treatment shall be provided whenever necessary. This care and treatment shall be provided free of charge. Detainees have the right to request a second medical opinion by a doctor of their choice, and to have access to their medical records.
- Answer: True
Rule 22(2) of the UN Standard Minimum Rules for the Treatment of Prisoners states that detainees or prisoners needing special treatment must be transferred to specialised institutions or civil hospitals for that treatment.
- Answer: E
All of the measures listed above are important in the prevention of torture and ill treatment. Additional prevention measures include non-refoulement or no transfer to a country where torture is likely, providing detainees access to family members and friends, and the training of state officials, including medical personnel, on torture prohibition.
- Answer: A, C, D
Effective investigation of alleged torture and ill treatment and criminal prosecution of alleged perpetrators are essential for accountability. Adequate victim and witness protection is a critical component of such prosecutions. Allowing torture to be prosecuted as a lesser crime such as “abuse of police duty” would likely have a permissive effect on torture and ill treatment practices.
- Answer: False
All detained people have the right to equal treatment without discrimination on the grounds of race, colour, sex, sexual orientation, language, religion, political or other opinion, national or social origin, property, birth or other status. Particular allowances should, however, be made for the rights and needs of special categories of detainees including women, juveniles, elderly people, foreigners, ethnic minorities, people with different sexual orientation, people who are sick, people with mental health problems or learning disabilities, and other groups or individuals who may be particularly vulnerable during detention.
Answer: A, B, D Torture as defined by CAT, involves the intentional infliction of severe mental or physical pain or suffering, by or with the consent or acquiescence of the state authorities, for a specific purpose, such as gaining information, … Continue reading
Toolkit: Istanbul Protocol Model Medical Curriculum
Subject: Module 1: International Legal Standards (Overview)
Subject: Module 1: International Legal Standards (Overview)
Consisting of 9 Modules (see Summary of Content below). The Modules serve as the overall knowledge base for the Model Curriculum.
Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment
PowerPoint (PPT) Presentations
There is a PPT Presentation to accompany each of the 9 Modules. The Presentations were designed primarily for instructors who prefer to use a lecture format. The content of the PPT presentations closely parallels that of the Modules.
Case Examples #01 and #02
Two case examples have been incorporated into Modules 7 and 8. They are designed to give students practical experience interviewing alleged victims of torture and documenting physical and psychological evidence. The medical evaluations that students develop from these case examples should be applied to Mock Court Proceedings in Module 9.
Psychological Evaluations 1 and 2
Two Psychological Evaluations are included in Module 6 to provide students with an opportunity to develop clinical impression from information contained in actual asylum cases.
For each Module, there is a related Self-Assessment that is designed specifically for individual student users to assess their knowledge of curriculum content. The Self-Assessments may be applied to other teaching formats as well.
In Module 3, students will listen to an audiotape of an interview with a torture survivor, Sr Diana Ortiz, to better understand the challenges of interviewing survivors, particularly the emotional reactions of survivors and clinicians.
Model Curriculum Consisting of 9 Modules (see Summary of Content below). The Modules serve as the overall knowledge base for the Model Curriculum. Istanbul Protocol Model Medical Curriculum (pdf) Istanbul Protocol Manual on the Effective Investigation and Documentation of Torture … Continue reading
Clinicians should carefully consider the context in which they are working, take necessary precautions and provide safeguards accordingly. If interviewing people who are still imprisoned or in similar situations in which reprisals are possible, all precautions should be taken to ensure that they do not place the detainee in danger (or in additional difficulty). Promises must not be made, for example, to provide security for the witness or for relatives who might be at risk, unless the interviewer is certain that they can be fulfilled. Witnesses might believe that international organisations or others investigating allegations of torture have more power to protect them than is the case. It is part of the informed consent process that individuals are aware of all the issues before they agree for a clinician to make a formal report. If the risk of harm from reprisals is a virtual certainty, conducting a medical evaluation may be considered unethical even if informed consent is obtained. This may be the case in the context of documenting human rights violations in places of ongoing conflict.
Whether or not certain questions can be asked safely will vary considerably and depends on the degree to which confidentiality and security can be ensured. When necessary, questions about forbidden activities should be avoided.
If the forensic medical examination supports allegations of torture, the detainee should not be returned to the place of detention, but rather should appear before the prosecutor or judge to determine the detainee’s legal disposition (see Procedural Safeguards below).
An interviewer will make notes of the interview, and may use other recording devices. The reasons for this should be explained to the interviewee who should be reassured as to how the notes and other records will be used and asked for consent. The way in which any records of such interviews are stored can be important in protecting the security of the interviewer and the interviewee. In many countries where torture is prevalent, the police have been known to raid clinics and search or confiscate medical records. In order to protect patients, therefore, in such conditions records should have no obvious identifying information on any document inside (such as initials or date of birth), and the files themselves being numbered with a register kept in a secure place elsewhere. Patients can be given cards with the identifying number so that treatment can be continued even if the register is not available. In some circumstances it may be necessary to hold records at a different location or even in a third country to ensure their security.
If information about an individual needs to be transmitted to another body, fax transmission is generally safer than e-mail as a copy of the latter may be stored on the sending computer or held on the server of the internet service provider. In some countries the authorities routinely screen all outgoing messages.
Clinicians should carefully consider the context in which they are working, take necessary precautions and provide safeguards accordingly. If interviewing people who are still imprisoned or in similar situations in which reprisals are possible, all precautions should be taken to … Continue reading