Istanbul Protocol Model Medical Curriculum

Educational Resources for Health Professional Students

Introduction

Torture can affect a child directly or indirectly. The impact can be due to the child having been tortured or detained, the torture of his/her parents or close family member or the witnessing of torture and violence. When individuals in a child’s environment are tortured, the torture will inevitably have an impact on the child, albeit indirectly, because torture affects the entire family and community of torture victims. A thorough discussion of the psychological impact of torture on children and complete guidelines for conducting an evaluation of a child who has been tortured is beyond the scope of this Manual. Nevertheless, several important points can be summarised.

First, when evaluating a child who is suspected of having undergone or witnessed torture, the clinician must make sure that the child receives support from caring individuals and that he/she feels secure during the evaluation. This may require a parent or trusted care provider to be present during the evaluation. Second, the clinician must keep in mind that children often do not express their thoughts and emotions regarding trauma verbally, but rather behaviourally. The degree to which a child is able to verbalize thought and affect depends on his/her age and developmental level as well as on other factors, such as family dynamics, personality characteristics and cultural norms.

If a child has been physically or sexually assaulted, it is important, if at all possible, for the child to be seen by an expert in child abuse. Genital examination of children, likely to be experienced as traumatic, should be performed by clinicians experienced in interpreting the findings. Sometimes it is appropriate to videotape the examination so that other experts can give opinions on the physical findings without the child having to be examined again. It may not be appropriate to perform a full genital or anal examination without a general anaesthetic. Furthermore, the examiner should be aware that the examination itself may be reminiscent of the assault, and it is possible that the child may make a spontaneous outcry or psychologically decompensate during the examination.

Torture can affect a child directly or indirectly. The impact can be due to the child having been tortured or detained, the torture of his/her parents or close family member or the witnessing of torture and violence. When individuals in … Continue reading

Notifying people of their rights

Everyone deprived of liberty has the right to be given a reason for the arrest and detention. Article 9(1) of the ICCPR states that: ‘Everyone has the right to liberty and security of person. No one shall be subjected to arbitrary arrest or detention. No one shall be deprived of his liberty except on such grounds and in accordance with such procedures as are established by law.’

Everyone deprived of liberty has the right to be given a reason for the arrest and detention. Article 9(1) of the ICCPR states that: ‘Everyone has the right to liberty and security of person. No one shall be subjected to … Continue reading

Examination Following a Recent Assault

While it is rare that a victim of rape during torture is released, it is still possible to identify acute signs of the assault. In these cases, there are many issues to be aware of that may impede the medical evaluation. Recently assaulted victims may be troubled and confused about seeking medical or legal help due to their fears, sociocultural concerns or the destructive nature of the abuse. In such cases, a doctor should explain to the individual all possible medical and judicial options and should act in accordance with the individual’s wishes. The duties of the physician include obtention of voluntary informed consent for the examination, recording of all medical findings of abuse and obtention of samples for forensic examination. Whenever possible, the examination should be performed by an expert in documenting sexual assault. Otherwise, the examining physician should speak to an expert or consult a standard text on clinical forensic medicine. When the physician is of a different gender from the victim, he or she should be offered the opportunity of having a chaperone of the same gender in the room. If an interpreter is used, then the interpreter may also fulfil the role of the chaperone. Given the sensitive nature of investigation into sexual assaults, a relative of the alleged victim is not normally an ideal person to use in this role. The individual should be comfortable and relaxed before the examination.

A thorough physical examination should be performed, including meticulous documentation of all physical findings, including size, location and colour, and, whenever possible, these findings should be photographed and evidence collected of specimens from the examination. The physical examination should not initially be directed to the genital area. Particular attention must be given to ensure a thorough examination of the skin, looking for cutaneous lesions that could have resulted from an assault. These include bruises, lacerations, ecchymoses and petechiae from sucking or biting. Lesions on the breasts, particularly from bites, should be enquired about in women who have been sexually assaulted. When the legs are examined, the inner thighs should be inspected thoroughly. Where women have had their legs forced apart, there may be finger bruising, scratches, cigarette burns, incisions and other wounds, or their late consequences.

When genital lesions are minimal, lesions located on other parts of the body may be the most significant evidence of an assault. Even during examination of the female genitalia immediately after rape, there is identifiable damage in less than 50 per cent of the cases. Anal examination of men and women after anal rape shows lesions in less than 30 per cent of cases. Clearly, where relatively large objects have been used to penetrate the vagina or anus, the probability of identifiable damage is much greater.

Where a forensic laboratory is available, the facility should be contacted before the examination to discuss which types of specimen can be tested, and, therefore, which samples should be taken and how. Many laboratories provide kits to permit physicians to take all the necessary samples from individuals alleging sexual assault. If there is no laboratory available, it may still be worthwhile to obtain wet swabs and dry them later in the air. These samples can be used later for DNA testing. Sperm can be identified for up to five days from samples taken with a deep vaginal swab and after up to three days using a rectal sample. Strict precautions must be taken to prevent allegations of cross-contamination when samples have been taken from several different victims, particularly if they are taken from alleged perpetrators. There must be complete protection and documentation of the chain of custody for all forensic samples.

If the woman is being examined shortly after the rape, it is important to discuss issues of pregnancy and emergency contraception, and however long has passed since the assault, sexually transmitted diseases (especially gonorrhoea, chlamydia, syphilis and trichomoniasis) and other infectious diseases such as Hepatitis B (HBV) and HIV must be considered (see below), and treated where present if the necessary facilities are available. If rape occurred within the previous seventy-two hours, consideration must be given to the administration of post-exposure prophylaxis (PEP) of anti-retrovirals (ARVs) for preventing infection by HIV and this depends on a detailed assessment of the nature of the sexual assault. The risk of infection with HBV should be assessed and the need for immunisation determined.

Some women are raped persistently over a long period which increases the likelihood that they will become pregnant; in some cases they are then detained until it is too late to consider termination of pregnancy (if that would otherwise be an option). In such cases routine ante-natal examinations should be performed including, if possible, ultrasounds. This will enable the time of conception to be estimated.

While it is rare that a victim of rape during torture is released, it is still possible to identify acute signs of the assault. In these cases, there are many issues to be aware of that may impede the medical … Continue reading

Written Reports

General Considerations

The purpose of written reports and oral testimony is to assess claims, document evidence of torture and ill-treatment, and effectively communicate this evidence to adjudicators. The purpose is not to “prove” or “disprove” the individual’s allegations of abuse. The health professional provides expert opinions on the degree to which the his/her findings correlate with the individual’s allegation of abuse. Clinical evaluations are often critical in enabling adjudicators to make accurate and just decisions in medico-legal cases. In addition, each written report and oral testimony represents an opportunity for clinicians to educate adjudicators on physical and psychological evidence of torture.

Expert medical reports and testimony can be of value in an number of different contexts:

  • The prosecution in national or international courts of perpetrators alleged to be responsible for torture
  • Claims for reparation
  • Challenging the credibility of statements extracted by torture
  • Identifying the need for further care and treatment
  • Identifying national and regional practices of torture in human rights investigations
  • Support of allegations of torture in asylum applications.

Medico-legal (or forensic) evaluations should be conducted with objectivity and impartiality, and this should be reflected in written reports and testimony. The evaluations should be based on clinical expertise and professional experience. As mentioned in Module 2, the ethical obligation of beneficence demands uncompromising accuracy and impartiality in order to establish and maintain professional credibility. When gathering information to prepare a report, it is important not to over-interpret the findings and so diminish the quality of the evidence. That is to say, however sympathetic the health professional may be to the individual, the report or certificate should not say more than can be supported by the evidence and the level of competence of the report writer to interpret it, or the case might be undermined.

Clinicians who conduct evaluations of alleged torture victims should have specific essential training in forensic documentation of torture and other forms of physical and psychological abuse. They should also have knowledge of prison conditions and torture methods used in the particular region where the individual was imprisoned and the common after-effects of torture. The written reports and oral testimony should be factual and carefully worded. Jargon should be avoided. All medical terminology should be defined so that it is understandable to lay persons. Many words have a specific meaning in medico-legal reports that differ from their use in everyday speech, such as ‘history’ or ‘laceration’. It may be necessary to append a glossary to the report, so that readers do not misinterpret some of the words by applying their everyday definitions.

The clinician should review the declaration (testimony) and any relevant medical or legal materials that the alleged torture victim has presented to the court, as it generally includes information that may be compared with the clinician’s evaluation. Any discrepancies that may arise should be pursued with the individual and/or the individual’s attorney to a point of clarity. Adjudicators often interpret inconsistent testimony as a lack of credibility on behalf of the alleged torture victim, when, in fact, such inconsistencies are often related to the presence of psychological, cultural, linguistic or other factors.

Effective written reports and oral testimony not only require knowledge of torture and its after-effects, but they also require accurate and effective communication skills. Such skills are not typically part of clinical training. Written reports and oral testimony of clinicians should not include any opinion(s) that cannot be defended under oath or during cross-examination. Furthermore, the quality of any testimony, whether written or oral, can only be as good as the interview and examination conducted.

Physical and psychological evaluations of alleged torture victims may provide important confirmatory evidence that a person was tortured. However, the absence of such physical evidence should not be construed to suggest that torture did not occur, since such acts of violence against persons frequently leave no marks or permanent scars. Historical information such as descriptions of torture devices, body positions and methods of restraint, descriptions of acute and chronic wounds and disabilities, and identifying information about perpetrators and the place(s) of detention may be very useful in corroborating an individual’s allegations of torture. In the clinician’s interpretation of findings, he/she should relate various categories of evidence, i.e., physical and psychological evidence of torture, and historical information as well

The purpose of written reports and oral testimony is to assess claims, document evidence of torture and ill-treatment, and effectively communicate this evidence to adjudicators. The purpose is not to “prove” or “disprove” the individual’s allegations of abuse. The health … Continue reading

Prevention

(i) To take effective legislative, administrative, judicial or other measures to prevent acts of torture, for example by:

  • Establishing effective monitoring mechanisms to prevent torture in all places of detention;
  • Ensuring that any statement that is established to have been made as a result of torture shall not be invoked as evidence in any proceedings, except against a person accused of torture as evidence that the statement was made;
  • Ensuring that the prohibition of torture is included in training of law enforcement and medical personnel, public and other relevant officials;
  • Not expelling, returning, extraditing or otherwise transferring a person to a country when there are substantial grounds for believing that the person would be tortured (non-refoulement).

(ii) To ensure that general safeguards againt torture exist in places of detentions such as:

  • Granting detainees prompt and unrestricted access to a lawyer and a doctor of their choice;
  • Informing family members or friends about the person’s detention;
  • Providing detainees access to family members and friends;
  • Not holding persons incommunicado detention;
  • Enabling detainees to promptly challenge the legality of their detention before a judge.

(i) To take effective legislative, administrative, judicial or other measures to prevent acts of torture, for example by: Establishing effective monitoring mechanisms to prevent torture in all places of detention; Ensuring that any statement that is established to have been … Continue reading

Preliminary Considerations

The documentation of torture and other ill-treatment depends on the gathering of detailed and accurate information from the individual on the circumstances of the alleged events, including details of any arrest, detention, conditions of detention and specific treatment while under interrogation. The interview should be structured and conducted according to the guidelines defined in “the general considerations for the interview”, “procedural safeguards” and “medical ethics” chapters of the Istanbul Protocol. These considerations apply to all persons carrying out interviews whether they are lawyers, medical doctors, psychologists, psychiatrists, human rights monitors or members of any other profession. Interview considerations that pertain specifically to the documentation of physical and psychological evidence of torure are included in Modules 5 and 6 respectively.

Torture is usually both physical and psychological in nature. It is important, therefore, for each clinician to elicit and relate physical and psychological information in their evaluations. It should be noted that, with appropriate training, physicians may become qualified to conduct psychological evaluations. Those who are not qualified, should refer the alleged victim to a qualified psychological expert (i.e. psychologist, psychiatrist, clinical social worker). Medical doctors should carefully consider the potential benefits and possible difficulties of qualifying as a psychological expert. It may be helpful to seek the advice of attorneys to better understand country-specific requirements to qualify as an expert witness on on psychological evidence of torture.

The degree of detail gathered during an interview with an alleged victim of torture depends on several factors, such as the aim of the interview/examination (producing a note in a medical record of incidental findings during a routine medical visit, versus being asked to provide a medical report for a judicial body), the location and circumstances of the interview (for example in a health clinic, in a police station or prison, or in a rehabilitation centre for survivors of torture) and the degree of access to the individual and amount of time available. This being said, the principles on interviewing can be adapted and applied to the various circumstances in which an individual alleging torture may be encountered.

Clinicians should not assume that the individual, such as the asylum applicant’s attorney, requesting a medico-legal evaluation has related all the material facts. It is the clinician’s responsibility to discover and report upon any material findings that he or she considers relevant, even if they may be considered irrelevant or adverse to the case of the party requesting the medical examination. Findings that are consistent with torture or other forms of ill-treatment must not be excluded from a medico-legal report under any circumstance.

The documentation of torture and other ill-treatment depends on the gathering of detailed and accurate information from the individual on the circumstances of the alleged events, including details of any arrest, detention, conditions of detention and specific treatment while under … Continue reading

Module 2 Answers

  1. Answer: B

    The Istanbul Protocol outlines international, legal standards on protection against torture and establishes specific guidelines for the effective investigation and documentation of torture and ill treatment. 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.

  2. Answer: True

    The Istanbul Protocol 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 Istanbul Protocol represents an elaboration of the minimum standards contained in the Istanbul Principles and should be applied in accordance with a reasonable assessment of available resources.

  3. Answer: A

    The Istanbul Protocol and its related Principles have been recognised as international standards for the effective investigation and documentation of torture and ill treatment by the UN General Assembly and the then UN Commission on Human Rights (since 2006, the UN Human Rights Council), the UN Special Rapporteur on Torture, the African Commission on Human and Peoples’ Rights, the European Union and other institutions and organizations.

  4. Answer: B

    Conducting an objective and impartial evaluation should not preclude the evaluator from being empathic. It is essential for clinicians to maintain professional boundaries and at the same time to acknowledge the pain and distress that they observe. The clinician should communicate his or her understanding of the individual’s pain and suffering and adopt a supportive, non-judgmental approach. Clinicians need to be sensitive and empathic in their questioning while remaining objective in their clinical assessment.

  5. Answer: A

    It is important to realize that the severity of psychological reactions depends on the unique cultural, social, and political meanings that torture and ill-treatment have for each individual, and significant ill effects do not require extreme physical harm. Seemingly benign forms of ill-treatment can and do have marked, long-term psychological effects. Although some survivors of torture may have few or no psychological sequelae, most individuals experience profound, long-term psychological symptoms and disabilities.

  6. Answer: B.

    Although there are a myriad of psychological issues that torture victims might have including C and D, PTSD and major depression are the two most common problems.

  7. Answer: B.

    Unfortunately, it is a common misconception among evaluators, attorneys and adjudicators that psychological evidence is of lesser legal value than “objective” physical findings. The aim and effect of torture is largely psychological. The psychological evaluation is critical in assessing the level of consistency between the alleged trauma and individual psychological responses. In some cases, the symptoms may be either attenuated or exacerbated depending on the meaning assigned to individual experiences.

  8. Answer: B

    As the Istanbul Protocol makes clear, the absence of physical and/or psychological evidence in a medical evaluation does not rule-out the possibility that torture or ill-treatment was inflicted. The Istanbul Protocol was developed to prevent torture and ill-treatment and to promote accountability. Governments must ensure that its official representatives do not engage in misuse or misrepresentation of the Istanbul Protocol to exonerate police who are accused of abuses or for any other purpose.

  9. Answer: B, D

    Each detainee must be examined in private. Police or other law enforcement officials should never be present in the examination room. This procedural safeguard may be precluded only when, in the opinion of the examining doctor, there is compelling evidence that the detainee poses a serious safety risk to health personnel. Under such circumstances, security personnel of the health facility, not the police or other law enforcement officials, should be available upon the medical examiner’s request. In such cases, security personnel should still remain out of earshot (i.e. be only within visual contact) of the patient. Prisoners should feel comfortable with where they are evaluated. In some cases, it may be best to insist on evaluation at official medical facilities and not at the place of detention. In other cases, detainees may prefer to be examined in the relative safety of their cell, if they feel the medical premises may be under surveillance, for example. The best place will be dictated by many factors, but in all cases, investigators should ensure that prisoners are not forced into accepting a place they are not comfortable with. Requests for medical evaluations by law enforcement officials are to be considered invalid unless they are requested by written orders of a public prosecutor.

  10. Answer: A

    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.

  11. Answer: A

    The presence of police, soldier, warden, or other law enforcement officers in the examination room, for whatever reason, should be noted in the physician’s official medical report. Notation of police, soldier, prison officer, or other law enforcement official’s presence during the examination may be grounds for disregarding a “negative” medical report.

  12. Answer: A.

    Many of the rules and principles of medical ethics have been adopted as professional codes of conduct. While ethics must guide every action of health professionals in their work, in the process of investigating and documenting allegations of torture, there are three areas in which the health professional must be particularly cognizant of specific ethical considerations. The first is the duty to the patient, the second is the clinical independence of the health professional and the third is in the production of medical records, reports and testimony.

  13. Answer: A

    The use of hoods or blindfolds has in itself been found to be a form of ill-treatment. In the health setting hoods or blindfolds not only impair any meaningful contact with the patient; they also prevent the identification of any health professionals and may thus add to a perception of impunity in cases of ill-treatment.

  14. Answer: D

    A, B, and C are all provision under the World Medical Association’s 1975 Tokyo Declaration.

  15. Answer: F

    All of the answers represent either passive or active complicity of health professionals in torture and ill treatment. Physicians and other medical personnel have the obligation not to condone or participate in torture in any way.

  16. Answer: F

    All of the elements listed are essential to informed consent.

  17. Answer: A

    The health professional must contemplate the risks to the patient, and indeed to themselves, in disclosing such information, and the potential benefits to society as a whole (e.g. potentially avoiding further harm to others), before acting. Whatever decision is reached, the health professional should endeavour to gain consent. In such cases, the fundamental ethical obligations to respect autonomy and to act in the best interests of the patient are more important than other considerations.

  18. Answer: B

    In an ideal situation, an independent doctor will have explained the risks of a prolonged hunger strike, and taken instructions on what the person wants to happen if he or she ceases to be capable of rational thought. This should happen in an environment where the patient’s confidentiality can be respected, and where he or she can be protected from undue pressure from political colleagues. In cases where prison doctors have been following hunger strikers before and during the fast, and know what the patients’ positions and convictions are, physicians should respect the principles stated in the Declaration of Malta. If a physician is called upon to take care of a hunger striker already in a comatose state, he or she will have no choice and will have to provide reanimation. A physician should not rely on what amounts to “hearsay” in such cases. The opinions of the immediate family should be taken into consideration, but are not paramount. Neither the opinions of the authorities nor those of the patient’s political colleagues should be given any weight.

  19. Answer: B

    The Declaration of Tokyo was revised in 2006 to include the following provision: “The physician shall not use nor allow to be used, as far as he or she can, medical knowledge or skills, or health information specific to individuals, to facilitate or otherwise aid any interrogation, legal or illegal, of those individuals.”

  20. Answer: G

    The primary goal of documenting allegations of human rights violations is to create an accurate, reliable and precise record of events. All of the forms of information listed are essential to the effective medical and legal investigations of torture and ill treatment.

Answer: B The Istanbul Protocol outlines international, legal standards on protection against torture and establishes specific guidelines for the effective investigation and documentation of torture and ill treatment. The Istanbul Protocol is a non-binding document. However, international law obliges governments … Continue reading

Psychological Evaluation #1

(based on an asylum evaluation conducted by Dr. Kathleen Allden, M.D. in November 2000, Boston, MA, USA)

I. Case Information

Name: Mr. __

Birth Date: x/xx/68

Birth Place: __

Gender: male

Clinician’s Name: Kathleen Allden, MD

Dates of Evaluation: August 23, 2000 (2 hours), September 6, 2000 (1 hour), September 13, 2000 (2 hours)

Interpreter: Not needed as client speaks English

Exam Requested by: Attorney Jane Doe

Subject Accompanied by: Attorney Jane Doe (first appointment only)

II. Clinician’s Qualifications [deleted]

Attached is my curriculum vitae.

I have personally examined this individual and have examined the facts recited in this written report. I believe all statements to be true. I would be prepared to testify to these statements based on my personal knowledge and belief.

III. Psychological / Psychiatric Evaluation

Background Information

Mr. __ is a 35 year old married man from [country A]. He came to the United States seeking asylum in February 2000. His wife and three children, ages 14, 10 and 5 years, are in a refugee camp in [country B], along with his mother and sister.

Summary of Collateral Sources

Draft Application for Asylum and Withholding of Removal supplied by his attorneys

Methods of Assessment Utilized

Clinical interviews

History of Torture and Ill-treatment

Mr. __ reports that he came to the United States in February 2000. He is seeking asylum because he feels it is not safe for him to return to [country A]. He says that in 1990 he was at his parents’ home when __ rebel forces attacked the house. He believes that his family was targeted because of his father’s job in the government, and because they are of the __ ethnic group. He was at home with his father, mother and sister when the house was attacked. Mr. __ and his family were taken to a rebel camp. He reports that the rebels forced him to hold his sister down while they gang raped her. Also, he was forced to watch as rebels tortured his father and cut off his limbs one at a time. He reports he was forced at gunpoint to hold his father down while they did this. He believes the rebels killed his father because at the time he was an officer in the government.

After a period of time, his mother and sister were able to leave the camp but Mr. __ says he was taken to another camp where he was burned and cut on the right arm and put in a pit. While in pit, the rebels urinated on him, threw dirty water on him and beat him. He remained in the pit for a long period of time. Conditions were filthy in the pit and his right arm became very infected. Mr. __ recalls becoming ill and coughing up brown sputum. While he was still in the pit, [country A] soldiers overtook the camp and freed him. He said that they could tell that he was not one of the __ rebel forces soldiers because it was obvious that he had been severely mistreated by them. For this reason, his life was spared at that time. He reports then being taken to the border where he escaped to [country B] and was able to reunite with his mother and sister.

During the years 1990-96, Mr. __ reports that there were many factions fighting in [country A]. He did not go back to [country A] until 1996 when there was a cease-fire. He went to check on the family’s property but found that the family’s house had been burned. He remained in [country A] where he participated in the presidential campaign of __, and was physically beaten by opposing political forces that were on the same side that had originally attacked his home and killed his father. The soldiers took him to a prison. Mr. __ and his family are members of the __ tribe. He reports that he and other __ tribe prisoners were taken away to the forest to be killed. The soldiers shot at the group of prisoners as the prisoners ran away. An unknown number were killed but Mr. __ escaped.

He went to live in barracks in an area where other __ tribe people were staying because they felt they might be safe there. In 1998, when __ rebel forces attacked this area, many people were killed. Soldiers attempted to arrest Mr. __. He believed they would take him away and kill him. He managed to escape and ran to __ peacekeeping base where other __ tribe people as well as other civilians had fled. __ peacekeeping base personnel helped Mr. __ and others flee the country by arranging for flights from an airbase. Mr. __ was flown to [country B] where he joined his mother and sister in a refugee camp.

In describing these events, Mr. __ reports that he witnessed many horrible atrocities. He said he saw soldiers ask people if they wanted a “long sleeve” or a “short sleeve” and then would chop off the arm accordingly. He also saw soldiers kill infants by bashing their heads until the brains came out. He reports seeing a group of children thrown in a well to die. While describing these experiences he said he felt ashamed to be telling me about these events. He said he felt ashamed of what had happened in his country and in other nearby countries such as [country C]. He said of the war and violence that he has experienced and witnessed, “It’s part of me now.” He describes feeling permanently changed, altered by these terrible things.

Current Psychological Complaints

Mr. __ reports that when he first arrived in the United States he was afraid to go out of the house. He lives with friends who reassured him that the United States is not like [country A] and that people are safe when they go out of their houses. He felt he might be attacked if he went out. With his friends’ encouragement, he gradually tried going out of the house and now is able to travel without significant difficulty. He has learned how to use public transportation and feels comfortable enough to use the bus.

He describes other symptoms and fears that were particularly bothersome when he first arrived in the United States but that have gradually diminished. For example, he would sleep in his clothes. He did this because in the past he felt he always had to be ready to run, ready to escape. When he came here he continued this habit until, gradually with friends’ encouragement, he was able to undress for sleep. He reports previously having difficulty falling asleep and staying asleep. He says that now he is able to sleep several hours per night but that he has nightmares of terrible past experiences during the war. His sleep disturbance and the frequency of his nightmares have improved slowly over the months since his arrival in the United States. He describes experiencing intrusive memories of the past and finds that he constantly worries about what would happen if he were sent back to [country A]. He describes being very sensitive to loud sounds and easily startled. During July 4 celebrations this summer, neighbor children were lighting firecrackers. This caused him to be very fearful and anxious as it reminded him of being in the war. His nightmares also worsened during that time period.

Mr. __ reports avoiding being reminded of the war and violence that he has experienced. For example, he avoids speaking about it. He also avoids television programmes that have violent scenes, or reports and news clips about war in [country C]. He says he avoids becoming angry or annoyed. He says he knows what people can do when they lose control and act on their anger. He says he tries to keep himself numb. He offers the example that if someone slapped him on the face, he would not feel it because he would be numb. He describes trying to push bad memories out of his mind and trying to distance himself from the past. He avoids going out on the street or in public and tries to stay indoors away from people he does not know. He says it is hard for him to see injustice or someone being mistreated. Because he becomes very angry when he witnesses injustices, he keeps himself isolated in order not to be exposed to situations that would anger him. He also feels that the cultural differences between the United States and his home are many and it is hard for him to cope with the differences. He says he only wants to be around people who encourage him and reassure him that things will turn out all right in the long run.

He worries about his family living as refugees in [country B]. His main goals are to bring his wife and children here and to work to send money to his mother and sister. (He has been told he will not be able to bring his mother and sister to the United States.) He says that having these goals helps him survive. He says that now that his father is dead it is his responsibility to look after the needs of his mother and the rest of the family. If it were not for these responsibilities, Mr. __ says he would prefer to be dead. He says he has seen too much suffering and cruelty. The past seems like a dream, the happy times in the past seem unreal. Although he contemplates suicide, he says all is not lost because if he is granted asylum, he may be able to bring his wife children to the United States so they can have a better future. He does not have confidence that there will be peace in his country for a long time.

Mr. __ says that his religious beliefs help him cope with his life. He reads the Bible every day. He speaks of his devotion to Jesus Christ and his faith in God.

Post-Torture History

Mr. __ was a refugee in [country B] before coming to the United States. He said that life in [country B] is very harsh. Food is scare, infectious diseases are common, and it is very hard to make a living. Also, people in the region do not trust people from [country A], according to Mr. __, fearing they are members of rebel groups. His family encouraged him to leave __ and go to the United States. He traveled to the United States via [country A] with the assistance of a close friend of the family. His mother, sister, wife and children are living in [country B] in a refugee camp. Currently, Mr. __ lives with friends in Massachusetts. He feels welcomed and supported by them. He has been staying with these friends since his arrival in the United States. His hosts are friends of his late father. Mr. __ does not work because he is not legally permitted to work. He feels he is able to work and he would like to work in order to earn money for his family.

Pre-Torture History

Family history: Mr. __ is one of two siblings; he has one sister. He grew up in the home of his mother and father, who were Baptists. His father was a government official in the former government. According to Mr. __, his father was able to earn a good living and the family was well provided for. Mr. __ met his wife when they were both in school; they were married around 1985. After they were married they lived with Mr. __’s parents. They have three children ages 14, 10, and 5. He describes a happy childhood and family life until the time that war broke out in his country in 1990.

Educational history: Mr. __ reports he has a high school education and completed a junior college programme in computer science.

Occupational history: Mr. __ is trained in computer science. He has not practiced that profession. While a refugee in [country A], he supported his family as a vendor.

Cultural and religious background: Mr. __ was raised as a Baptist and continues to practice his religion in the United States. He is from the __ tribe.

Medical History

Prior to the war, Mr. __’s had several episodes of malaria. Otherwise his health was good. During the time he was kept in the pit he developed a severe respiratory illness which he describes as bronchitis with a productive cough and vomiting that required long-term treatment with antibiotics after he was finally released. He says he still has right-sided chest pain and that when he takes a deep breath, he hears wheezes in his chest. He still coughs up phlegm. His chest pain is worse during rainy weather. Also, he complains of right arm pain where his arm was cut by his torturers. He has not had a physical exam since coming to the United States.

Past Psychiatric History

There is no past history of mental illness.

Substance Use and Abuse History

Prior to coming to the United States, Mr. __ reports that he had great difficulty falling asleep. He would drink alcohol to help fall asleep. He does not do this now. He denies using illicit drugs.

Mental Status Examination

  1. General appearance – Mr. __ is a neatly dressed man who was very polite and cooperative during the interviews. He was clearly distressed by having to retell his history of trauma. He was tearful and moderately agitated especially during our first meeting.
  2. Motor activity – No obvious psychomotor retardation. He was somewhat agitated and frustrated at times but able to tolerate the long interviews.
  3. Speech – His English is fluent but his accent is very heavy and I had difficulty understanding him at times. His speech was logical and goal directed. He was able to express his emotions and ideas very well.
  4. Mood and affect – Frequently during the interviews, he was clearly overwhelmed with feelings of loss and sadness. He also expressed horror at witnessing extreme cruelty and violence. He appeared frustrated at not being able to communicate to me how extremely awful the atrocities that he witnessed were. His affect was labile. He was often tearful. He was able to smile on occasion.
  5. Thought content – His thoughts centered on two main themes, his worries for his family and the horrors he has witnessed and experienced. These worries and memories seem to occupy his thought much of the time.
  6. Thought process – There is no evidence of paranoia, delusions, referential ideation or other disturbance of thought. There is no evidence of hallucinations.
  7. Suicidal and homicidal ideation – There is no evidence of homicidal ideation but he has thoughts of suicide. He says that he would prefer to be dead and that the only reason that he stays alive is that his family is his responsibility and he hopes to be able to help them have a better life.
  8. Cognitive exam – He is oriented and alert. He gives the proper date and place. He does not seem to have difficulty with long term recall but admits that giving precise dates of events is very hard for him. His immediate recall is impaired as evidenced by is ability to recall only 4 of 6 digits when asked to do so. His intermediate recall is similarly impaired as evidenced by his ability to recall only 2 of 3 objects that he is asked to recall after a 3-minute time lapse. His overall global cognitive function may also be impaired as evidenced by is inability to spell a five-letter word backwards.

Clinical Impression (Interpretation of Findings)












Conclusion and Recommendations












(based on an asylum evaluation conducted by Dr. Kathleen Allden, M.D. in November 2000, Boston, MA, USA) I. Case Information Name: Mr. __ Birth Date: x/xx/68 Birth Place: __ Gender: male Clinician’s Name: Kathleen Allden, MD Dates of Evaluation: August … Continue reading

Module 3 Answers

  1. Answer: A

    The primary purpose of a medical evaluation of torture and ill treatment is to assess the degree to which physical and psychological findings correlate with the individual allegations of abuse and to communicate effectively the clinician’s medical findings and interpretations to the judiciary or other appropriate authorities.

  2. Answer: F

    Clinicians must have the capacity to create a climate of trust in which disclosure of crucial, though perhaps very painful or shameful, facts can occur. All of the considerations listed will aid clinicians in earning the trust of survivors of torture.

  3. Answer: C

    Medical evaluations, whether for physical or psychological evidence, usually require considerable time, about 2 to 4 hours. If more time is required, it is advisable to schedule a second interview. Interviews lasting 6 hours or more may be particularly difficult for the individual being interviewed.

  4. Answer: D

    Forensic medical services should be under judicial or an independent authority and not under the same governmental authority as the police or prison system.

  5. Answer: A

    Physical and psychological examinations by their very nature may re-traumatise an individual by provoking and/or exacerbating psychological distress and symptoms by eliciting painful memories. The interview must be structured to minimise the risk of re-traumatisation by balancing the need to obtain detailed accurate account of events and the importance of respecting the needs of the person being interviewed.

  6. Answer: B

    The preferred gender of the examining clinician should not be presumed. Ideally, an investigation team should contain specialists of both genders, permitting the alleged torture victim to choose the gender of the investigator and, where necessary, the interpreter.

  7. Answer: C

    All of the statements about the use of interpreters are accurate with the exception of C. The age of the interpreter may be relevant. A young male individual may be able to discuss sexual torture with an older woman to whom he may relate as to an aunt, but not to a woman of his own age. Similarly, a young female individual may find an older man easier to talk to than one who is of a similar age to her torturer.

  8. Answer: A

    Transference refers to the feelings a survivor has towards the clinician that relate to past experiences but which are misunderstood as directed towards the clinician personally. Fear and mistrust may be particularly strong in cases where physicians or other health workers were participants in the torture.

  9. Answer: F

    All of the emotional reactions listed are common counter-transference reactions that an interviewer is likely experience while listening to the interview with Sr. Diana Ortiz.

  10. Answer: A, B

    The interviewer did not attempt to relocate the interview to a more comfortable and private location; Sr. Diana suggested that they move out of the cold weather into a nearby hotel. While the interviewer was empathetic to some extent, he maintained a somewhat detached demeanor and did not acknowledge the difficulty of recounting highly traumatic experiences.

  11. Answer: A

    Before beginning any medical evaluation, forensic clinicians must explain their role to the individual and make clear any limits on medical confidentiality.

  12. Answer: A, C, D

    All of the strategies listed may help to manage and limit secondary trauma with the exception of B. Discussing your emotional reactions with the survivor/alleged victim would be inappropriate and likely harmful to the individual.

  13. Answer: A

    Inquiries should be structured to elicit an open-ended, chronological account of events experienced during detention 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. Leading questions are avoided wherever possible, because individuals may answer with what they think the health professional wants to hear.

  14. Answer: E

    All of the techniques listed may help to improve the accuracy of information obtained in a medical evaluation.

  15. Answer: H

    Inconsistencies may result from a number of factors that may be directly related to the torture and ill treatment or to the psychological and/or neurological symptoms that result from torture and ill treatment. Interview conditions and cross cultural factors may be significant as well. Clinicians should be familiar with such factors to effectively explain any inconsistencies observed.

  16. Answer: F

    All of the steps listed may help clinicians to assess inconsistencies that may be identified in the course of a medical evaluation of torture and ill treatment.

  17. Answer: B

    Inquiries into prior political activities and beliefs and opinions are relevant insofar as they help to explain why the person was detained and/or tortured, but such inquiries are best made indirectly by asking the person what accusations were made, or why they think they were detained and tortured. The psychosocial history is particularly important in understanding the meaning that individuals assign to traumatic experiences.

  18. Answer: A

    Correlations between specific allegations of abuse and subsequent physical evidence require clinicians to obtain detailed information for each form of abuse alleged as stated in the question.

  19. Answer: B

    A medico-legal report should not be falsified under any circumstance. The ethical obligation of beneficence demands uncompromising accuracy and impartiality in order to establish and maintain professional credibility which, in turn, benefits survivors of torture. A medico-legal report should not be falsified under any circumstance.

  20. Answer: A

    Wherever possible, examinations to document torture for medico-legal purposes should be combined with an assessment for other needs, whether referral to specialist physicians, psychologists, physiotherapists or those who can offer social advice and support. Investigators should be aware of local rehabilitation and support services. Those who appear to be in need of further medical or psychological care should be referred to the appropriate services.

Answer: A The primary purpose of a medical evaluation of torture and ill treatment is to assess the degree to which physical and psychological findings correlate with the individual allegations of abuse and to communicate effectively the clinician’s medical findings … Continue reading