Istanbul Protocol Model Medical Curriculum

Educational Resources for Health Professional Students

The aims and goals of investigation

Torture and other ill-treatment are prohibited in international law and are likely also to be a crime under national law. International law requires not only that torture not be used, but also that any allegation of torture be investigated, and that those responsible be brought to justice.

Effective investigation, including the aspect of medical documentation, is a vital component in the struggle to eradicate the practise of torture. Legal bodies, domestic and international alike, rely on factual evidence to reach their conclusions and uphold justice.

By shedding light on cases of torture and other ill-treatment, effective investigation and documentation can assist in the achievement of a number of important goals:

  • Raising awareness of the infliction of torture and its absolute prohibition
  • Battling impunity: bringing torture into the public eye assists in calling states to account for their actions and having them fulfill their legal obligations. On a different level, torture reporting can also help to cast light on the individuals who carry out such practises, to make sure that they cannot continue to engage in such behaviour without negative consequences.
  • Redress for the survivor: there are a number of remedies and objectives that may assist the individual survivor of torture, for example:
    • Preventing and ending ongoing abuse: in certain cases, allegations of torture may be raised by a person who is still in custody of the authorities. Effective and swift investigation can help put an end to the suffering. In other cases, the individual may be seeking protection from abuse in another country, and the determination of whether the individual was a survivor of torture and is personally at risk can prevent the person being deported back into the hands of their torturers.
    • Compensation and other forms of restitution: survivors of torture may, for example, be able to claim compensation for monetary loss, physical and mental harm, and other damage caused by the torture
  • Rehabilitation: many torture survivors are in need of rehabilitation services, including medical treatment, both physical and psychological, legal assistance, and social services. Effective investigation and documentation can assist in diagnosis, treatment (including rehabilitation) and prognosis of the patient.
  • Official and public acknowledgement of their suffering can also be important in the recovery process of survivors of torture.
  • Reform: drawing attention to a situation is not just about seeking condemnation or holding a state accountable. Even more importantly, it is about seeking constructive and long-term improvements in a country, which will contribute to the ultimate elimination of torture. This will often require changes both in the legislative framework and in official attitudes to torture. The eradication of torture is a fundamental and necessary step for any society aspiring to protect human rights and care for its people.

Torture and other ill-treatment are prohibited in international law and are likely also to be a crime under national law. International law requires not only that torture not be used, but also that any allegation of torture be investigated, and … Continue reading

Purpose of Medical Evaluations

According to the Istanbul Protocol, the broad purpose of the medical evaluation is to establish the facts related to alleged incidents of torture (IP, §120). The purpose of the written or oral testimony of the physician is to provide expert opinion on the degree to which medical findings correlate with the patient’s allegation of abuse and to communicate effectively the physician’s medical findings and interpretations to the judiciary or other appropriate authorities. In addition, medical testimony often serves to educate the judiciary, other government officials and the local and international communities on the physical and psychological sequelae of torture. The examiner should be prepared to do the following (IP, §121):

  • Assess possible injury and abuse, even in the absence of specific allegations by individuals, law enforcement or judicial officials;
  • Document physical and psychological evidence of injury and abuse;
  • Correlate the degree of consistency between examination findings and specific allegations of abuse by the patient;
  • Correlate the degree of consistency between individual examination findings with the knowledge of torture methods used in a particular region and their common after-effects;
  • Render expert interpretation of the findings of medico-legal evaluations and provide expert opinion regarding possible causes of abuse in asylum hearings, criminal trials and civil proceedings;
  • Use information obtained in an appropriate manner to enhance fact-finding and further documentation of torture.

According to the Istanbul Protocol, the broad purpose of the medical evaluation is to establish the facts related to alleged incidents of torture (IP, §120). The purpose of the written or oral testimony of the physician is to provide expert … Continue reading

Physical Evidence of Torture

Witness and survivor testimony are necessary components in the documentation of torture. To the extent that physical evidence of torture exists, it may provide important confirmatory evidence that a person was tortured. Torture victims may have injuries that are substantially different from other forms of trauma. Although acute lesions may be characteristic of the alleged injuries, most lesions heal within about six weeks of torture, leaving no scars or, at the most, non-specific scars. This is often the case when torturers use techniques that prevent or limit detectable signs of injury. Under such circumstances, the physical examination may be within normal limits, but this in no way negates allegations of torture. As the Istanbul Protocol makes clearly, 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. A detailed account of the patient’s observations of acute lesions and the subsequent healing process often represent an important source of evidence in corroborating specific allegations of torture or ill-treatment.

A medical evaluation for legal purposes should be conducted with objectivity and impartiality. The evaluation should be based on the physician’s clinical expertise and professional experience. The ethical obligation of beneficence demands uncompromising accuracy and impartiality in order to establish and maintain professional credibility. When possible, clinicians who conduct evaluations of detainees should have specific essential training in forensic documentation of torture and other forms of physical and psychological abuse. They should have knowledge of prison conditions and torture methods used in the particular region where the patient was imprisoned and the common after-effects of torture. The medical report should be factual and carefully worded. Jargon should be avoided. All medical terminology should be defined so that it is understandable to lay persons.

In addition, the physician should not assume that the official requesting a medico-legal evaluation has related all the material facts. It is the physician’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.

Witness and survivor testimony are necessary components in the documentation of torture. To the extent that physical evidence of torture exists, it may provide important confirmatory evidence that a person was tortured. Torture victims may have injuries that are substantially … Continue reading

Module 4 Answers

  1. Answer: B, C, D

    It is important to realize that torturers often attempt to conceal their deeds. For example, physical evidence of beating may be limited when wide, blunt objects are used for beatings. Similarly, victims are sometimes covered by a rug, or shoes in the case of falanga, to distribute the force of individual blows. For the same reason, wet towels may be used with electric shocks. Also, torture victims may be intentionally detained until obvious signs of abuse have resolved.

  2. Answer: A

    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.

  3. Answer: A, B, C

    While the symptoms and conditions listed in A, B and C may be associated with falanga, they are not considered pathognomonic.

  4. Answer: A

    Small tympanic membrane ruptures (less than 2 mm in diameter) usually heal within 10 days.

  5. Answer: D, E

    “Palestinian” suspension results in traction on the lower roots of the brachial plexus and is therefore most likely to result in a sensory deficit in the ulnar distribution. A “winged” scapula can be observed on physical examination as a prominent vertebral border when hands are pressed against a wall with outstretched arms.

  6. Answer: A

    Various forms of positional torture are commonly associated with musculoskeletal symptoms and disabilities, but usually do not result in specific or permanent dermatologic or radiographic findings.

  7. Answer: A, C, D E

    Crushing and stretch injuries commonly cause contusions and may cause abrasions depending on the nature of the objects used and the forces applied. Rough objects and tangential forces may result in abrasions. Incisions are unlikely as they result from sharp, penetrating objects. Extensive muscle necrosis can result in the release of myoglobin which can cause acute renal failure and death unless dialysis is initiated.

  8. Answer: E

    All of the statements regarding burn injuries are accurate.

  9. Answer: E

    Electric shocks have been commonly used by torturers for many years because they cause exquisite pain, but rarely leave identifiable physical signs. Depending on the path of the current, electric shocks can result in dislocation of joints, arrhythmias, urination and defecation.

  10. Answer: A

    Occasionally the electrodes can leave small burns, probably from sparking. Lesions tend to be circular, hyperpigmented and less than 0.5 cm in diameter. Although non-specific, they can corroborate allegations of electric shock torture, especially if they are in certain parts of the body.

  11. Answer: E

    Hypoxia can cause permanent brain injury and exposure to contaminated water or other caustic liquids may result in acute broncho-pulmonary infections, conjunctivitis and otitis media.

  12. Answer: B

    Waterboarding is a form of asphyxiation torture that dates back to the Middle Ages and, recently, has been practised by the United States. Victims are strapped to a board or made to lie in a supine position with their heads lower than the rest of their bodies. The face is covered with cloth, and water is poured over the victim’s mouth to create the sensation of drowning. This deliberate infliction of severe physical and mental pain constitutes torture.

  13. Answer: E

    Violent shaking can result in all of the problems listed.

  14. Answer: B, C, D

    Rape is only one of many forms of sexual assault including forced nudity, groping, molestation and forced sexual acts. Often, sexual assaults will be accompanied by direct or implied threats. In the case of women, the threat may be one of becoming pregnant. For men, those inflicting the torture may also threaten (incorrectly but usually deliberately) that the victim will become impotent or sterile. For men or women there may be the threat of contracting HIV or other sexually transmitted infections (STIs) and often the threat or fear that sexual humiliation, assault or rape will lead to ostracism from the community and being prevented from ever marrying or starting a family. Rape is always associated with the risk of developing sexually transmitted diseases, including HIV. Ideally, medical evaluations of alleged sexual assault should include a team of experienced clinical experts.

  15. Answer: G

    All of the methods listed have been determined to constitute torture by the UN Committee Against Torture and/or the Special Rapporteur on Torture.

  16. Answer: B, C, D

    Despite the fact that torture is an extraordinary life experience capable of causing a wide range of psychological suffering, extreme trauma such as torture does not always produce psychological problems. Therefore, if an individual does not have mental problems, it does not mean that he/she was not tortured. When there are no physical or psychological findings, this does not refute or support whether torture had actually occurred. Major Depression and PTSD are the most common diagnoses among survivors of torture and ill treatment. The course of Major Depression and PTSD varies over time. There can be asymptomatic intervals, recurrent episodes, and episodes during which an individual is extremely symptomatic.

  17. Answer: A

    The psychological consequences of torture and ill treatment develop in the context of personal meaning and personality development. They also may vary over time and can be shaped by cultural, social, political, interpersonal, biological and intrapsychic factors that are unique to each individual.

  18. Answer: B

    Descriptive methods of evaluating psychological evidence of torture are best when attempting to evaluate psychological or psychiatric reactions and disorders because what is considered disordered behaviour or a disease in one culture may not be viewed as pathological in another. While some psychological symptoms may be present across differing cultures, they may not be the symptoms that concern the individual the most. Therefore, the clinician’s inquiry has to include the individual’s beliefs about their experiences and meanings of their symptoms, as well as an evaluating the presence or absence of symptoms of trauma-related mental disorders.

  19. Answer: I

    All of the factors listed can affect psychological outcomes following torture and ill treatment.

  20. Answer: G

    All of the risk factors listed can contribute to the possibility of developing mental illness among refugee survivors of torture.

Answer: B, C, D It is important to realize that torturers often attempt to conceal their deeds. For example, physical evidence of beating may be limited when wide, blunt objects are used for beatings. Similarly, victims are sometimes covered by … Continue reading

Introduction

The term, ‘medical ethics,’ broadly describes the moral framework in which health professionals are bound to carry out their work. 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.

There are certain ethical issues which are more likely to come to the fore depending on the various situations in which health professionals may encounter those alleging or showing signs of torture. This section points out the particular ethical considerations raised by situations such as the examination of an individual who is brought to a hospital or clinic still in the custody of the police, military or other security forces, and difficulties encountered by health professionals employed by the police, military or prison authorities.

The term, ‘medical ethics,’ broadly describes the moral framework in which health professionals are bound to carry out their work. Many of the rules and principles of medical ethics have been adopted as professional codes of conduct. While ethics must … Continue reading

Types of questions

If possible, the individual should be asked to give a chronological account of the incident(s) in question. Generally, open-ended questions should be used, for example: ‘Can you tell me what happened?’ or ‘Tell me more about that.’ The individual should be allowed to tell his or her story with as few interruptions as possible. Further details can be elicited with appropriate follow-up questions, such as: ‘How big was the cell?’, ‘Was there any lighting?’ and ‘How could you go to the toilet?’ Asking too many questions too quickly might confuse the individual, or even remind him or her of being interrogated.

Leading questions are avoided wherever possible, because individuals may answer with what they think the health professional wants to hear. This is especially important when interviewing for medico-legal purposes, where the testimony may be challenged in court. Closed questions, which provide the interviewee with a limited number of options and, particularly, list questions, can cause confusion in the individual and might create unnecessary inconsistencies. For example, an individual might be asked, ‘Were you arrested by the police or the army?’ limiting the answer to a choice between the two. If he or she was arrested by a special task force of soldiers and policemen working together, it would be difficult to give an accurate answer without appearing to contradict the health professional. This could in turn create inconsistencies between statements.

The pace of the interview must be dictated by the individual. Even if there is limited time for the interview (such as in a police station or prison), the interviewee should not feel rushed. It is better to focus on a few specific points than to try to cover too much ground in too little time. If there are many interviewees to be seen over several days, each should be seen once or twice for a substantial period of time, rather than several shorter sessions.

In a clinical setting, the interviewer should allow enough time between appointments to allow for this and for sufficient time to write up his or her notes. It is good practise to write up the notes of each interview at the end of that session, as various aspects of the individuals’ accounts may become confused if the interviewer attempts to write up all the interviews in a later single session, and details may be forgotten.

If possible, the individual should be asked to give a chronological account of the incident(s) in question. Generally, open-ended questions should be used, for example: ‘Can you tell me what happened?’ or ‘Tell me more about that.’ The individual should … Continue reading

Medical history

As stated in Module 3 [1], the pysician should obtain a complete medical history, including information about prior medical, surgical or psychiatric problems. S/he should:

  • Be sure to document any history of injuries, medical conditions and surgery before the period of detention and any possible after­effects;
  • Avoid leading questions;
  • Structure inquiries to elicit an open-ended, chronological account of the events experienced during detention.

Specific historical information may be useful in correlating regional practices of torture with individual allegations of abuse. Examples of useful information include descriptions of torture devices, body positions, methods of restraint, descriptions of acute or chronic wounds and disabilities and identifying information about perpetrators and places of detention. While it is essential to obtain accurate information regarding a torture survivor’s experiences, open-ended interviewing methods require that a patient disclose these experiences in their own words using free recall. An individual who has survived torture may have trouble expressing in words his or her experiences and symptoms. In some cases, it may be helpful to use trauma event and symptom checklists or questionnaires. If the interviewer believes it may be helpful to use trauma event and symptom checklists, there are numerous questionnaires available; however, none are specific to torture victims. All complaints of a torture survivor are significant. Although there may be no correlation with the physical findings, they should be reported. Acute and chronic symptoms and disabilities associated with specific forms of abuse and the subsequent healing processes should be documented.

Acute Symptoms

The individual should be asked to describe any injuries that may have resulted from the specific methods of alleged abuse. For example, bleeding, bruising, swelling, open wounds, lacerations, fractures, dislocations, joint stress, haemoptysis (coughing up blood), pneumothorax (lung puncture), tympanic membrane perforation, genitourinary system injuries, burns (including colour, bulla or necrosis according to the degree of burn), electrical injuries (size and number of lesions, their colour and surface characteristics), chemical injuries (colour, signs of necrosis), pain, numbness, constipation and vomiting. The intensity, frequency and duration of each symptom should be noted. The development of any subsequent skin lesions should be described and whether or not they left scars. Ask about health on release; was he or she able to walk, confined to bed? If confined, for how long? How long did wounds take to heal? Were they infected? What treatment was received? Was it a physician or a traditional healer? Be aware that the detainee’s ability to make such observations may have been compromised by the torture itself or its after-effects and should be documented. It is important to note that acute lesions are often characteristic since they may show a pattern of inflicted injury that differs from non-inflicted injuries, for example by their shape, repetitiveness, and distribution on the body.

Chronic Symptoms

Elicit information of physical ailments that the individual believes were associated with torture or ill-treatment. Note the severity, frequency and duration of each symptom and any associated disability or need for medical or psychological care. Even if the after-effects of acute lesions are not observed months or years later, some physical findings may still remain, such as electrical current or thermal burn scars, skeletal deformities, incorrect healing of fractures, dental injuries, loss of hair and myofibrosis. Common somatic complaints include headache, back pain, gastrointestinal symptoms, sexual dysfunction and muscle pain. Common psychological symptoms include depressive affect, anxiety, insomnia, nightmares, flashbacks and memory difficulties (see Module 6 [2]).

As stated in Module 3, the pysician should obtain a complete medical history, including information about prior medical, surgical or psychiatric problems. S/he should: Be sure to document any history of injuries, medical conditions and surgery before the period of … Continue reading

Module 5 Answers

  1. Answer: B

    Although acute lesions may be characteristic of the alleged injuries, most lesions heal within about six weeks of torture, leaving no scars or, at the most, non-specific scars.

  2. Answer: C

    A complete physical examination is recommended unless the allegations of torture are limited and there is no history of loss of consciousness or neurological or psychological symptoms that may affect recall of torture allegations. Under such circumstances, a directed examination may be appropriate in which only pertinent positive and negative evidence is pursued on examination.

  3. Answer: F

    All of the forms of historical information listed may be useful in correlating regional practices of torture with individual allegations of abuse.

  4. Answer: C

    Inquiries should be structured to elicit an open-ended, chronological account of events experienced during detention.

  5. Answer: E

    In addition to location, size, shape and color, each of the factors listed above should be included in clinical descriptions of skin lesions.

  6. Answer: B

    Lacerations are caused by a tangential force such as a blow or a fall and produce tears of the skin. The wound edges tend to be irregular, and often any may be bruised and/or abraded. Tissue bridges may be present. Incisions are caused by sharp objects like a knife, bayonet, or broken glass that produce a more or less deep, sharp and well-demarcated skin wound.

  7. Answer: C or D

    The photograph shows a large 4 cm x 6 cm contusion with underlying edema and/or hematoma formation. There are a series of parallel linear abrasions that correspond to the ridges of a police baton (see photo below). These physical findings should be considered “highly consistent” with or “virtually diagnostic” of the alleged injury since it is very unlikely they were caused by any other mode of injury or pathophysiological process. “Proof” of torture implies 100% certainty and should be avoided unless it can be supported by the evidence. In this case the injury may have been inflicted in the context of “resisting arrest.”
    [Courtesy of Amnesty International, The Netherlands.]

  8. Answer: A, B, D

    Contusions cause blood to leak from small vessels. If the skin and subcutaneous tissues are thin, the bruise becomes apparent relatively quickly and may take the shape of the weapon used. The extent and severity of a contusion are related to the amount of force applied, but more importantly vascular structures affected. Elderly people and children who have loosely supported vascular structure will bruise more easily than young adults. Many medical conditions are associated with easy bruising. As the extravasated red cells are destroyed, the aging bruise goes through variable colour changes. Speculative judgments should be avoided in the evaluation of the nature and age of blunt traumatic lesions.

  9. Answer: B, C, D

    Full thickness wounds heal in one of two ways. When the wound is small and the edges are opposed, it heals from the top down (by primary intention). This tends to leave a small, tidy scar. If this process cannot occur, especially if the wound gapes, it heals from below (by secondary intention). This is a slow process and prone to infection, and will leave a wide scar. Scars related to self-inflicted injuries are generally superficial and within easy reach of the dominant hand. Contusions and abrasions may cause hyperpigmented scars, especially in darker skins, due to post-inflammatory hyperpigmentation. Also scars of distinctive shape and if in multiples suggest intentional injuries rather than those caused accidentally.

  10. Answer: B

    The photograph shows an oval scar above the left hip that is approximately 7 cm x 4 cm. It is a macular lesion with a depigmented, atrophic center, lacking normal skin accessories (hair). The periphery shows a hyperpigmented zone about 1 cm. wide. This scar is most consistent with a 2nd degree burn from a heated instrument.

  11. Answer: A

    This scar is the result of an abrasion injury as the individual was dragged across a rough surface.

  12. Answer: C

    This man sustained blunt trauma to the right supraorbital region which resulted in a typical laceration scar. The appearance of the scar is the result of the healing of irregular wound edges and tissue bridges.

  13. Answer: B

    The photograph shows 2 linear incisions resulting from slashes with a knife. The biconvex appearance of the scars suggest that they healed by secondary intention. These scars are most consistent with incisions because of the sharp, well-demarcated appearance of the scars.

  14. Answer: C

    The multiple linear, scars are most consistent with lacerations from whipping with an electrical wire.

  15. Answer: D

    The photograph shows evidence of multiple cigarette burns 7 days following the injury.

  16. Answer: A, B, C

    Whenever possible, the examination of women alleging rape 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. A thorough physical examination should be performed, including meticulous documentation of all physical findings. It is rare to find any physical evidence when examining female genitalia more than one week after 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. It is unwise to draw conclusions about a refusal to consent to genital examination. If the alleged victim refuses consent, the doctor should record any relevant observations on the alleged victim’s demeanour, such as embarrassment or fear, or cultural considerations.

  17. Answer: F

    All of the statements listed are true.

  18. Answer: A

    Rectal tears with or without bleeding may be noted. Disruption of the rugal pattern may manifest as smooth fan-shaped scarring. When these scars are seen out of midline (i.e. not at 12 or 6 o’clock), they can be an indication of penetrating trauma.

  19. Answer: A

    Poor quality photographs are better than none, but they should be followed up with professional photographs as soon as possible.

  20. Answer: E

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

Answer: B Although acute lesions may be characteristic of the alleged injuries, most lesions heal within about six weeks of torture, leaving no scars or, at the most, non-specific scars. Answer: C A complete physical examination is recommended unless the … Continue reading

Istanbul Protocol Model Medical Curriculum

Model Curriculum on the Effective Medical Documentation
of Torture and Ill-treatment

Educational Resources for Health Professional Students
Prevention through Documentation Project, 2006-2009

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Downloadable version:

Model Curriculum on the Effective Medical Documentation of Torture and Ill-treatment Educational Resources for Health Professional Students Prevention through Documentation Project, 2006-2009 Downloadable version: Istanbul Protocol Model Medical Curriculum (pdf)

Assessment for Referral

The clinician should not hesitate to seek any further consultation and examination that he or she considers necessary for the evaluation. Those who need further medical and/or psychological care should be referred to appropriate services as discussed in Module 3. During ongoing care, further evidence may be detected that may not have been foreseen. If there is a rehabilitation centre for torture survivors in the region, the clinician may contact them for further support and advice.

In countries with there is a tradition of systematic torture, and pressure on health care professionals, the examining clinician may also prefer to refer patients to specialists to increase the number of medical witnesses to the torture (e.g. consulting with a dermatologist for a simple contusion).

The clinician should not hesitate to seek any further consultation and examination that he or she considers necessary for the evaluation. Those who need further medical and/or psychological care should be referred to appropriate services as discussed in Module 3. … Continue reading