Istanbul Protocol Model Medical Curriculum

Educational Resources for Health Professional Students

Head Trauma and Post-traumatic Epilepsy

Head trauma is among the most common forms of torture. Even repeated minor head trauma can cause permanent damage to brain tissues. This can in turn cause permanent physical handicap. Lacerations and abrasions of the head and their late consequences should be documented as above. Scalp bruises are frequently not visible externally acutely unless there is swelling. Bruises also may be difficult to see in dark skinned individuals, but will be tender to palpation.

Survivors of torture often report that they were unconscious at times, but it is impossible for them to know what happened unless they were with a reliable witness. It is necessary to try to differentiate between loss of consciousness following blows to the head, post-traumatic epilepsy (see below), asphyxiation, pain and exhaustion, or any combination of these.

Many victims of torture have suffered blows to the head, and many complain of persistent or recurrent headaches, whether or not they have sustained any head injury. Generally the headaches are psychosomatic or due to tension headache. In some cases with a history of repeated blows to the head, it is possible to feel areas of hyperaesthesia (extreme sensitivity of neurological sensation) and some thickening of the scalp from scar tissue.

Headache may also be the initial symptom of an expanding subdural haematoma. There may be associated psychological changes of acute onset, and a CT scan or MRI must be arranged urgently, if one is available. It may also be appropriate to arrange psychological or neuropsychological assessment. Soft tissue swelling and/or haemorrhage will usually be detected with CT or MRI. In cases of trauma caused by falls, contracoup lesions (on the opposite side to the point of impact) of the brain may be observed on investigation, whereas following direct trauma, the main damage to the brain may be seen directly under the point of impact.

Violent shaking of the upper body has been reported as a form of torture (as it has as a form of child abuse). Survivors complain of severe headaches and persistent changes in cognitive function. In these cases no injuries are visible. Shaking can lead to death due to cerebral oedema and subdural bleeding. Retinal haemorrhages have been noted on post-mortem examination and, when seen in children, are very suggestive of shaking injuries.

Immediately after severe head injury there may be concussive convulsions, but these do not necessarily lead to epilepsy. Convulsions (or seizures) in the first week or so after a severe head injury tend to be tonic-clonic. They may recur for a year or more, but are not generally lifelong. Severe head injuries leading to brain lesions, specifically in the temporal lobe, can cause convulsions that start months or years after the incident. The latter are complex partial seizures.

Typically (>90% of cases), complex partial seizures start with an aura (a strange feeling that precedes the convulsion). This is followed by an absence that can last up to two minutes. Concurrent automatic movements, particularly lip smacking have been reported. After these episodes there is usually a period of a few minutes of disorientation. Often the aura is described as a strange feeling in the stomach, but it may involve bizarre smells or tastes. These must be differentiated from the re-experiencing phenomena of PTSD where the person is always capable of being roused and never completely loses consciousness.

In most countries the prevalence of epilepsy in the population is 2%. About 65% of epilepsy is due to complex partial seizures. The cause of complex partial seizures is unknown in 45% of cases. Traumatic events including birth events account for 3% of it. The likelihood of acquiring epilepsy after a head injury depends on the severity of the injury (see table).

Degree of head injury Loss of consciousness Relative risk of epilepsy Duration of increased risk
Minor < 30 minutes 1.5 5 years
Moderate < 24 hours 2.9 (three times)
Severe > 24 hours 17.2 (17 times) 20 years

Survivors of torture rarely have an accurate account of their head injuries, and unless they have an external reference, they cannot know for certain how long they were unconscious. One problem with attributing epilepsy to head trauma is that there is rarely any information about the individual’s neurological state prior to the incident.

Head trauma is among the most common forms of torture. Even repeated minor head trauma can cause permanent damage to brain tissues. This can in turn cause permanent physical handicap. Lacerations and abrasions of the head and their late consequences … Continue reading

Legal Investigation of Torture

According to the Istanbul Protocol, investigations into torture should seek to establish the facts of alleged incidents in an effort to identify and facilitate the prosecution of perpetrators and/or secure redress for the victims. When possible, forensic experts should obtain detailed information on the following topics: 1) the circumstances leading up to the torture; 2) the approximate dates and times when the torture occurred; 3) detailed physical descriptions about the people involved in the arrest, detention and torture; 4) the contents of what was asked of or told to the victim; 5) a description of the usual routine in the place of detention; 6) details about the methods of torture and/or ill-treatment used; 7) any instances of sexual assault; 8 ) resulting physical injuries; 9) weapons or physical objects used; and 10) the identity of any witnesses.

When designing commissions of inquiry, states or organisations should be very clear in defining the scope of the investigation. By framing the inquiries in a neutral manner (without predetermined outcomes), allowing for flexibility, and being clear about which events and/or issues are under investigation, the proceedings can achieve greater legitimacy among both commission members and the general public.

Commissions should be given the authority to obtain information by compelling testimonies under legal sanction, ordering the production of State documents, including medical records, and protecting witnesses. In addition, the commissions should be granted the power to conduct on-site visits and issue a public report.

Perhaps most crucial to the legitimacy of any medico-legal investigation is their impartiality. According to the Istanbul Protocol, “…[c]ommission members should not be closely associated with any individual, State entity, political party or other organisation potentially implicated in the torture. They should not be too closely connected to an organisation or group of which the victim is a member, as this may damage the commission’s credibility.”

In addition, commissions should, whenever possible, rely on their own investigators and expert advisers, especially when examining misconduct by members of the government.

Following the inquiry, the commission should issue a public report, with minority members filing a dissenting opinion. These reports should include: the scope of inquiry and terms of reference, as described above; the procedures and methods of evaluation; a list of all testifying witnesses—except for those whose identities are protected—with their age and gender; the time and place that each sitting occurred; all relevant political, social and economic conditions that may have influenced the inquiry; the specific events that occurred and supporting evidence; the commissions’ conclusions; and finally, a set of recommendations. In response to these reports, the State should issue a public statement describing how it plans to heed the commission’s recommendations.

The Istanbul Protocol also includes obligations of governments to ensure minimum standards for the effective investigation and documentation of torture and ill-treatment as stipulated in the Istanbul Principles as mentioned above.

According to the Istanbul Protocol, investigations into torture should seek to establish the facts of alleged incidents in an effort to identify and facilitate the prosecution of perpetrators and/or secure redress for the victims. When possible, forensic experts should obtain … Continue reading

Introduction

Psychological reactions to torture present physicians, clinicians and social scientists with the challenge of evaluating and assisting individuals who have survived crises of life-threatening proportions. For many that have survived torture, the experience can cause profound effects at a deeply personal level that may persist and fluctuate for many years. Psychological consequences develop in the context of personal meaning and personality development. They will vary over time and are shaped by cultural, social, political, interpersonal, biological and intrapsychic factors that are unique to each individual. One should not assume that all forms of torture have the same outcome. However, over the past two decades much has been learned about psychological, biological and neuropsychiatric responses to extreme stress, including torture, and clusters of typical symptoms have emerged that are recognised across cultures.

Psychological reactions to torture present physicians, clinicians and social scientists with the challenge of evaluating and assisting individuals who have survived crises of life-threatening proportions. For many that have survived torture, the experience can cause profound effects at a deeply … Continue reading

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