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Istanbul Protocol Model Medical Curriculum
Educational Resources for Health Professional Students
Consisting of 9 Modules (see Summary of Content below). The Modules serve as the overall knowledge base for the Model Curriculum.
Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment
PowerPoint (PPT) Presentations
There is a PPT Presentation to accompany each of the 9 Modules. The Presentations were designed primarily for instructors who prefer to use a lecture format. The content of the PPT presentations closely parallels that of the Modules.
Case Examples #01 and #02
Two case examples have been incorporated into Modules 7 and 8. They are designed to give students practical experience interviewing alleged victims of torture and documenting physical and psychological evidence. The medical evaluations that students develop from these case examples should be applied to Mock Court Proceedings in Module 9.
Psychological Evaluations 1 and 2
Two Psychological Evaluations are included in Module 6 to provide students with an opportunity to develop clinical impression from information contained in actual asylum cases.
For each Module, there is a related Self-Assessment that is designed specifically for individual student users to assess their knowledge of curriculum content. The Self-Assessments may be applied to other teaching formats as well.
In Module 3, students will listen to an audiotape of an interview with a torture survivor, Sr Diana Ortiz, to better understand the challenges of interviewing survivors, particularly the emotional reactions of survivors and clinicians.
Model Curriculum Consisting of 9 Modules (see Summary of Content below). The Modules serve as the overall knowledge base for the Model Curriculum. Istanbul Protocol Model Medical Curriculum (pdf) Istanbul Protocol Manual on the Effective Investigation and Documentation of Torture … Continue reading
Clinicians should carefully consider the context in which they are working, take necessary precautions and provide safeguards accordingly. If interviewing people who are still imprisoned or in similar situations in which reprisals are possible, all precautions should be taken to ensure that they do not place the detainee in danger (or in additional difficulty). Promises must not be made, for example, to provide security for the witness or for relatives who might be at risk, unless the interviewer is certain that they can be fulfilled. Witnesses might believe that international organisations or others investigating allegations of torture have more power to protect them than is the case. It is part of the informed consent process that individuals are aware of all the issues before they agree for a clinician to make a formal report. If the risk of harm from reprisals is a virtual certainty, conducting a medical evaluation may be considered unethical even if informed consent is obtained. This may be the case in the context of documenting human rights violations in places of ongoing conflict.
Whether or not certain questions can be asked safely will vary considerably and depends on the degree to which confidentiality and security can be ensured. When necessary, questions about forbidden activities should be avoided.
If the forensic medical examination supports allegations of torture, the detainee should not be returned to the place of detention, but rather should appear before the prosecutor or judge to determine the detainee’s legal disposition (see Procedural Safeguards below).
An interviewer will make notes of the interview, and may use other recording devices. The reasons for this should be explained to the interviewee who should be reassured as to how the notes and other records will be used and asked for consent. The way in which any records of such interviews are stored can be important in protecting the security of the interviewer and the interviewee. In many countries where torture is prevalent, the police have been known to raid clinics and search or confiscate medical records. In order to protect patients, therefore, in such conditions records should have no obvious identifying information on any document inside (such as initials or date of birth), and the files themselves being numbered with a register kept in a secure place elsewhere. Patients can be given cards with the identifying number so that treatment can be continued even if the register is not available. In some circumstances it may be necessary to hold records at a different location or even in a third country to ensure their security.
If information about an individual needs to be transmitted to another body, fax transmission is generally safer than e-mail as a copy of the latter may be stored on the sending computer or held on the server of the internet service provider. In some countries the authorities routinely screen all outgoing messages.
Clinicians should carefully consider the context in which they are working, take necessary precautions and provide safeguards accordingly. If interviewing people who are still imprisoned or in similar situations in which reprisals are possible, all precautions should be taken to … Continue reading
Interviews for medical evaluations usually begin with the clinician introducing himself or herself followed by:
- Explanation of the purpose of the evaluation
- Reviewing the conditions of the evaluation, i.e.
- Independence of the evaluator
- Confidentiality of the clinician’s findings and limits thereof
- Right to refuse answering questions
- Importance of detail and accuracy of information
- Acknowledge likely difficulty of recalling certain events
- Ability to take breaks
- Access to refreshments and toilet facilities
- Statement on the overall content of the interview including: detailed questions on events before during and after the alleged torture, followed by a physical examination, should this be the case, and the possibility of photographs
- Discussing the likely benefits and risks of the evaluation
- Addressing any questions or concerns that the individual may have
- Obtaining consent to proceed with the evaluation.
For forensic evaluations, the clinician should establish the identity of the subject. As previously mentioned, law enforcement officials should not be present during the evaluation. If such officials refuse to leave the examination room, it should be noted in the clinician’s report or and/or the evaluation may be cancelled.
When the medical evaluation is being conducted by more than one clinician, i.e. one for physical evidence and another for psychological evidence, the content of the interview should focus on the information most relevant to their expertise.
Interviews for medical evaluations usually begin with the clinician introducing himself or herself followed by: Explanation of the purpose of the evaluation Reviewing the conditions of the evaluation, i.e. Independence of the evaluator Confidentiality of the clinician’s findings and limits … Continue reading
Beating is the most common form of physical torture. When the aim is to disguise its effects, beating may be performed with heavy, flexible implements such as sandbags or lead-filled plastic pipes, which may leave short-lived bruising but no permanent scarring. Sometimes the torturers perform the beating over clothing or folded towels. The impact of the blows is still severe and such beating may cause deep muscle bruising (which may take several days to reach the surface) or internal bleeding. This has been reported to lead to acute renal failure due to release of myoglobin (see Module 5). In many countries, severe beatings, which cause widespread bruising, are discontinued after the first few days of detention so that when the victim is produced to court or released after days or weeks later, all obvious signs of beating will have faded.
Falanga, also referred to as falaka, can be defined as the applications of blunt trauma to the soles of the feet. The technique has been practised throughout history. It is still very common, particularly in the Middle East, but also in the Indian subcontinent and, according to Amnesty International, in over thirty countries worldwide. In some countries, such as Turkey, it is applied almost as a routine at the time of detention and many torture survivors report having suffered it on numerous occasions.
It may be applied by batons, whips or canes to the bare feet or with shoes still on, and the immediate effect will depend on these variables. Often the victim is made to walk round on rough paving afterwards, sometimes carrying another on his back. This last detail is clearly intended to add to the humiliation as well as the pain.
As with most forms of physical torture, the physical findings associated with falanga change over time. These changes can be summarised as follows:
Acute Symptoms and Signs
The immediate effect of falanga is bleeding and oedema in the soft tissues of the feet, as well as severe pain. At clinical examination, changes are also confined to the soft tissues. Swelling of the feet, discoloration of the soles due to haematoma formation and various degrees of skin lesions are typical and diagnostic findings. Extensive ulcerations and gangrene of toes due to ischaemia have been described, but are not common. Fractures of tarsals, metatarsals and phalanxes are described as occurring occasionally. The acute changes disappear spontaneously within weeks, as the oedema and extravasation of blood resolve, but the induced soft tissue lesions may be permanent.
Symptoms and Signs in the Chronic Phase
The majority of torture victims submitted to falanga complain of pain and impaired walking. The cardinal symptom is pain in the feet and calves, and two types of pain are usually present:
- A deep, dull cramping pain in the feet, which intensifies with weight bearing and muscle activity spreading up the lower legs
- A superficial burning, stinging pain in the soles, often accompanied by sensory disturbances and frequently also a tendency for the feet to alternate between being hot and cold, suggestive of autonomic instability
Because of the pain, walking is impaired in most falanga victims. Walking speed and walking distance are reduced. Typically, the torture victim is only able to walk a limited distance, during which the pain will increase and make continued muscle activity impossible. At rest, the pain subsides and the victim can resume walking.
Theories Explaining the Persistent Pain and Foot Dysfunction After Falanga
The aetiology and pathogenesis of the persistent pain and disability after falanga is not fully understood. Several theories have been put forward, and most likely a combination of trauma mechanisms are responsible.
Reduced Shock Absorbency in the Heel Pads
The footpads are situated under the weight-bearing bony structures, at which in particular the heel pads act as the first in a series of shock absorbers. The heel pad is normally a firm elastic structure covering the calcaneus. It has a complex internal architecture consisting of closely packed fat cells surrounded by septa of connective tissue, which also contain the nerve and vessel supply to the tissues. Because of its structure, the heel pad is under constant hydraulic pressure and maintains its shape during weight load in the standing position.
After falanga, the heel pad may appear flat and wide, with displacement of the tissues laterally during weight loading. This is observed at inspection from behind, with the torture victim in the standing position. At palpation, the elasticity in the heel pad is reduced and the underlying bony structures are easily felt through the tissues. The pathophysiology of the reduced elasticity in the heel pad is thought to be tearing of the connective tissue septa, leading to deprivation of blood supply and secondary atrophy of fat cells with loss of the shock absorbing ability.
Damaged footpads are not pathognomonic of falanga, but are also described in connection with other conditions unrelated to torture, e.g. lesions in long-distance runners and patient with fractures of the heel bone. It should also be stressed that normal footpads at clinical examination does not rule out exposure to falanga.
Changes in the Plantar Fascia
The plantar fascia springs from the calcaneus and proceeds to the forefoot. It is tightened during foot of supporting the longitudinal arches of the foot, assisting the foot muscles during walking. Changes in the plantar fascia are present in some torture victims after falanga and are probably due to the repeated direct traumas to this superficial structure. After falanga, the fascia may appear thickened with an uneven surface at palpation, and tenderness may be found throughout the whole length of the fascia, from its spring to the insertion. Disruption of the plantar fascia has been reported, based on the finding of increased passive dorsiflexion in the toes at clinical examination.
Closed Compartment Syndrome
The plantar muscles of the foot are arranged in tight compartments—an anatomical arrangement which makes it possible for a closed compartment syndrome to develop. A closed compartment syndrome is defined as a painful ischaemic, circulatory disturbance in connection with an increase in pressure and volume inside a well-defined muscle compartment. In the acute form, with a rapidly increasing pressure, e.g. caused by bleeding inside the compartment, the symptoms are alarming and the consequences severe with necrosis of involved tissues if left untreated.
Chronic compartment syndromes may occur as a result of an increase in the muscle bulk and/or a narrowing of the compartment. Clinically, this condition presents itself with pain that intensifies with load and which finally makes continued muscle activity impossible. The pain subsides after a short period of rest, but recurs if muscle activity is resumed—a picture not unlike that seen in impaired walking after falanga.
In a MRI study comparing torture victims exposed to falanga with healthy volunteers, significant thickening of the plantar fascia was found in all victims. Apart from this, morphological changes were present in the fascia, possibly representing scar tissue formation. No signs of detachment of the plantar fascia, closed compartment syndrome or changes in the heel pads were shown in this study.
The skin of the soles in the normal foot is apart from the arch area, very thick and firmly tied to the underlying tissues. It is very rich in sensory nerve endings, which register touch and pressure. Peripheral nerve lesion affecting the small nerves of the soles is a very possible consequence of falanga. Neurogenic pain due to nerve lesion is therefore a possible contributing pain mechanism.
Deviations from the normal gait pattern are very frequent after exposure to falanga. Many torture victims develop a compensatory altered gait with loading of the lateral border (supinating the foot) or loading of the medial border (pronating the foot) to avoid pain at heel strike. The unwinding of the foot is likewise abnormal. Maximal extension and weight loading of the first toe is typically avoided at take-off.
Stride and walking speed are reduced. The gait is broad, stiff and insecure as seen in patients with peripheral neuropathy from other causes. Postural reflexes are elicited from the soles, and, together with the ability to register distribution of pressure, these reflexes are essential for balance and walking. Nerve lesion influencing the proprioception may therefore also contribute to the overall picture. As a consequence of the altered function of the foot, altered gait and frequently concurrent exposure to other forms of torture involving the lower extremities, a chain reaction of muscular imbalance occurs. The various muscle groups of the lower legs are often painful due to increased muscle tone, tight muscles and fasciae, tender and trigger points, and musculo-tendinous inflammation.
Clinical Examination for Falanga
The clinical examination of torture victims exposed to falanga should include:
- Inspection and palpation of the soft tissues of the feet: heel pads, plantar fascia, skin
- Assessment of foot function and gait
- Examination of soft tissues and joints in the lower extremities
- Neurological examination
It should be stressed once again that none of the findings at clinical examination in the late phases after falanga are pathognomonic, and that a normal examination of the feet does not rule out the possibility of this specific torture method. Special investigations that may aid in correlating allegations of falanga include x-rays, scintography and MRI (see Module 5). Treatment in the chronic phase often includes gentle massage to the muscles of the feet, calves and thighs, re-education of the walking pattern and supportive footwear, especially designed to offer cushioning of the heels.
Beating Beating is the most common form of physical torture. When the aim is to disguise its effects, beating may be performed with heavy, flexible implements such as sandbags or lead-filled plastic pipes, which may leave short-lived bruising but no … Continue reading
Modules 7 and 8 each include a case example of alleged torture and ill-treatment. The Modules are designed for students to develop the clinical skills necessary for the effective documentation of medical evidence torture, including both physical and psychological evidence. These cases were used extensively in Istanbul Protocol trainings in Mexico and also, with some modifications, in Sudan. The content of each was specifically designed to represent common evaluation scenarios and to include a wide range of challenges related to the documentation of physical and psychological evidence of torture. The cases are complementary, i.e. one with “strong psychological and weak physical evidence” (Case #01) and the other with “strong physical and minimal psychological evidence” (Case #02) and reflect composite imformation of actual cases. Each case consists of 1) a brief Case Summary/Refferal that the students read before the evaluation, 2) a Case Narrative to guide role-players in acting their part as an alleged torture victim, and 3) a detailed set of Guidelines for Instructors (and/or individual student users if that is the case) which outline learning objectives, relevant case information, and points for discussion for each of the 8 primary components of medical evaluation:
- Introduction/Conditions of Interview & Identification Information
- Past Medical and Surgical History & Psychosocial History – Pre-Arrest
- Trauma History
- Review of Torture Methods
- Physical Symptoms (acute and chronic) and Disabilities
- Psychological Assessment and Mental Status Examination
- Physical Examination
- Interpretation of Findings & Conclusions
It is highly recommended for the instructors to contact local treatment centers for survivors of torture, and/or other experienced clincians or providers who may be available to participate in the case examples.
Modules 7 and 8 each include a case example of alleged torture and ill-treatment. The Modules are designed for students to develop the clinical skills necessary for the effective documentation of medical evidence torture, including both physical and psychological evidence. … Continue reading
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
Toolkit: Istanbul Protocol Model Medical Curriculum
Subject: Module 5: Physical Evidence of Torture and Ill-Treatment
Subject: Module 5: Physical Evidence of Torture and Ill-Treatment
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
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
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
Toolkit: Istanbul Protocol Model Medical Curriculum
Subject: Module 6: Psychological Evidence of Torture and Ill-Treatment
Subject: Module 6: Psychological Evidence of Torture and Ill-Treatment