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Effective medical investigation and documentation of torture and ill-treatment require clinicians to have a detailed understanding of torture methods and their physical and psychological sequelae. This Module provides a review of common torture methods and their medical consequences. It is important to keep in mind that it is difficult to separate physical from psychological torture, as each has a component of the other; for example, hooding not only impedes normal breathing, but also produces disorientation and fear. In addition, physical forms of torture and ill treatment will generally produce both physical and psychological sequelae, and psychological forms of torture and ill-treatment often result in psychological sequelae, but may also produce physical sequelae as well.

The methods of torture and ill-treatment included in this module are not exhaustive. The actual methods that a survivor experiences are only limited by the imagination and cruelty of his or her torturers. As mentioned in Module 1, it is important to realize that, although there is much similarity of torture methods around the world, there can be regional and country-specific variations. Instructors and students who use this Model Curriculum should be aware of regional, country-specific, and local practises and adapt them to the Model Curriculum materials accordingly with relable and current human rights reports.

Although physical torture as practised around the world has many features in common, almost invariably including beating, slapping and kicking, more sophisticated techniques have been developed in many areas. In countries whose authorities wish to disguise the fact that torture takes place, methods are devised, sometimes with the help of doctors, that produce maximum pain with minimum external evidence. This must be recognised by the examiner if the after-effects of these techniques are not to be missed, especially after the passage of time. Documentation of special methods of torture alleged by an individual requires that the examiner has a detailed knowledge of torture techniques used in the country where the torture was alleged to have taken place. With this knowledge the interviewer can take an informed and detailed history (taking care to avoid using leading questions). This helps to give a precise picture of such details of torture as the victim’s posture, clothing, blindfolding or hooding, the implements used, duration of assault and his or her condition at the end of the session – whether he or she could walk or whether there were any bleeding wounds. It cannot be emphasised too strongly that such a detailed history is essential to ensure that, during the subsequent physical examination, signs in the relevant areas of the body are not missed and that a correct differentiation from accidental or self-inflicted injury is made. For this reason it is necessary to review, at length, some of the techniques employed in different countries before outlining the symptoms and signs to be expected during history-taking and physical examination. Of particular value in assessing the severity of the attack is a history of loss of consciousness, though this should be elaborated by questions aimed at finding out whether unconsciousness was caused by blows to the head, asphyxiation, unbearable pain or exhaustion.

As discussed in Module 3, survivors may be unable to describe exactly what happened to them because they may have been blindfolded, lost consciousness, sustained head injury, or have difficulty recalling or revealing the especially traumatic components of their experience. It is important to realize that torturers often attempt to conceal their deeds. For example, physical evidence of beating may be limited when a wide, blunt objects are used for beatings. Similarly, victims are sometimes covered by a rug, or shoes in the case of falaka, to distribute the force of individual blows. For the same reason, wet towels may be used with electric shocks. In other cases, torturers use methods with the intent of producing maximal pain and suffering with minimal evidence, for example, forced positioning, near asphyxiation, mock executions, temperature manipulation, sensory deprivation, prolonged isolation, threats of harm to the individual and his or her family, and sexual humiliations, among many others.

It is important to understand that some methods on their own may amount to torture; in other cases significance is attached to the use of a combination of methods, which may collectively amount to torture. Also, the length of time over which the individual is subjected to the methods may be decisive. Again, for this reason, it is important to document as accurately and completely as possible all the events to which an individual was exposed and their consequences.

The Subjective Element of Suffering

It is important to keep in mind that, when assessing the degree of suffering involved, one should take into account the identity and background of the alleged victim. For example, certain situations that might be relatively bearable for some people could be degrading and humiliating to those of a particular gender, culture or religious faith. Torture and other ill-treatment can also often go hand-in-hand with discrimination, based on race, religion, gender or other factors, which may exacerbate the distress. In addition, physical and mental suffering can differ amongst categories of victims, for example some tortures may exacerbate pre-existing health problems, and children may experience a higher degree of suffering than adults undergoing similar ill-treatment. All these factors should be taken into account in documenting the alleged victim’s experience.