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Eye Trauma
Suspension
Toolkits > Istanbul Protocol Model Medical Curriculum > Module 4: Torture Methods and their Medical Consequences > Torture Methods > Restraint, Shackling and Positional Torture

Restraint, Shackling and Positional Torture

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Some degree of restraint is clearly necessary and legitimate at the time of arrest or during transfer in order to prevent a detainee from escaping. However, once detention has been secured, there can be no legitimate need for artificial restraint. The use of shackles or leg irons is specifically forbidden by Rule 33 of the UN Standard Minimum Rules for the Treatment of Prisoners. In spite of this ruling, extreme and prolonged measures are very often taken. Sometimes an attempt is made to justify its use as preventing escape but usually they are applied to cause humiliation or as a punishment. The restraint may be continued for days or even weeks, far longer than needed for legitimate purposes.

Handcuffs, wrist or ankle ties leave no mark if they are applied properly, and in some countries officers take care to prevent damage. In India, for instance, police often use the detainee’s turban cloth to bind the wrists or ankles. Conversely, restraints may cause abrasions or bruising even after a short time if they are of rough or harsh material or are applied too tightly. Thin ligatures tightly applied may cause deep wounds after a few hours. This type of handcuff, which automatically continues to tighten if the prisoner struggles, is particularly dangerous and can cause characteristic lesions.

The use of leg irons is widespread in police stations and prisons. Pakistani prisons are particularly notorious for its use, often for long periods of time. They are used as punishment, as a means of extorting bribes and intimidating or humiliating prisoners. Often the rings round the ankles are roughly finished and cause severe abrasions and scarring which may be highly consistent with allegations of abuse.

There are many forms of positional torture, all of which tie or restrain the victim in contorted, hyperextended or other unnatural positions, which cause severe pain and may produce injuries to ligaments, tendons, nerves and blood vessels. Characteristically, these forms of torture leave few, if any, external marks or radiological findings, despite subsequent frequently severe chronic disability.

Positional torture is directed towards tendons, joints and muscles. The ‘five-point tie’ is a technique of trussing up a captive used in several African countries. A single fine rope is tied round the wrists, ankles and neck or mouth, holding the trunk tightly in extreme extension. An attempt to relieve the pain by moving one limb tightens it more around the others. If this type of restraint is continued for any length of time there is almost certain to be permanent scarring and perhaps peripheral nerve or vascular lesions.

In China, many forms of shackling are used as punishment and are given nicknames to disguise the appallingly painful methods used. For instance, Su Qin bei jian (literally, ‘Su Qin carries a sword on his back’) describes the shackling of one arm pulled over the shoulder to the other which is twisted behind the back. Another is liankao, describing various methods of shackling the hands and feet behind the back.

Cramped or distorted postures or prolonged standing are used routinely in many countries. An example is Israel, where ‘moderate physical pressure’ is permitted by law. Several techniques have been devised by the General Security Service (Shin Bet) and routinely used to put detainees under undue stress. In shabeh the victim is shackled for hours to a low chair whose front legs have been shortened so that the detainee must constantly struggle to avoid sliding off. Shabeh is usually combined with methods of abuse, i.e. placing an often filthy sack over the victim’s head, exposing him or her to loud music and sometimes to extreme temperatures and sleep deprivation.

An illustration of “Shabeh” positional torture. (From the B’TSELEM Human Rights Report, 1998)

In gambaz the detainee is forced to crouch on his toes in the ‘frog’ position for long periods. In kas’at tawila the subject is made to kneel with his back up against a table and his cuffed arms resting on the table behind him while the interrogator’s legs push against his shoulders. A small chamber nick-named ‘the refrigerator’ is used to keep the victim immobile for hours or days.

An example of positional torture. (Courtesy of the Human Rights Foundation of Turkey)

The UN Committee against Torture has determined that restraining detainees in very painful positions is by itself an act of both torture and cruel, inhuman or degrading treatment.[1] It recently determined that the use of “short shackling” by US (United States) personnel constitutes either torture or cruel, inhuman or degrading treatment and has recommended that the method be prohibited.[2] In a review of US practises, the UN Special Rapporteur on Torture has condemned the use of stress positions on detainees by the United States as violating the Convention Against Torture.[3]


[1] Hashemian F, Crosby S, Iacopino V, Keller A, Nguyen L, Ozkalipici O, et, al. Broken Laws, Broken Lives: Medical Evidence of Torture by US Personnel and It’s Impact. Physicians for Human Rights. June, 2008. pp. 100. (Hereafter: Broken Laws, Broken Lives)

[2] Broken Laws, Broken Lives pp. 100.

[3] Broken Laws, Broken Lives pp. 100

Eye Trauma
Suspension
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  • Istanbul Protocol Model Medical Curriculum

    • Preface
      • Copyright and Acknowledgements
      • Resources
      • Glossary
    • Introduction
      • Curriculum Materials
      • Summary of Content
      • How to Use These Educational Resources
    • Module 1: International Legal Standards (Overview)
      • Torture
        • What is Torture
        • Purpose of Torture
        • History of Torture
        • Other Definitions
        • Cruel Inhuman & Degrading Treatment & Punishment (CID)
        • Prohibition of Torture in International Law
        • The United Nations Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment 1984
        • Torture in the World Today
        • Country-Specific Legal Standards and Torture Practices
        • The Perpetrators
        • Common Situations for Torture Allegations
        • Where Does Torture and Ill-treatment Occur?
        • Obligation to Investigate and Bring Justice
        • Formal Inspection of Detention Facilities
        • Official Complaints to Human Rights Bodies and Other Organizations
        • Recently Released Detainees
        • NGO Information Gathering
        • Late Allegations
      • Prevention and Accountability
        • Prevention
        • Accountability
        • Reparation
      • International Supervisory Machinery and Complaints Procedures
        • The Human Rights Committee
        • The UN Committee against Torture
        • Regional Mechanisms
        • Other monitoring mechanisms
        • The UN Special Rapporteur on Torture and other Cruel, Inhuman and Degrading Treatment or Punishment
        • International criminal courts and tribunals
        • The International Committee of the Red Cross (ICRC)
      • Safeguards Against Torture for Those Deprived of Their Liberty
        • Notifying people of their rights
        • Use of officially recognized places of detention and the maintenance of effective custody records
        • Avoiding incommunicado detention
        • Humane conditions of detention
        • Limits on interrogation
        • Access to a lawyer and respect for the functions of a lawyer
        • Access to a doctor
        • The right to challenge the lawfulness of detention
        • Safeguards for special categories of detainees
      • Module 1 Presentation: International Legal Standards
      • Self-Assessment and Quiz
        • Module 1 Answers
    • Module 2: Istanbul Protocol Standards for Medical Documentation of Torture and Medical Ethics
      • The Istanbul Protocol
        • About the Istanbul Protocol
        • Brief History
        • International Recognition of the Istanbul Protocol
      • An Overview of the Istanbul Protocol
        • Legal Investigation of Torture
        • General Considerations for Interviews
        • Physical Evidence of Torture
        • Psychological Evidence of Torture
        • Interpretation of Findings and Referrals
        • Misuse of the Istanbul Protocol
        • Procedural Safeguards for Detainees
      • Medical Ethics
        • Introduction
        • Duties of the health professional
        • International Codes
        • Ethical rules directly prohibiting involvement in torture
        • Primary loyalty to the patient
        • Dual Obligations
        • The treatment of prisoners and detainees
        • Issues surrounding examinations of individuals in the presence of security forces
        • Abusive medical treatment
        • Consent and confidentiality
        • Security
        • Involvement of other health professionals in torture
        • Seeking further information and support
        • Country-specific legal responsibilities of health professionals for forensic documentation of torture and ill-treatment
      • General Guidelines for Gathering Evidence and Documenting Findings
        • The aims and goals of investigation
        • Multidisciplinary approach to documentation
        • Role of the health professional in the team
        • Role of the lawyer in the team
        • Role of the NGO member in the team
        • Role of judges and prosecutors
      • Documenting the allegations
        • The aim of medical documentation
        • Types of evidence
        • Medical evidence
        • Gathering of evidence
        • Essential information
        • Quality of information
        • Comparing records
      • Module 2 Presentation: Istanbul Protocol Standards for Medical Documentation of Torture and Medical Ethics
      • Self-Assessment and Quiz
        • Module 2 Answers
    • Module 3: Interview Considerations
      • Preliminary Considerations
        • Purpose of Medical Evaluations
        • Interview Settings
        • Trust
        • Informed Consent
        • Confidentiality
        • Privacy
        • Empathy
        • Objectivity
        • Safety and Security
        • Procedural Safeguards for Detainees
        • Risk of Re-traumatisation
        • Gender Considerations
        • Interviewing Children
        • Cultural and Religious Awareness
        • Working with Interpreters
        • Transference and Counter-Transference Reactions
      • Conducting Interviews
        • Types of questions
        • Cognitive Techniques
        • Summarising and clarifying
        • Difficulties Recalling and Recounting
        • Assessing Inconsistencies
      • Interview Content
        • Identification and Introduction
        • Psychosocial History (Pre-Arrest)
        • Past Medical History
        • Summary of Detention(s) and Abuse
        • Circumstances of Detention(s)
        • Prison/Detention Place Conditions
        • Allegations of Torture and Ill-treatment
        • Review of Symptoms
        • Psychosocial History (post-arrest)
        • Assessments of Physical and Psychological Evidence
        • Physical Examination
        • Closing
        • Indications for Referral
      • Module 3 Presentation: Interview Considerations
      • Self-Assessment and Quiz
        • Module 3 Answers
    • Module 4: Torture Methods and their Medical Consequences
      • Introduction
      • Torture Methods
        • Beatings/Falanga
        • Ear Trauma
        • Eye Trauma
        • Restraint, Shackling and Positional Torture
        • Suspension
        • Crushing and Stretching Injuries
        • Burning
        • Electrical injuries
        • Asphyxiation
        • Violent Shaking
        • Sexual Assault
        • Sexual Humiliation
        • Prolonged Isolation and Sensory Deprivation
        • Sleep Deprivation
        • Temperature Manipulation
        • Sensory Bombardment
        • Threats of Harm
      • Psychological Consequences of Torture
        • Introduction
        • The Paradox of Psychological Consequences of Torture
        • The Psychological Consequences of Torture
        • Social, Political and Cultural Context
        • Risk factors for Trauma and Torture-Related Disorders
        • Psychological Symptoms
      • Module 4 Presentation: Torture Methods and their Medical Consequences
      • Self-Assessment and Quiz
        • Module 4 Answers
    • Module 5: Physical Evidence of Torture and Ill-Treatment
      • Physical Evidence of Torture
        • Medical history
      • The Physical Examination
        • Dermatologic Evaluation
        • Head and Neck
        • Chest and Abdomen
        • Musculoskeletal System
      • Neurological Examination
        • Head Trauma and Post-traumatic Epilepsy
        • Nerve Damage
      • Examination of Women
        • Examination Following a Recent Assault
        • Examination After the Immediate Phase
        • Follow-up
        • Genital Examination of Women
      • Genital Examination of Men
      • Perianal Examination
      • Medical Photography
        • Assessment for Referral
      • Diagnostic Tests
      • Module 5 Presentation: Physical Evidence of Torture and Ill-Treatment
      • Self-Assessment and Quiz
        • Module 5 Answers
    • Module 6: Psychological Evidence of Torture and Ill-Treatment
      • The Central Role of the Psychological Evaluation
        • Conducting the Psychological Evaluation
        • Psychological Findings and Diagnostic Considerations
        • Components of the Psychological/Psychiatric Evaluation
      • Children and Torture
        • Introduction
        • Developmental Considerations
        • Clinical Considerations
        • Role of the Family
      • Apendix I: Sample Psychological Evaluations
        • Psychological Evaluation #1
        • Psychological Evaluation #2
      • Apendix II: ICD-10
      • Module 6 Presentation: Psychological Evidence of Torture and Ill-Treatment
      • Self-Assessment and Quiz
        • Module 6 Answers
    • Module 7: Case Example #01
      • Introduction
      • Preliminary Considerations
      • Materials
      • Module 7 Presentation: Case Example #01
      • Self-Assessment and Quiz
        • Module 7 Answers
    • Module 8: Case Example #02
      • Introduction
      • Preliminary Considerations
      • Materials
      • Module 8 Presentation: Case Example #02
      • Self-Assessment and Quiz
        • Module 8 Answers
    • Module 9: Report Writing and Testifying in Court
      • Written Reports
        • General Considerations
        • Content of Written Reports
        • Conclusions
        • Inconsistencies
      • Providing Testimony in Court
      • Appendix: Court Testimony Guidelines and Maxims
      • Module 9 Presentation: Report Writing and Testifying in Court
      • Self-Assessment and Quiz
        • Module 9 Answers
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