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The Physical Examination

The physical examination is usually the last component of a medical evaluation of an alleged torture victim, after the acquisition of all background information, allegations of abuse, acute and chronic symptoms and disabilities, and after the psychological evaluation, if, in fact, the psychological evaluation is performed by the same clinician who is assessing physical evidence and conducting the physical examination.

As mentioned in Module 2 [1], it is essential to obtain the individual’s informed consent prior to the physical examination. The physical examination must be conducted by a qualified physician. Whenever possible, the patient should be able to choose the gender of the physician and, where used, interpreter. If the doctor is not the same gender as the patient, a chaperone who is of the same gender as the patient should be used unless the patient objects. The patient must understand that he or she is in control and has the right to limit the examination or to stop at any time (see Module 3 [2]). 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 are pursued on examination.

In this Module, there are many references to specialist referral and further investigations. Unless the patient is in detention, it is important that physicians have access to physical and psychological treatment facilities, so that any identified need can be followed up. In many situations, certain diagnostic test techniques will not be available, and their absence must not invalidate the report.

In cases of alleged recent torture and when the clothes worn during torture are still being worn by the torture survivor, they should be taken for examination without washing, and a fresh set of clothes should be provided. Wherever possible, the examination room should be equipped with sufficient illumination and medical equipment for the examination. Any deficiencies should be noted in the report. The examiner should note all pertinent positive and negative findings, using body diagrams to record the location and nature of all injuries (see anatomical drawings in Appendix 3 of the Istanbul Protocol [3] to record the location and nature of all injuries). Some forms of torture such as electrical shock or blunt trauma may be initially undetectable, but may be detected during a follow-up examination. Although it will rarely be possible to record photographically lesions of prisoners in custody of their torturers, photography should be a routine part of examinations. If a camera is available, it is always better to take poor quality photographs than to have none. They should be followed up with professional photographs as soon as possible.