Training

Copyright and Acknowledgements

Copyright

© International Rehabilitation Council for Torture Victims

This Model Curriculum was developed by Physicians for Human Rights USA (PHR USA) as part of the Prevention through Documentation (PtD) Project, an initiative of the International Rehabilitation Council for Torture Victims (IRCT), Human Rights Foundation of Turkey (HRFT), REDRESS, and Physicians for Human Rights.

All rights reserved. This work may be reproduced for distribution on a not-for-profit basis for training, educational and reference purposes provided that the International Rehabilitation Council for Torture Victims is acknowledged. All materials distributed must contain this copyright notice: “© International Rehabilitation Council for Torture Victims.”

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International Rehabilitation Council for Torture Victims (IRCT)
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P.O. Box 9049
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DENMARK

ISBN: 978-87-88882-23-0

Acknowledgements

The Model Curriculum was developed by Vincent Iacopino MD, PhD, Senior Medical Advisor, Physicians for Human Rights using the resources listed below. The Model Curriculum was edited by Madhavi Dandu, MD, MPH, University of California, San Francisco and copy edited by Gregory Wong, Wesleyan University. Editorial comments and suggestions were kindly provided by Önder Özkalıpçı MD, International Rehabilitation Council for Torture Victims; Alejandro Moreno, MD, JD, Boston Center for Refugee Health and Human Rights

Many of the materials used for the preparation of the Model Curriculum were developed through the Preventing Torture through Investigation and Documentation (PtD) Project, a collaboration between the Human Rights Foundation of Turkey, REDRESS, Physicians for Human Rights, and the International Rehabilitation Council for Torture Victims. The contributors of those materials included: Hülya Üçcpınar, Türkcan Baykal and Şebnem Korur Fincancı, with comments and contributions provided by Lutz Oette, Anna-Lena Svensson-McCarthy, Nieves Molina Clemente, Ole Vedel Rasmussen, Thomas Wenzel and Vincent Iacopino.

The PowerPoint files that were developed for each of the nine Modules in the Model Curriculum were based on contributions from a number of individuals:

  • Module 1: Vincent Iacopino, Physicians for Human Rights; Bent Sorensen, International Rehabilitation Council for Torture Victims
  • Module 2: Vincent Iacopino, Physicians for Human Rights; Önder Özkalıpçı MD, International Rehabilitation Council for Torture Victims; Caroline Schlar, Action for Torture Survivors (HRFT), Geneva; Jon Snaedal, Istanbul Protocol Implementation Project Training, Tbilisi, Georgia
  • Module 3: Türkcan Baykal MD, Human Rights Foundation of Turkey; Allen Keller MD Bellevue/NYU Program for Survivors of Torture; Uwe Jacobs PhD, Survivors International; Kathleen Allden, MD, Indochinese Psychiatric Clinic; Vincent Iacopino, Physicians for Human Rights
  • Module 4: Vincent Iacopino, Physicians for Human Rights; Önder Özkalıpçı MD, International Rehabilitation Council for Torture Victims; Alejandro Moreno, MD, JD, Boston Center for Refugee Health and Human Rights; Ole Vedel Rasmussen, MD, DMSc, International Rehabilitation Council for Torture Victims; Türkcan Baykal MD, Human Rights Foundation of Turkey; Caroline Schlar, PhD, Human Rights Foundation of Turkey, Emre Kapnın, Human Rights Foundation of Turkey; Kathleen Allden, MD, Indochinese Psychiatric Clinic
  • Module 5: Vincent Iacopino, Physicians for Human Rights; Önder Özkalıpçı MD, International Rehabilitation Council for Torture Victims; Alejandro Moreno, MD, JD, Boston Center for Refugee Health and Human Rights; Ole Vedel Rasmussen, MD, DMSc, International Rehabilitation Council for Torture Victims; Lis Danielsen, MD, DMSc, International Rehabilitation Council for Torture Victims
  • Module 6: Türkcan Baykal MD, Human Rights Foundation of Turkey, Caroline Schlar, PhD, Human Rights Foundation of Turkey, Emre Kapnın, Human Rights Foundation of Turkey; Kathleen Allden, MD, Indochinese Psychiatric Clinic; Vincent Iacopino, Physicians for Human Rights
  • Module 7: Vincent Iacopino, Physicians for Human Rights; Alejandro Moreno, MD, JD, Boston Center for Refugee Health and Human Rights; Önder Özkalıpçı MD, International Rehabilitation Council for Torture Victims
  • Module 8: Vincent Iacopino, Physicians for Human Rights; Alejandro Moreno, MD, JD, Boston Center for Refugee Health and Human Rights; Önder Özkalıpçı MD, International Rehabilitation Council for Torture Victims
  • Module 9: Vincent Iacopino, Physicians for Human Rights; Alejandro Moreno, MD, JD, Boston Center for Refugee Health and Human Rights; Önder Özkalıpçı MD, International Rehabilitation Council for Torture Victims

The two Case Examples included in Modules 7 and 8 were developed by: Vincent Iacopino, Physicians for Human Rights; Alejandro Moreno, MD, JD, Boston Center for Refugee Health and Human Rights; Önder Özkalıpçı MD, International Rehabilitation Council for Torture Victims. The PowerPoint presentations were edited by Madhavi Dandu, MD, MPH, University of California, San Francisco and copy edited by Gregory Wong, Wesleyan University.

The two Psychological Evaluations used in Module 6 were provided by: Uwe Jacobs PhD, Survivors International; Kathleen Allden, MD, Indochinese Psychiatric Clinic.

All Self-Assessment files were developed by Vincent Iacopino, Physicians for Human Rights with editorial comments and suggestions provided by Madhavi Dandu, MD, MPH, University of California, San Francisco and copy edited by Gregory Wong, Wesleyan University.

Copyright © International Rehabilitation Council for Torture Victims This Model Curriculum was developed by Physicians for Human Rights USA (PHR USA) as part of the Prevention through Documentation (PtD) Project, an initiative of the International Rehabilitation Council for Torture Victims … Continue reading

Assessment for Referral

The clinician should not hesitate to seek any further consultation and examination that he or she considers necessary for the evaluation. Those who need further medical and/or psychological care should be referred to appropriate services as discussed in Module 3. During ongoing care, further evidence may be detected that may not have been foreseen. If there is a rehabilitation centre for torture survivors in the region, the clinician may contact them for further support and advice.

In countries with there is a tradition of systematic torture, and pressure on health care professionals, the examining clinician may also prefer to refer patients to specialists to increase the number of medical witnesses to the torture (e.g. consulting with a dermatologist for a simple contusion).

The clinician should not hesitate to seek any further consultation and examination that he or she considers necessary for the evaluation. Those who need further medical and/or psychological care should be referred to appropriate services as discussed in Module 3. … Continue reading

Module 7 Answers

  1. Answer: A, B, D

    All of the considerations listed are important for effective interviews with the exception of C. All individuals alleging torture, including those in custody, should be informed that they are not required to answer any question that they choose not to.

  2. Answer: B, C

    Informed consent is required before all medical evaluations and explaining the potential benefits and risks of the evaluation is part of the consent process.

  3. Answer: D

    Given the possibility of intense shame and ongoing fear, it would be prudent to select a translator who is not related to Mrs. Yousif and is not a member of the refugee community. The clinician should reassure Mrs. Yousif of the measures you will take to ensure confidentiality of the information she provides.

  4. Answer: C

    Initially, questions should be open-ended, allowing a narration of the trauma with minimal interruptions. Closed questions are often used to add clarity to a narrative account or to carefully redirect the interview if the individual wanders off the subject.

  5. Answer: A

    Other traumatic experiences may contribute to the psychological symptoms of survivors of torture. In Mrs. Yousif’s case, the killing of her husband and burning of her home and village likely contributed to her psychological symptoms.

  6. Answer: C

    Inability to protect the ones we love from extreme harm often results in severe and prolonged emotional reactions such as guilt, shame and rage. Mrs. Yousif indicated that she has a profound sense of guilt over what happened to her daughter and is often preoccupied with thoughts of what she should have done differently.

  7. Answer: E, F, G

    Mrs. Yousif’s trauma history did not included allegations of blindfolding. Although she reported being stuck in the head with the butt of a handgun and kicked in the side of her face, she did not have any lapses in consciousness. The abuses that she described do not suggest significant disorientation that is often associated with prolonged isolation and sleep deprivation. She does have marked symptoms of PTSD, however, and both fear of reprisals and lack of trust in the examining clinician should be anticipated given her previous interactions with police and medical personnel.

  8. Answer: A

    The content of perpetrators’ verbal remarks often refers to the intent of the abuse and is often relevant to the individual meaning assigned to the torture experience.

  9. Answer: E

    Moving on with the interview would certainly be appropriate, but the other options listed (B, C and D) also may help to inform the alleged victim’s decision on whether to discuss the allegation of sexual assault further. The option of offering to limit reporting to a judge, only, may depend on the acceptability of this option within the domestic legal system and/or the extent to which absolute confidentiality can be maintained.

  10. Answer: H

    All of the indirect questions listed may be helpful in assessing the possibility of rape and other forms of sexual assault.

  11. Answer: A, C

    Mrs. Yousif’s history is highly consistent with a Bell’s Palsy after being kicked on the right side of her face with subsequent swelling, temporarily affecting the right Facial Nerve. Her observation of “tram-track” lines following beating with a hose is also highly consistent with the alleged abuse as it indicates first-hand knowledge of the alleged experience.

  12. Answer: F

    Mrs. Yousif presented to Nyala Hospital 2 days after the alleged assault. In the acute setting for rape allegations, all of the measures listed should be taken. For CDC recommendations on antiretroviral postexposure prophylaxis after sexual exposure to HIV, see: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5402a1.htm.

  13. Answer: A

    Mrs. Yousif meets diagnostic criteria for PTSD: She was exposed to multiple traumatic events or experiences involving intense fear, horror, or helplessness and the events or experiences involved threats of death, serious injury, or physical integrity. She has at least one re-experiencing symptom, at least 3 avoidance symptoms, and at least 2 persistent indicators of increased arousal. Since her symptoms have persisted for longer than 3 months, her PTSD should be considered “chronic.”

  14. Answer: B

    While the content of PTSD symptoms may be consistent or highly consistent with allegations of torture and ill treatment, the diagnosis of PTSD, in and of itself, is not specific for torture and/or ill treatment. On the other hand, there is often a strong relationship between an individual’s psychological symptoms and the individual meaning of torture experiences.

  15. Answer: E

    All of the traumatic experiences listed likely contribute to Mrs. Yousif’s psychological symptoms.

  16. Answer: E

    All of the factors listed may help to distinguish cause-specific psychological symptoms.

  17. Answer: B

    It is rare to find any physical evidence when examining female genitalia more than one week after an assault. For this reason, and the risk re-traumatizing Mrs. Yousif unnecessarily, a pelvic examination is not recommended. The most significant component of a medical evaluation in the chronic phase of rape allegations is the psychological assessment and other, non-gynecologic, physical findings.

  18. Answer: E

    All of the symptoms of sexual dysfunction listed may be observed following rape.

  19. Answer: B

    While Mrs. Yousif’s physical findings are consistent with the alleged trauma, they may be the result of other injuries. [Note, the description of the complex, atrophic scar over the dorsum of the left hand is consistent with the history of a laceration that healed by secondary intention; it apparently became infected, formed an abscess and required incision and drainage.]

  20. Answer: C

    Mrs. Yousif’s psychological symptoms are highly consistent with the torture and ill treatment that she alleged. The severity of her symptoms is consistent with the multiple traumas she reported. In addition to meeting diagnostic criteria for PTSD and Major Depressive Disorder, the content of some of her psychological symptoms refer specifically to the alleged abuse. Her intense feelings of guilt over her daughter’s rape and the consistency between her observed affect during the interview and the content of the evaluation are also highly consistent with the torture and ill treatment she alleged.

Answer: A, B, D All of the considerations listed are important for effective interviews with the exception of C. All individuals alleging torture, including those in custody, should be informed that they are not required to answer any question that … Continue reading

What is Torture

Torture, as understood in international law, involves several elements: the infliction of severe pain (whether physical or psychological) by a perpetrator who acts purposefully and on behalf of the state. The United Nations Convention against Torture defines torture this way:

For the purposes of [the] Convention, the term “torture” means any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity. It does not include pain or suffering arising only from, inherent in or incidental to lawful sanctions.

— [Article 1.]

Torture, as understood in international law, involves several elements: the infliction of severe pain (whether physical or psychological) by a perpetrator who acts purposefully and on behalf of the state. The United Nations Convention against Torture defines torture this way: … Continue reading

Dermatologic Evaluation

Physical evidence of torture is often revealed in a comprehensive examination of the skin. Description of skin lesions should include the following:

  • Localisation (use body diagram): symmetrical, asymmetrical
  • Shape: round, oval, linear, circumferential, etc
  • Size: (use ruler)
  • Colour
  • Surface: scaly, crusty, ulcerative, bullous, necrotic
  • Periphery: regular or irregular, zone in the periphery
  • Demarcation: sharply, poorly demarcated
  • Level in relation to surrounding skin: atrophic, hypertrophic, macular

Common injuries to the skin can be classified as:

  • Abrasions (or grazes)
  • Contusions (commonly known as bruises)
  • Lacerations (also, commonly but confusingly, known as cuts)
  • Incisions (including stab wounds)
  • Burns and scalds.

Abrasions

An abrasion is a scraping away of the superficial portions of the epidermis or destruction of the superficial layers by tangential application of force against the rough surface of the blunt object. Abrasions are more commonly observed over bony prominences or where a thin layer of skin overlies bone. When the blunt instrument scrapes off the superficial layers of the skin the surface is striped. If abrasions are deep and extend down to the dermis, capillaries may bleed, and serosanguineous fluid deposits on the surface of the skin that forms a brownish scab when it dries out. The abrasion remains moist until it forms a scab which consists of a hardened exudate. During the two or three days following the injury, abrasions produce fluid that crusts over. This makes them very susceptible to infection, which delays and distorts the healing process. The scab organizes in a few days and covers the lesions for up to a few weeks, and then it usually leaves a pink intact surface after detaching. The pink colour gradually fades, within a few months. Unless the abrasions are of full-thickness, they will heal with few remaining signs, although they can leave hyperpigmentation or hypopigmentation.

Linear abrasions are referred to as scratches. These are caused by pointed objects such as wire-ends and pins. Sometimes victims of torture may be thrown from moving vehicles so that they slide on the road, or they may be dragged out on the ground during arrest or capture. In these cases extensive abrasions may be seen, and particles of dirt, sand, etc. will predispose the abrasion to infection. The same particles may become embedded in the skin and leave a sort of ‘tattoo’ effect that can persist for years.

Abrasions may show a pattern that reflects the contours of the instrument or surface that inflicted the injury. Identifiable patterns of scratches can be seen, for example, from fingernails. Elongated broad abrasions can be caused by the friction on the skin from objects such as ropes and cords. When the blunt force is directed perpendicular to the skin over the bony prominences, it will generally crush the skin at that point. Sometimes if there is anything between the object and the skin, its imprint may be observed on the skin, such as a shoe print. In hanging and other asphyxiations by ligature, patterned abrasions can often be found on the neck.

Contusions

A contusion or bruise is caused when blunt trauma occurs to the subcutaneous tissue resulting in rupture of blood vessels with extravasation into the neighbouring soft tissue. The continuity of the skin surface is unbroken. Contusions may be present not only in skin but also in muscles and internal organs. A haematoma is a focal collection of blood in the area of the bruise.

Contusions cause blood to leak from small blood vessels, making the area tender and sometimes boggy. If the skin and subcutaneous tissues are thin, the bruise becomes apparent relatively quickly and may take the shape of the weapon used, although this might not be obvious in darker skins. The extent and severity of a contusion are related to the amount of force applied, but more importantly vascular structure of the traumatised area affects them. Elderly people and children who have loosely supported vascular structure will bruise more easily than young adults. Many medical conditions are associated with easy bruising or purpura, including blood disorders, vascular disorders, and vitamin and other nutritional deficiencies. Certain types of medication can also impair clotting and result in more extensive bruising.

Sometimes the shape of the bruise helps to identify shape of the blunt instrument that caused the injury. For example, a blow from a baton or heavy stick often leaves two parallel lines of bruising (tramline bruising) caused by the blood being pushed sideways by the contact. Ideally bruises should be photographed as soon as possible (see Medical Photography section below), before they spread or fade.

When the bruise is deep, the blood tracks slowly to the surface, and it may be several hours or even days before anything is visible. It is often helpful in such cases to re-examine the patient a day or two later. In such cases the extravasated blood (blood that has been lost from the vessels) follows tissue planes and may emerge some distance from the original injury, and is unlikely to be tender. For example, bruising of any part of the face may appear below the eye. Thus the site of the bruise is not the site of the injury, but the size of the bruise could be evidence of the force of the blow. This should be made clear in any report.

Bruises change colour and fade over a period of hours and days as the blood pigments are metabolised and absorbed, but this takes a variable period of time in different parts of the body following a single incident. However, if there are bruises at different stages of resolution in the same place, this could support allegations of repeated assaults over several days.

Speculative judgments should be avoided in the evaluation of the nature and age of blunt traumatic lesions since a lesion may vary according to the age, sex, condition, and health of the patient, the tissue characteristics, and the severity of the trauma. Fresh and old injuries can be seen together on people who have a long history of torture.

Irradiation, corticosteroids, scurvy, diabetes, hepatic cirrhosis, uraemia, denervation of the wounded area, blood loss, cold, concussion, and shock all inhibit wound healing. Wounds heal faster in young people. Bruises resolve over a variable period, ranging from days to weeks. Reddish-blue, blue or purplish-black bruises are almost certainly recent. As the extravasated red cells are destroyed, the aging bruise goes through variable colour changes of bluish-green, greenish-yellow and brown. Estimating the age of non-recent bruises is one of the most contentious areas of forensic medicine.

Lacerations

Lacerations are caused by a tangential force such as a blow or a fall and produce tears of the skin. The wound edges tend to be irregular, and often any may be bruised or/and abraded. There might be tissue bridges (where the skin has not separated along the entire length of the wound). Lacerations develop easily on the protruding parts of the body since the skin is compressed between the blunt object and the bone surface under the subdermal tissues. With sufficient force, however, the skin can be torn on any portion of the body.

Incisions

Incisions are caused by sharp objects like a knife, bayonet, or broken glass that produce a more or less deep, sharp and well-demarcated skin wound. The acute appearance is usually easy to distinguish from the irregular and torn appearance of lacerations. The term ‘cut’ should never be used in a report, as colloquially the term usually means a laceration.

Incisional wounds have clearly defined edges and, on close inspection, it may be possible to see that hairs have been cut. There are no tissue bridges. Sometimes the wound can be jagged, suggesting that it was not caused by a single stroke. However, because the skin stretches as it is cut, the size of the wound is not necessarily related to the size of the implement used.

Small wounds and those that are supported by surrounding tissues heal at the surface, and they may be difficult to see after only a few days. If the wound is in a part of the skin that is not supported, it will gape. Unless it is sutured or otherwise closed, it will heal from inside.

Stab wounds are incisions that are deeper than they are wide. They should be examined carefully because of the risk of damage to deeper structures.

Burns and scalds

Burns are usually caused by dry heat, but the skin can also be scalded with very hot liquids or burnt with chemicals. Burning is a form of torture that frequently leaves permanent changes in the skin. The shape of the lesion can sometimes, but not always, reveal the shape of the object that caused the burn. The damage caused by heat is proportional to the temperature and the duration of exposure. Burns are classified into three degrees, according to severity.

  • In superficial (first degree) burns, there is no permanent damage to the epidermis. They present as a reddening of the skin.
  • In partial thickness (second degree) burns, some of the epidermis is destroyed and there may also be damage to deeper tissues. They present as moist, red, blistered lesions and are normally very painful.
  • In full thickness (third degree) burns, there is complete destruction of the epidermis and significant damage to deeper tissues. Sometimes third-degree burns are seen with complete destruction of all layers of the skin. The shape of the lesions may or may not reflect the shape of object that caused the thermal injury. They may not be as painful as partial thickness burns. If the burns are widespread, there is usually death from shock and fluid loss.

Cigarettes are commonly used by torturers to inflict pain. Most cigarette burns are superficial and fade over a few hours to a few days. They tend to be circular, have a diameter of up to 1 cm. They cause an erythematous (reddening of the skin) and an oedematous circle that can blister. Deeper burns are caused when the lit cigarette is pressed against the skin for a longer time. When this happens the lesion is deeper and there might be a full thickness burn in the centre surrounded by blisters. If the cigarette is rubbed in it leaves a larger and more irregular lesion. The cigarette fire has a conical structure and its intensity may vary on different parts of the surface. Sometimes there is indistinct blister formation and the lesion is deeper in one part, with blisters partially or totally surrounding it. There may be complete disruption of the epidermis and most of the basal layer.

Electric burns usually consist of a red brown circular lesion, 1 – 3 mm in diameter, usually without inflammation, and may result in a hyperpigmented scar. The skin surfaces involved must be examined carefully because the lesions are often not easily discernible.

Electrical burns may produce specific histologic changes, but these are not always present, and the absence of such changes in no way mitigates against the lesion being an electrical burn. The decision must be made on a case by case basis as to whether or not the pain and discomfort associated with a skin biopsy can be justified by the potential results of the procedure.

Burns from hot objects tend to take the shape of the surface that caused the burn. The wound contracts as it heals, so the lesion may be smaller than the object.

Liquids flow on contact with the skin, and this can leave a distinctive pattern reflecting the survivor’s posture at the time of the incident. Scalds lose heat rapidly so the resulting lesion diminishes away from the point of first contact, whereas chemical burns are often more extensive. A number of lesions from scalding in different parts of the body are suggestive of torture. A single burn might be caused by torture but could also be due to an accident either at work or otherwise. A good occupational history is paramount.

Complex Lesions

Many lesions comprise areas of different types of wounds. For example, as noted above, many lacerations are bruised and abraded at their edges. Wounds caused by broken glass may be a mixture of incision and laceration.

Bites tend to be a mixture of laceration and crush injury. Human bites, especially those that are sexual in nature, can show petechiae from sucking. Petechiae are obvious in the twenty-four hours following the assault. The marks from human bites have a semicircular shape and appear blunt. Animal bites cause deeper and sharper wounds. It is important to look for lacerations caused by the claws.

Scarring

It is often the case that a health professional will see a survivor of torture months or years after the incidents. In such cases the wounds are likely to have healed to a greater or lesser extent. Healing is influenced and often impaired by many factors that can be present in places of detention including persistent, untreated infection; repeated trauma to the same area; and malnutrition. When faced with the examination of old injuries, it is thus important to obtain a detailed history from the individual of the acute appearance of the injury, any treatment received (such as sutures, antibiotics) and a description of how the wound healed and in what time frame. Such descriptions from a lay person may in themselves assist in corroborating allegations since they may indicate medical phenomena that a lay person would not usually be aware of. Such a description of wound healing may also reveal elements of the detention which are also deliberately neglected, such as:

  • Inadequate healthcare provision
  • Poor toilet and washing facilities
  • Insufficient or nutritionally incomplete diet.

The commonest physical finding following the late examination of survivors of torture is scarring. Most scars are nonspecific, but some individual scars can be helpful in supporting a history of torture, as can the pattern of scarring. Occasionally the individual will have photographs of the acute lesions, and these can be very helpful in giving an opinion on the cause of the late signs. However, before citing such photographs in an expert report, it is essential to be certain of the date of the photographs, and that they really are of that individual.

Full thickness wounds (those that go through the epidermis) heal in one of two ways. When the wound is small and the edges are opposed, it heals from the top down (by primary intention). This tends to leave a small, tidy scar. Pockets of infection inside can become abscesses.

If this process cannot occur, especially if the wound gapes, it heals from below (by secondary intention). This is a slow process and prone to infection, and will leave a wide scar. When the original wound was straight, and especially if it was an incision, the scar tends to be symmetrical, with curved edges, and is widest at the middle (a biconvex scar).

The number, position and size of lesions may indicate other aspects of the conditions in which the individual was detained. For example, if the floor of a cell is flooded for any reason, and there is no access to a toilet so that the person has to urinate and defecate in the cell, the detainees will have to sit or stand in dilute sewage. In these circumstances, minor wounds, whether caused by assault or accident, may well become infected and can leave many small scars around the lower legs or buttocks. These must be differentiated from lesions left by childhood skin infections and other causes. All scars should be documented, including those that the individual feels were caused in incidents other than torture.

If a scar has suture marks around it, this should be documented, as this demonstrates that medical care was given. Equally it should also be noted if there are scars from wounds that have clearly not received medical attention, or have been seriously infected. Scars from surgery should also be noted, especially if it is alleged to be associated with torture, for example the removal of a ruptured spleen.

Sometimes scars are self-inflicted in order to support a weak medico-legal case, but these are often apparent. Generally they are superficial and within easy reach of the dominant hand.

Small regular patterns of scarring, particularly but not exclusively in Africans, could either be tribal marking or caused by traditional healers. The former are generally on the face. The latter tend to be multiple, symmetrical, and around painful parts of the body. However, some torturers may also produce small symmetrical patterns of scarring.

Bullet wounds are rarely caused during torture but may be caused prior to arrest or during escape (sometimes security forces stage escapes before shooting detainees). Generally, as a bullet enters the body it leaves a small, regular wound, but as it leaves the wound is much larger and more ragged. The appearance depends on the distance from the weapon and its type. If there is an entry wound but no exit wound, it may be appropriate to arrange an X-ray to find out if the bullet is still in the body. A photograph or, if a camera is not available, a drawing of the wounds might be helpful if an expert opinion needs to be sought.

Upper limbs

Small wounds to the backs of the hands can be caused by punching or being hit. Wounds on the backs of the forearm could be defence injuries. The inside of the non-dominant forearm is the usual location of self-inflicted wounds. Superficial abrasions or reddening around the wrists could have been caused by tight handcuffs or cords. At a later stage there is often hair loss and there may be hyperpigmentation.

Finger and toe nails can be extracted or crushed during torture, but the late appearance is normally indistinguishable from infection or innocent trauma. Vaccination scars should be noted to ensure they are not attributed to ill-treatment.

Lower limbs

Scars on the knees and shins are common in many people, especially those who have played contact sports. Thus lesions in this part of the body can rarely be significant, though they might be consistent with allegations of torture. Additionally, tropical ulcers in childhood can leave large, irregular scars primarily around the lower legs. Lesions on the upper thighs and particularly those inside the thighs are much more important, as they are less likely to be the result of disease or accidental causes.

Keloid scarring

Keloids are scars that exceed the boundaries of the original wound. They are much more common in some skin types than others. The exact pathogenesis is unclear, but the tendency to them is probably inherited. Those who have a tendency to keloid will probably have several thickened scars on their bodies. Thus such scars are more difficult to attribute to specific allegations of torture.

Post-inflammatory hyperpigmentation

Hyperpigmentation can follow inflammation in darker skins, irrespective of the cause. It is not seen in pale skins, nor in very dark skins. The hyperpigmentation retains the shape of the original inflammation, which can be important forensically. For example, classic tramline bruising (e.g. parallel lines of bruising) following a blow from a baton or similar object or inflammation from burns can leave distinctive patterns of hyperpigmentation. The increased pigmentation can last for between five and ten years.

Whipping can sometimes leave lines of hyperpigmentation, especially in darker skin. These lesions are rarely confused with striae distensae (see below) commonly referred to as “stretch marks.”

Less regular patterns of hyperpigmentation are seen following abrasions, again particularly in darker skins. Tight ropes or handcuffs may leave marks around the wrists, and marks following rope burns can be seen elsewhere on the body where the individual has been tied up or suspended. These are rarely pathognomonic individually, but the locations and distribution of the marks can support the history of torture.

As hyperpigmentation can follow any inflammation, any other cause of inflammation can cause a similar pattern. For example, lines of increased pigmentation that follow an irritant dermatitis from contact with plant stems can be mistaken for similar lines following whipping (although it is not unknown for victims to be whipped with irritant plant stems as a form of ill-treatment).

Striae Distensae

Striae distensae (stretch marks) are most common on the abdomen (especially after pregnancy), the lower back, the upper thighs, and around the axillae. They are hypopigmented lines in which the skin might be folded. They must not be confused with scars from whipping. In striae, the skin is intact. They can be evidence of significant weight loss, for example in detention.

Physical evidence of torture is often revealed in a comprehensive examination of the skin. Description of skin lesions should include the following: Localisation (use body diagram): symmetrical, asymmetrical Shape: round, oval, linear, circumferential, etc Size: (use ruler) Colour Surface: scaly, … Continue reading

Introduction

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:

  1. Introduction/Conditions of Interview & Identification Information
  2. Past Medical and Surgical History & Psychosocial History – Pre-Arrest
  3. Trauma History
  4. Review of Torture Methods
  5. Physical Symptoms (acute and chronic) and Disabilities
  6. Psychological Assessment and Mental Status Examination
  7. Physical Examination
  8. 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

Preface

Torture is one of the most traumatic and destructive human experiences. Its purpose is to deliberately destroy not only the physical and emotional well-being of individuals but also, in some instances, the dignity and will of entire communities. Although international human rights and humanitarian law consistently prohibit torture under any circumstance, torture and ill-treatment are practised in nearly half of the world’s countries. Prevention of and accountability for torture are essential to the rule of law and the development of civil society. It concerns all people because these practises impugn the very meaning of our existence and our hopes for a brighter future. Respect for such a basic human right may well demonstrate our capacity to respect other human rights as well.

In recent years, health professionals have recognised the importance of human rights in health, and increasingly have worked to protect and promote human rights as a means of promoting health and preventing human suffering. They have played an important role in the prevention of and accountability for torture through the effective investigation and documentation of torture and ill-treatment. Health professionals were instrumental in the development of the first international guidelines for medico-legal documentation of torture and ill-treatment that are contained in the UN’s Manual on the Effective Investigation and Documentation of Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (Istanbul Protocol). The Istanbul Protocol was developed in 1999; it was the result of three years of analysis, research, and drafting undertaken by more than 75 forensic doctors, physicians, psychologists, human rights monitors, and lawyers representing 40 organisations and institutions from 15 countries.

Medical documentation of torture and ill-treatment is often crucial in judicial proceeding, human rights investigations and monitoring, and in the care of torture survivors. Medical evaluations of torture and ill-treatment involve a thorough clinical evaluation of an individual’s physical and/or psychological health. Medico-legal documentation of torture and ill-treatment requires a careful clinical history and examination by a health professional who is knowledgeable about the medical and psychosocial consequences of torture and sensitive to cross-cultural issues and interpersonal dynamics between traumatised individuals and persons in positions of authority.

This Model Curriculum on the Effective Medical Documentation of Torture and Ill-treatment (Model Curriculum) was developed to enable health professional students to effectively investigate and document torture and ill-treatment. It consists of nine Modules and related supporting documents and contains essential information for students to develop the knowledge and skills required to conduct medical evaluations of torture and ill-treatment. The Modules include information on how to interview an alleged torture victim as well as the comprehensive guidelines for performing clinical examinations to detect physical and psychological evidence of torture and ill-treatment.

Each Module includes a summary of objectives and content, suggested discussion questions and teaching formats, and a list of primary references. The Modules are designed to be used by instructors in seminar discussions or lecture presentations, and by individual students or student groups. The Content of the Model Curriculum is based on the Istanbul Protocol and a number of manuals and resources that were subsequently developed by Istanbul Protocol authors and editors, and their colleagues.

Torture is one of the most traumatic and destructive human experiences. Its purpose is to deliberately destroy not only the physical and emotional well-being of individuals but also, in some instances, the dignity and will of entire communities. Although international … Continue reading

Module 8 Answers

  1. Answer: B

    Police or other law enforcement officials should never be present in the examination room. This procedural safeguard may be precluded only when, in the opinion of the examining doctor, there is compelling evidence that the detainee poses a serious safety risk to health personnel. Under such circumstances, security personnel of the health facility, not the police or other law enforcement officials, should be available upon the medical examiner’s request. In such cases, security personnel should still remain out of earshot (i.e. be only within visual contact) of the patient. The presence of police officers, soldiers, prison officers or other law enforcement officials in the examination room, for whatever reason, should be noted in the physician’s official medical report. The presence of police officers, soldiers, prison officials or other law enforcement officials during the examination may be grounds for disregarding a negative medical report. The identity and titles of others who are present in the examination room during the medical evaluations should be indicated in the report.

  2. Answer: B

    Under no circumstances should a copy of the medical report be transferred to law enforcement officials or security personnel.

  3. Answer: B

    The routine use of restraints during medical consultation or treatment is contrary to medical ethics and international standards on treatment of prisoners. Health professionals must not accept such practises. Restraints not only interfere with the proper diagnosis, management and treatment of patients, but they also run contrary to the inherent dignity of all human beings. The only possible acceptable justification for use of restraints is as a last resort when there is substantiated reason to believe that this particular detainee presents an immediate and current violent threat to himself or others. Health professionals can and should question the use of restraints if they have reason to doubt such a risk exists. In the exceptional circumstances that restraints are used, they should be as minimal as possible.

  4. Answer: A

    It is important to obtain a complete medical history, including prior medical, surgical and/or psychiatric problems. Clinicians should document any history of injuries before the period of detention and any possible after-effects. Knowledge of prior injuries may help to differentiate physical findings related to torture from those that are not.

  5. Answer: B

    Mr. Adam’s psychosocial history contains information relevant to his psychological symptoms, or lack thereof, following the alleged torture and ill treatment. Mr. Adam’s political beliefs and activities have likely mitigated more severe psychological symptoms. His predominant reaction of anger is, in part, likely due to the killing of one of his brothers by security forces.

  6. Answer: C

    Mr. Adam’s history is significant for multiple lapses in consciousness. He was not blindfolded during the alleged torture, only during transport to the place where he was detained. Also, he does not demonstrate evidence of organic brain impairment or significant psychological sequelae.

  7. Answer: C

    Mr. Adam indicated that his multiple episodes of loss of consciousness were associated with asphyxia and electric shocks to his penis. Diagnostic imaging of the brain and EEG studies are not indicated in the absence of significant head trauma, seizure activity or a focal neurological deficit. Given minimal psychological symptoms and normal cognitive functioning, neuropsychological testing would not be indicated. A complete neurological examination would be adequate under the circumstances.

  8. Answer: B

    Sexual assault, including rape, is common among male detainees. Given the intense shame that is usually associated with sexual assault, additional information may not be spontaneously reported. It is important, therefore, to ask Mr. Adam something like: “Many men who are detained by police and security forces are assaulted sexually, including rape. Did anything like this happen to you?”

  9. Answer: A

    Mr. Adam’s difficulty having erections is most likely psychosomatic in origin since he indicated that he has noted normal erections upon waking from sleep.

  10. Answer: B

    Although Mr. Adam’s alleges being suspended from his hands tied behind his back, his acute symptoms of arm pain when lifting heavy objects and right arm numbness subsequently resolved. In the absence of any current complaint and/or numbness or weakness on physical examination, an EMG is not indicated.

  11. Answer: B

    Electric shock often does not result in acute lesions. When present, electric burns usually consist of a red brown circular lesion, 1 – 3 mm in diameter, usually without inflammation, and may result in a hyperpigmented scar. The absence of such changes should not be construed as an inconsistency.

  12. Answer: A, possibly C

    Survivors of torture who ascribe positive meaning to their suffering (e.g. World War II veterans and political activists) often have fewer and less severe psychological symptoms. Fear of police reprisals would likely increase Mr. Adam’s psychological symptoms. Although support from family member also may mitigate psychological symptoms, Mr. Adam’s parents expressed strong disapproval of his political activity and consider his action to be “foolish and dangerous.” This has resulted in considerable discord between them. He and his father have not spoken to one another in the past several weeks. Nonetheless, his parents’ concern may represent a longstanding source of support.

  13. Answer: C

    Cigarette burns typically result in 5 to 10 mm, circular, macular scars with a depigmented centre and a hyperpigmented, relatively indistinct periphery. The lack of a depigmented centre in Mr. Adam’s case may be related to the relative degree of heat applied. The characteristics of the lesions and location on one arm only, are highly consistent with his allegations of cigarette burns.

  14. Answer: B

    Mr. Adam was examined months after he was released from detention. The possibility of self-inflicted injuries cannot be fully excluded.

  15. Answer: C

    Mr. Adam’s physical examination findings of hyperpigmented, circumferential scars above both wrists are highly consistent with his allegations of “rope burns” from suspension torture.

  16. Answer: E

    All of the explanations listed indicate why these physical findings are not likely to be the result of self-inflicted injuries.

  17. Answer: D

    Striae distensae (stretch marks) are most common on the abdomen (especially after pregnancy), the lower back, the upper thighs, and around the axillae. They are hypopigmented lines in which the skin might be folded. They must not be confused with scars from whipping. In striae, the skin is intact. Axillary striae may not be noticed by individuals until after suspension torture.

  18. Answer: B

    Mr. Adam’s psychological findings may not be as extensive or severe as some might expect, but this can be adequately explained by symptom mitigation from his political beliefs and activities and possibly by support from family and friends. Effective coping mechanism also may help to explain his resilience, but this was not thoroughly assessed in Case Example #02. Mr. Adam’s allegations of abuse appear to be at least “consistent with” his psychological evaluation findings.

  19. Answer: B

    Psychological instruments may serve as a useful adjunct to the qualitative, psychological evaluation and may be particularly helpful if an individual has trouble expressing in words his or her experiences and symptoms. This is not the case for Mr. Adam, however. In addition, caution must be exercised in the interpretation of responses and scores of psychological instruments because established norms do not exist for many populations.

  20. Answer: E

    All of the considerations listed would support the credibility of Mr. Adam’s allegations of torture and ill treatment and, if relevant, may be included in the clinician’s written reports and oral testimony. Note that inconsistencies that are attributable to an individual’s torture experience may, in fact, support an individual’s allegations of abuse, rather than undermine it.

Answer: B Police or other law enforcement officials should never be present in the examination room. This procedural safeguard may be precluded only when, in the opinion of the examining doctor, there is compelling evidence that the detainee poses a … Continue reading

About the Istanbul Protocol

Istanbul Protocol thumbnailThe Manual on Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, commonly known as the Istanbul Protocol, outlines international, legal standards on protection against torture and sets out specific guidelines on how effective legal and medical investigations into allegations of torture should be conducted.

The Istanbul Protocol is an important source as it both reflects existing obligations of States under international treaty and customary international law and aids States to effectively implement relevant standards. It became a United Nations official document in 1999. The Istanbul Protocol is intended to serve as a set of international guidelines for the assessment of persons who allege torture and ill-treatment, for investigating cases of alleged torture, and for reporting such findings to the judiciary and any other investigative body. The investigation and documentation guidelines also apply to other contexts, including human rights investigations and monitoring, assessment of individuals seeking political asylum, the defence of individuals who “confess” to crimes during torture, and assessment of needs for the care of survivors of torture. In the case of health professionals who are coerced to neglect, misrepresent, or falsify evidence of torture, the manual also provides an international point of reference for health professionals and adjudicators alike.

The documentation guidelines apply to individuals who allege torture and ill-treatment, whether the individuals are in detention, applying for political asylum, refugees or internally displaced persons, or the subject of general human rights investigations. The guidelines provided cover a range of topics including:

  • Relevant international legal standards
  • Relevant Ethical Codes
  • Legal Investigation of Torture
  • General Considerations for Interviews
  • Physical Evidence of Torture
  • Psychological Evidence of Torture

Many procedures for a torture investigation are included in the manual, such as how to interview the alleged victim and other witnesses, selection of the investigator, safety of witnesses, how to collect alleged perpetrator’s statement, how to secure and obtain physical evidence, and detailed guidelines on how to establish a special independent commission of inquiry to investigate alleged torture and ill-treatment. The manual also includes comprehensive guidelines for clinical examinations to detect physical and psychological evidence of torture and ill-treatment.

The Istanbul Protocol also outlines minimum standards for state adherence to ensure the effective documentation of torture in its Principles on the Effective Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, or “Istanbul Principles” The guidelines contained in the Istanbul Protocol are not designed to be fixed, rather, they represent an elaboration of the minimum standards contained in the Istanbul Principles and should be applied in accordance with a reasonable assessment of available resources.

The Istanbul Protocol is a non-binding document. However, international law obliges governments to investigate and document incidents of torture and other forms of ill-treatment and to punish those responsible in a comprehensive, effective, prompt and impartial manner. The Istanbul Protocol is a tool for doing this.

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The Manual on Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, commonly known as the Istanbul Protocol, outlines international, legal standards on protection against torture and sets out specific guidelines on how effective … Continue reading

Module 9 Answers

  1. Answer: A, B, C, E, F

    Expert medical reports and testimony can be of value in all of the contexts listed with the exception of D. As the Istanbul Protocol makes clear, a medical evaluation does not exclude the possibility that the alleged torture took place. Medical evaluations should not be used to “prove” that law enforcement officials, or any other alleged perpetrator, is innocent of alleged acts or torture and ill treatment.

  2. Answer: A

    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. Clinical evaluations are often critical in enabling adjudicators to make accurate and just decisions in medico-legal cases by providing an assessment of the degree of consistency between allegations of torture and ill treatment and physical and psychological evidence.

  3. Answer: F

    All of the items listed may represent relevant qualifications.

  4. Answer: A

    Qualifying as a medical expert depends on relevant knowledge and skills for both physical and psychological evidence of torture. Physicians who are not psychiatrists may qualify as experts on psychological evidence of torture and ill treatment as symptoms of depression and anxiety are common in general populations and many primary care physicians can acquire the knowledge and skills to diagnose these conditions and initiate appropriate care. The diagnosis of trauma-related disorders such as PTSD requires more specific training and experience for all clinicians, including psychiatrists, psychologists and clinical social workers.

  5. Answer: B

    The evaluating clinician should review the alleged victim’s affidavit (declaration) 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.

  6. Answer: E

    All of the items listed are true.

  7. Answer: E

    All sources of information listed above can and should be used to corroborate allegations of torture and ill treatment as long as the medical evaluator deems them to be relevant and credible.

  8. Answer: A

    Adjudicators are often unaware of the complexities of effective documentation of torture and ill treatment and their decisions may be influenced by pre-existing prejudice. Clinicians can and should take the opportunity to educate adjudicators on physical and psychological evidence of torture and ill treatment, i.e. explaining likely causes of inconsistencies, the sensitivity and specificity of physical findings and diagnostic tests, the utility and limitations of psychological instruments and diagnoses, the significance of historical evidence, etc.

  9. Answer: A

    First evaluations may be less convincing in a court of law than those conducted by clinicians with extensive experience. It is therefore advisable to conduct one’s first evaluation(s) under the supervision or of a more experienced evaluator.

  10. Answer: A

    Historical information may be very useful in corroborating an individual’s allegations of torture because it indicates first-hand knowledge of the alleged experience.

  11. Answer: B

    Istanbul Protocol guidelines include recommendations for care when they are clinically indicated. This is a professional duty independent of the immediate objectives of the legal team.

  12. Answer: A

    The clinician’s interpretation of findings and conclusions on the possibility of torture and ill treatment should be based on all categories of corroborating evidence, including physical and psychological evidence, historical information, and any other relevant resource materials.

  13. Answer: F

    All of the considerations listed support the credibility of an individual’s allegations or torture and ill treatment and, if relevant, may be included in the clinician’s written reports and oral testimony. Note that inconsistencies that are attributable to an individual’s torture experience may, in fact, support an individual’s allegations of abuse, rather than undermine it.

  14. Answer: B

    Credibility is not an all-or-nothing concept – there is a continuum between the absolute truth and the complete fabrication of events, with at least three points in-between: a) a mixture of falsehood and truth; b) conscious or subconscious exaggeration – saying that the ill-treatment was more frequent and more severe than actually happened; and c) genuine errors arising from mistakes and misunderstandings. Clinicians should try to identify potential reasons for exaggeration or fabrication, keeping in mind that fabrications may require detailed knowledge about trauma-related symptoms and findings that individuals rarely possess.

  15. Answer: H

    Inconsistencies may result from a number of factors that may be directly related to the torture and ill treatment or to the psychological and/or neurological symptoms that result from torture and ill treatment. Interview conditions and cross cultural factors may be significant factors as well. Clinicians should be familiar with such factors to effectively explain any inconsistencies observed.

  16. Answer: A

    Adjudicators and cross-examining attorneys may dismiss the medical expert’s findings on the basis of “hear-say” evidence, i.e. that the medical expert is stating a fact that was simply reported to him or her. A statement qualifying the veracity of testimony is therefore advisable.

  17. Answer: B

    While PTSD and MDD are common among survivors of torture, the diagnosis of either one is not cause-specific. Experiences other than torture and ill treatment also may be the cause of these diagnoses or sub-threshold symptoms.

  18. Answer: E

    All of the guidelines listed are relevant considerations for oral testimony by medical experts.

  19. Answer: E

    It is common in medico-legal contexts for the clinician to be asked whether psychological symptoms were caused by the alleged torture and ill-treatment or other traumatic experiences that may have occurred before or after the alleged events. Clinicians should note temporal relationships between the onset of symptoms and the alleged torture and ill-treatment and subsequent trends in psychological symptoms in relation to external stressors. They should also consider content-specific symptoms that may relate to the alleged torture and ill-treatment such as: the content of nightmares, triggers for intrusive recollection, reliving experiences, and avoidance reactions.

  20. Answer: B

    In court, the finding of credibility is a legal matter that is the responsibility of the judge. The expert witness is one resource that the judge draws upon to make that determination. The clinician need not feel the compulsion to make that determination for the judge, and, indeed, judges may resent an expert who tries to do so. What the clinician can do is address any observed inconsistencies and answer the questions of the attorneys and the judge as thoroughly and professionally as possible, along with his/her opinion about credibility, and let the judge arrive at his/her own conclusion.

Answer: A, B, C, E, F Expert medical reports and testimony can be of value in all of the contexts listed with the exception of D. As the Istanbul Protocol makes clear, a medical evaluation does not exclude the possibility … Continue reading