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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
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
Toolkit: Istanbul Protocol Model Medical Curriculum
Subject: Module 4: Torture Methods and their Medical Consequences
Subject: Module 4: Torture Methods and their Medical Consequences
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
(i) To take effective legislative, administrative, judicial or other measures to prevent acts of torture, for example by:
- Establishing effective monitoring mechanisms to prevent torture in all places of detention;
- Ensuring that any statement that is established to have been made as a result of torture shall not be invoked as evidence in any proceedings, except against a person accused of torture as evidence that the statement was made;
- Ensuring that the prohibition of torture is included in training of law enforcement and medical personnel, public and other relevant officials;
- Not expelling, returning, extraditing or otherwise transferring a person to a country when there are substantial grounds for believing that the person would be tortured (non-refoulement).
(ii) To ensure that general safeguards againt torture exist in places of detentions such as:
- Granting detainees prompt and unrestricted access to a lawyer and a doctor of their choice;
- Informing family members or friends about the person’s detention;
- Providing detainees access to family members and friends;
- Not holding persons incommunicado detention;
- Enabling detainees to promptly challenge the legality of their detention before a judge.
(i) To take effective legislative, administrative, judicial or other measures to prevent acts of torture, for example by: Establishing effective monitoring mechanisms to prevent torture in all places of detention; Ensuring that any statement that is established to have been … Continue reading
While it is rare that a victim of rape during torture is released, it is still possible to identify acute signs of the assault. In these cases, there are many issues to be aware of that may impede the medical evaluation. Recently assaulted victims may be troubled and confused about seeking medical or legal help due to their fears, sociocultural concerns or the destructive nature of the abuse. In such cases, a doctor should explain to the individual all possible medical and judicial options and should act in accordance with the individual’s wishes. The duties of the physician include obtention of voluntary informed consent for the examination, recording of all medical findings of abuse and obtention of samples for forensic examination. Whenever possible, the examination should be performed by an expert in documenting sexual assault. Otherwise, the examining physician should speak to an expert or consult a standard text on clinical forensic medicine. When the physician is of a different gender from the victim, he or she should be offered the opportunity of having a chaperone of the same gender in the room. If an interpreter is used, then the interpreter may also fulfil the role of the chaperone. Given the sensitive nature of investigation into sexual assaults, a relative of the alleged victim is not normally an ideal person to use in this role. The individual should be comfortable and relaxed before the examination.
A thorough physical examination should be performed, including meticulous documentation of all physical findings, including size, location and colour, and, whenever possible, these findings should be photographed and evidence collected of specimens from the examination. The physical examination should not initially be directed to the genital area. Particular attention must be given to ensure a thorough examination of the skin, looking for cutaneous lesions that could have resulted from an assault. These include bruises, lacerations, ecchymoses and petechiae from sucking or biting. Lesions on the breasts, particularly from bites, should be enquired about in women who have been sexually assaulted. When the legs are examined, the inner thighs should be inspected thoroughly. Where women have had their legs forced apart, there may be finger bruising, scratches, cigarette burns, incisions and other wounds, or their late consequences.
When genital lesions are minimal, lesions located on other parts of the body may be the most significant evidence of an assault. Even during examination of the female genitalia immediately after rape, there is identifiable damage in less than 50 per cent of the cases. Anal examination of men and women after anal rape shows lesions in less than 30 per cent of cases. Clearly, where relatively large objects have been used to penetrate the vagina or anus, the probability of identifiable damage is much greater.
Where a forensic laboratory is available, the facility should be contacted before the examination to discuss which types of specimen can be tested, and, therefore, which samples should be taken and how. Many laboratories provide kits to permit physicians to take all the necessary samples from individuals alleging sexual assault. If there is no laboratory available, it may still be worthwhile to obtain wet swabs and dry them later in the air. These samples can be used later for DNA testing. Sperm can be identified for up to five days from samples taken with a deep vaginal swab and after up to three days using a rectal sample. Strict precautions must be taken to prevent allegations of cross-contamination when samples have been taken from several different victims, particularly if they are taken from alleged perpetrators. There must be complete protection and documentation of the chain of custody for all forensic samples.
If the woman is being examined shortly after the rape, it is important to discuss issues of pregnancy and emergency contraception, and however long has passed since the assault, sexually transmitted diseases (especially gonorrhoea, chlamydia, syphilis and trichomoniasis) and other infectious diseases such as Hepatitis B (HBV) and HIV must be considered (see below), and treated where present if the necessary facilities are available. If rape occurred within the previous seventy-two hours, consideration must be given to the administration of post-exposure prophylaxis (PEP) of anti-retrovirals (ARVs) for preventing infection by HIV and this depends on a detailed assessment of the nature of the sexual assault. The risk of infection with HBV should be assessed and the need for immunisation determined.
Some women are raped persistently over a long period which increases the likelihood that they will become pregnant; in some cases they are then detained until it is too late to consider termination of pregnancy (if that would otherwise be an option). In such cases routine ante-natal examinations should be performed including, if possible, ultrasounds. This will enable the time of conception to be estimated.
While it is rare that a victim of rape during torture is released, it is still possible to identify acute signs of the assault. In these cases, there are many issues to be aware of that may impede the medical … Continue reading
Torture and other ill-treatment are prohibited in international law and are likely also to be a crime under national law. International law requires not only that torture not be used, but also that any allegation of torture be investigated, and that those responsible be brought to justice.
Effective investigation, including the aspect of medical documentation, is a vital component in the struggle to eradicate the practise of torture. Legal bodies, domestic and international alike, rely on factual evidence to reach their conclusions and uphold justice.
By shedding light on cases of torture and other ill-treatment, effective investigation and documentation can assist in the achievement of a number of important goals:
- Raising awareness of the infliction of torture and its absolute prohibition
- Battling impunity: bringing torture into the public eye assists in calling states to account for their actions and having them fulfill their legal obligations. On a different level, torture reporting can also help to cast light on the individuals who carry out such practises, to make sure that they cannot continue to engage in such behaviour without negative consequences.
- Redress for the survivor: there are a number of remedies and objectives that may assist the individual survivor of torture, for example:
- Preventing and ending ongoing abuse: in certain cases, allegations of torture may be raised by a person who is still in custody of the authorities. Effective and swift investigation can help put an end to the suffering. In other cases, the individual may be seeking protection from abuse in another country, and the determination of whether the individual was a survivor of torture and is personally at risk can prevent the person being deported back into the hands of their torturers.
- Compensation and other forms of restitution: survivors of torture may, for example, be able to claim compensation for monetary loss, physical and mental harm, and other damage caused by the torture
- Rehabilitation: many torture survivors are in need of rehabilitation services, including medical treatment, both physical and psychological, legal assistance, and social services. Effective investigation and documentation can assist in diagnosis, treatment (including rehabilitation) and prognosis of the patient.
- Official and public acknowledgement of their suffering can also be important in the recovery process of survivors of torture.
- Reform: drawing attention to a situation is not just about seeking condemnation or holding a state accountable. Even more importantly, it is about seeking constructive and long-term improvements in a country, which will contribute to the ultimate elimination of torture. This will often require changes both in the legislative framework and in official attitudes to torture. The eradication of torture is a fundamental and necessary step for any society aspiring to protect human rights and care for its people.
Torture and other ill-treatment are prohibited in international law and are likely also to be a crime under national law. International law requires not only that torture not be used, but also that any allegation of torture be investigated, and … Continue reading
The documentation of torture and other ill-treatment depends on the gathering of detailed and accurate information from the individual on the circumstances of the alleged events, including details of any arrest, detention, conditions of detention and specific treatment while under interrogation. The interview should be structured and conducted according to the guidelines defined in “the general considerations for the interview”, “procedural safeguards” and “medical ethics” chapters of the Istanbul Protocol. These considerations apply to all persons carrying out interviews whether they are lawyers, medical doctors, psychologists, psychiatrists, human rights monitors or members of any other profession. Interview considerations that pertain specifically to the documentation of physical and psychological evidence of torure are included in Modules 5 and 6 respectively.
Torture is usually both physical and psychological in nature. It is important, therefore, for each clinician to elicit and relate physical and psychological information in their evaluations. It should be noted that, with appropriate training, physicians may become qualified to conduct psychological evaluations. Those who are not qualified, should refer the alleged victim to a qualified psychological expert (i.e. psychologist, psychiatrist, clinical social worker). Medical doctors should carefully consider the potential benefits and possible difficulties of qualifying as a psychological expert. It may be helpful to seek the advice of attorneys to better understand country-specific requirements to qualify as an expert witness on on psychological evidence of torture.
The degree of detail gathered during an interview with an alleged victim of torture depends on several factors, such as the aim of the interview/examination (producing a note in a medical record of incidental findings during a routine medical visit, versus being asked to provide a medical report for a judicial body), the location and circumstances of the interview (for example in a health clinic, in a police station or prison, or in a rehabilitation centre for survivors of torture) and the degree of access to the individual and amount of time available. This being said, the principles on interviewing can be adapted and applied to the various circumstances in which an individual alleging torture may be encountered.
Clinicians should not assume that the individual, such as the asylum applicant’s attorney, requesting a medico-legal evaluation has related all the material facts. It is the clinician’s responsibility to discover and report upon any material findings that he or she considers relevant, even if they may be considered irrelevant or adverse to the case of the party requesting the medical examination. Findings that are consistent with torture or other forms of ill-treatment must not be excluded from a medico-legal report under any circumstance.
The documentation of torture and other ill-treatment depends on the gathering of detailed and accurate information from the individual on the circumstances of the alleged events, including details of any arrest, detention, conditions of detention and specific treatment while under … Continue reading
- Answer: B
The Istanbul Protocol outlines international, legal standards on protection against torture and establishes specific guidelines for the effective investigation and documentation of torture and ill treatment. 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.
- Answer: True
The Istanbul Protocol 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 Istanbul Protocol represents an elaboration of the minimum standards contained in the Istanbul Principles and should be applied in accordance with a reasonable assessment of available resources.
- Answer: A
The Istanbul Protocol and its related Principles have been recognised as international standards for the effective investigation and documentation of torture and ill treatment by the UN General Assembly and the then UN Commission on Human Rights (since 2006, the UN Human Rights Council), the UN Special Rapporteur on Torture, the African Commission on Human and Peoples’ Rights, the European Union and other institutions and organizations.
- Answer: B
Conducting an objective and impartial evaluation should not preclude the evaluator from being empathic. It is essential for clinicians to maintain professional boundaries and at the same time to acknowledge the pain and distress that they observe. The clinician should communicate his or her understanding of the individual’s pain and suffering and adopt a supportive, non-judgmental approach. Clinicians need to be sensitive and empathic in their questioning while remaining objective in their clinical assessment.
- Answer: A
It is important to realize that the severity of psychological reactions depends on the unique cultural, social, and political meanings that torture and ill-treatment have for each individual, and significant ill effects do not require extreme physical harm. Seemingly benign forms of ill-treatment can and do have marked, long-term psychological effects. Although some survivors of torture may have few or no psychological sequelae, most individuals experience profound, long-term psychological symptoms and disabilities.
- Answer: B.
Although there are a myriad of psychological issues that torture victims might have including C and D, PTSD and major depression are the two most common problems.
- Answer: B.
Unfortunately, it is a common misconception among evaluators, attorneys and adjudicators that psychological evidence is of lesser legal value than “objective” physical findings. The aim and effect of torture is largely psychological. The psychological evaluation is critical in assessing the level of consistency between the alleged trauma and individual psychological responses. In some cases, the symptoms may be either attenuated or exacerbated depending on the meaning assigned to individual experiences.
- Answer: B
As the Istanbul Protocol makes clear, the absence of physical and/or psychological evidence in a medical evaluation does not rule-out the possibility that torture or ill-treatment was inflicted. The Istanbul Protocol was developed to prevent torture and ill-treatment and to promote accountability. Governments must ensure that its official representatives do not engage in misuse or misrepresentation of the Istanbul Protocol to exonerate police who are accused of abuses or for any other purpose.
- Answer: B, D
Each detainee must be examined in private. 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. Prisoners should feel comfortable with where they are evaluated. In some cases, it may be best to insist on evaluation at official medical facilities and not at the place of detention. In other cases, detainees may prefer to be examined in the relative safety of their cell, if they feel the medical premises may be under surveillance, for example. The best place will be dictated by many factors, but in all cases, investigators should ensure that prisoners are not forced into accepting a place they are not comfortable with. Requests for medical evaluations by law enforcement officials are to be considered invalid unless they are requested by written orders of a public prosecutor.
- Answer: A
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.
- Answer: A
The presence of police, soldier, warden, or other law enforcement officers in the examination room, for whatever reason, should be noted in the physician’s official medical report. Notation of police, soldier, prison officer, or other law enforcement official’s presence during the examination may be grounds for disregarding a “negative” medical report.
- Answer: A.
Many of the rules and principles of medical ethics have been adopted as professional codes of conduct. While ethics must guide every action of health professionals in their work, in the process of investigating and documenting allegations of torture, there are three areas in which the health professional must be particularly cognizant of specific ethical considerations. The first is the duty to the patient, the second is the clinical independence of the health professional and the third is in the production of medical records, reports and testimony.
- Answer: A
The use of hoods or blindfolds has in itself been found to be a form of ill-treatment. In the health setting hoods or blindfolds not only impair any meaningful contact with the patient; they also prevent the identification of any health professionals and may thus add to a perception of impunity in cases of ill-treatment.
- Answer: D
A, B, and C are all provision under the World Medical Association’s 1975 Tokyo Declaration.
- Answer: F
All of the answers represent either passive or active complicity of health professionals in torture and ill treatment. Physicians and other medical personnel have the obligation not to condone or participate in torture in any way.
- Answer: F
All of the elements listed are essential to informed consent.
- Answer: A
The health professional must contemplate the risks to the patient, and indeed to themselves, in disclosing such information, and the potential benefits to society as a whole (e.g. potentially avoiding further harm to others), before acting. Whatever decision is reached, the health professional should endeavour to gain consent. In such cases, the fundamental ethical obligations to respect autonomy and to act in the best interests of the patient are more important than other considerations.
- Answer: B
In an ideal situation, an independent doctor will have explained the risks of a prolonged hunger strike, and taken instructions on what the person wants to happen if he or she ceases to be capable of rational thought. This should happen in an environment where the patient’s confidentiality can be respected, and where he or she can be protected from undue pressure from political colleagues. In cases where prison doctors have been following hunger strikers before and during the fast, and know what the patients’ positions and convictions are, physicians should respect the principles stated in the Declaration of Malta. If a physician is called upon to take care of a hunger striker already in a comatose state, he or she will have no choice and will have to provide reanimation. A physician should not rely on what amounts to “hearsay” in such cases. The opinions of the immediate family should be taken into consideration, but are not paramount. Neither the opinions of the authorities nor those of the patient’s political colleagues should be given any weight.
- Answer: B
The Declaration of Tokyo was revised in 2006 to include the following provision: “The physician shall not use nor allow to be used, as far as he or she can, medical knowledge or skills, or health information specific to individuals, to facilitate or otherwise aid any interrogation, legal or illegal, of those individuals.”
- Answer: G
The primary goal of documenting allegations of human rights violations is to create an accurate, reliable and precise record of events. All of the forms of information listed are essential to the effective medical and legal investigations of torture and ill treatment.
Answer: B The Istanbul Protocol outlines international, legal standards on protection against torture and establishes specific guidelines for the effective investigation and documentation of torture and ill treatment. The Istanbul Protocol is a non-binding document. However, international law obliges governments … Continue reading