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Torture

Primary loyalty to the patient

The principles of medical ethics make it clear that the primary loyalty of the health professional is to the patient. While the health professional may feel bound towards the state as an employer or for ideological reasons, their first and foremost obligation is always to the patient. According to the Tokyo Declaration “…the doctor’s fundamental role is to alleviate the distress of his or her fellow men, and no motive whether personal, collective or political shall prevail against this higher purpose.”

In fact, according to the World Medical Association’s Declaration on the Rights of the Patient, “whenever legislation, government action or any other administration or institution denies patients these rights, physicians should pursue appropriate means to assure or to restore them.”

The principles of medical ethics make it clear that the primary loyalty of the health professional is to the patient. While the health professional may feel bound towards the state as an employer or for ideological reasons, their first and … Continue reading →

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Confidentiality

Clinicians have a duty to maintain confidentiality of information and to disclose information with only the interviewee’s informed consent. The clarification of confidentiality and its limits are of paramount importance for a well-conducted interview. The interviewee should be clearly informed of any limits on the confidentiality of the evaluation and of any legal obligations for disclosure of the information gathered by means of the interview and medical/psychological examination at the beginning of the interview.

Individuals may fear that information revealed in the context of an evaluation cannot be safely kept from being accessed by persecuting governments. Fear and mistrust may be particularly strong in cases where physicians or other health workers were participants in the torture. In many circumstances, the evaluator will be a member of the majority culture and ethnicity, whereas the patient, in the situation and location of the interview, is likely to belong to a minority group or culture. This dynamic of inequality may reinforce the perceived and real imbalance of power and may increase the potential sense of fear, mistrust and forced submission in the interviewee.

Clinicians have a duty to maintain confidentiality of information and to disclose information with only the interviewee’s informed consent. The clarification of confidentiality and its limits are of paramount importance for a well-conducted interview. The interviewee should be clearly informed … Continue reading →

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Self-Assessment and Quiz

  1. In which of the following contexts may expert medical reports and testimony be of value?
    1. Prosecution of alleged perpetrators
    2. Challenging the credibility of statements extracted by torture
    3. Reparations and rehabilitation of alleged victims
    4. Exonerating law enforcement officials accused of torture and ill treatment
    5. Human rights investigations
    6. Medical assessments of asylum applicants
    7. All of the above
  2. Regardless of the context of a medical evaluation, the purpose of written reports and oral testimony by medical experts is to assess the degree to which physical and psychological findings correlate with the individual allegations of abuse.
    1. True
    2. False
  3. Which of the following may be relevant qualifications for medical expertise on physical and/or psychological evidence of torture?
    1. Medical education and clinical training
    2. Psychological/psychiatric training
    3. Experience in documenting evidence of torture and Ill-treatment
    4. Relevant training courses and seminars
    5. Relevant publications and presentations
    6. All of the above
  4. Physicians who are not psychiatrists may qualify as experts on psychological evidence of torture and ill treatment:
    1. True
    2. False
  5. Clinicians should not review the alleged victim’s affidavit as it may create a bias for the evaluating clinician.
    1. True
    2. False
  6. Which of the following are true about written reports and oral testimony?
    1. They require accurate and effective communication skills
    2. They should be factual and carefully worded; jargon should be avoided
    3. They should not include any opinion(s) that cannot be defended under oath or during cross-examination
    4. The quality can only be as good as the interview and examination conducted
    5. All of the above
  7. Which of the following sources of information should not be used as a reference to a medical evaluation or torture and ill treatment?
    1. Client affidavit of alleged torture and ill treatment
    2. NGO (non-governmental organization) Human rights reports
    3. Government reports on torture and ill treatment practices
    4. Medical records following the alleged torture and ill treatment
    5. None of the above
  8. Written reports and oral testimony represent an opportunity for clinicians to educate adjudicators on physical and psychological evidence of torture and ill treatment.
    1. True
    2. False
  9. Clinicians who are conducting their first medical evaluation may enhance the accuracy and credibility of their evaluation by conducting the evaluation under the supervision of, or having it formally reviewed by, a more experienced clinician.
    1. True
    2. False
  10. Historical information such as descriptions of torture devices, body positions and methods of restraint, descriptions of acute and chronic wounds and disabilities, and identifying information about perpetrators and the place(s) of detention may be very useful in corroborating an individual’s allegations of torture.
    1. True
    2. False
  11. The need for medical and/or psychological care should be noted in your medical evaluation only when the alleged torture victim’s attorney requests it.
    1. True
    2. False
  12. The clinician’s interpretation of findings and conclusions, should relate various categories of evidence, i.e., physical and psychological evidence of torture, and historical information as well.
    1. True
    2. False
  13. Which of the following considerations support the clinical assessments of credibility and argue against the possibility of malingering or simulation?
    1. Lack of over-endorsement of physical and/or psychological symptoms
    2. Lack of a suspiciousness or defensiveness
    3. Consistency between the observed affect of the interviewee and the content of the evaluation.
    4. Consistency between an individual’s pre-torture personality and the meaning the individual assigns to his or her torture/ill treatment experiences
    5. Inconsistencies that are attributable to an individual’s torture experience
    6. All of the above
  14. Exaggeration of psychological symptoms usually indicates that the individual’s allegation of torture and ill treatment are false.
    1. True
    2. False
  15. Which of the following may be helpful in explaining inconsistencies in the alleged victim’s account of torture and ill treatment?
    1. Disorientation during torture, blindfolding, drugging, and lapses of consciousness
    2. Neurological or psychological memory disturbances
    3. Feelings of guilt or shame
    4. Cultural differences in the perception of time
    5. Lack of trust in the examining clinician and/or interpreter
    6. Fear of reprisals
    7. Lack of privacy during the interview
    8. All of the above
  16. It is often helpful to include a statement on the veracity of testimony in a written medical report, such as: “I personally know the facts recited below, except as to those stated on information and belief, which I believe to be true.”
    1. True
    2. False
  17. The presence of diagnostic criteria for PTSD or Major Depressive Disorder (MDD) provides stronger evidence of torture and/or ill treatment than sub-threshold symptoms of these diagnoses.
    1. True
    2. False
  18. Which of the following are important considerations for clinicians who provide testimony on torture and ill treatment in court?
    1. Do not “react” to provocative statements.
    2. Clarify questions that you do not understand before providing an answer.
    3. Do not offer opinions on subjects about which you are not qualified to comment.
    4. Speak clearly, slowly, and make eye contact with whomever you are speaking.
    5. All of the above
  19. Which of the following can help to distinguish psychological symptoms caused by torture and ill treatment versus other traumatic experiences or losses?
    1. Temporal relationships between the onset of psychological symptoms and the alleged torture and ill-treatment
    2. Trends in psychological symptoms in relation to external stressors
    3. Content of nightmares and intrusive recollections
    4. Triggers for intrusive recollection, reliving experiences, and avoidance reactions
    5. All of the above
  20. Istanbul Protocol guidelines for medical evaluations of alleged torture and ill treatment include a formal assessment of the individual’s credibility.
    1. True
    2. False

In which of the following contexts may expert medical reports and testimony be of value? Prosecution of alleged perpetrators Challenging the credibility of statements extracted by torture Reparations and rehabilitation of alleged victims Exonerating law enforcement officials accused of torture … Continue reading →

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The UN Special Rapporteur on Torture and other Cruel, Inhuman and Degrading Treatment or Punishment

Established in 1985 by the UN Commission on Human Rights, this mandate is a non-treaty, “UN Charter-based” body, the purpose of which is to examine international practise relating to torture in any state regardless of any treaty the state may be bound by. On the basis of information received, the Special Rapporteur can communicate with governments and request their comments on cases that are raised. He or she can also make use of an “urgent action” procedure, requesting a government to ensure that a particular person, or group of persons, are treated humanely. The Special Rapporteur can also conduct visits if invited, or given permission, by a state to do so. The reports of these missions are usually issued as addenda to the main report of the Special Rapporteur to the UN Commission on Human Rights.

The Special Rapporteur reports annually and publicly to the UN Commission on Human Rights and to the UN General Assembly. The reports to the Commission contain summaries of all correspondence transmitted to governments by the Special Rapporteur and of correspondence received from governments. The reports may also include general observations about the problem of torture in specific countries, but do not contain conclusions on individual torture allegations. The reports may address specific issues or developments that influence or are conducive to torture in the world, offering general conclusions and recommendations.

Established in 1985 by the UN Commission on Human Rights, this mandate is a non-treaty, “UN Charter-based” body, the purpose of which is to examine international practise relating to torture in any state regardless of any treaty the state may … Continue reading →

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Documenting the allegations

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Assessing Inconsistencies

Inconsistencies in a person’s story may arise from any or all of these factors. If possible, the investigator should ask for further clarification. These possibilities should be explored in detail. When clarification is not possible, the investigator should look for other evidence that supports or refutes the story. A network of consistent supporting details can corroborate and clarify the person’s story. Although the individual may not be able to provide the details desired by the investigator, such as dates, times, frequencies and exact identities of perpetrators, a broad outline of the traumatic events and torture will emerge and stand up over time.

If, on the other hand, the clinician suspects fabrication (sometimes called “simulation”), the clinician 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. It may be helpful to refer the individual to another clinician for a second opinion. If the suspicion of fabrication persists, it should be documented by both clinicians.

Inconsistencies in a person’s story may arise from any or all of these factors. If possible, the investigator should ask for further clarification. These possibilities should be explored in detail. When clarification is not possible, the investigator should look for … Continue reading →

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Module 1 Presentation: International Legal Standards


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Download: Module 1: International Legal Standards (PowerPoint Presentation) (ppt)

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Self-Assessment and Quiz

  1. The primary purpose of a medical evaluation of torture and ill treatment is to assess the degree to which physical and psychological findings correlate with individual allegations of abuse.
    1. True
    2. False
  2. Which of the following will aid clinicians in earning the trust of individuals who have experienced torture and ill treatment?
    1. Active listening
    2. Meticulous communication
    3. Courtesy, genuine empathy and honesty
    4. Explaining what to expect in the evaluation
    5. Being mindful of the tone, phrasing and sequencing of questions (sensitive questions should be asked only after some degree of rapport has been developed)
    6. All of the above
  3. Clinicians planning to conduct a medical evaluation for physical or psychological evidence of torture and ill treatment should schedule adequate time:
    1. About 30 minutes
    2. About 1 hours
    3. About 2 to 4 hours
    4. More than 6 hours
  4. Which of the following is not a procedural safeguard according to the Istanbul Protocol?
    1. It is mandatory that detainees undergo a preliminary medical examination at the time of detention; a further examination and evaluation should be made upon their release.
    2. The officials who supervise the transportation of the detainee should be responsible to the public prosecutors and not to other law enforcement officials.
    3. The medical examination for detainees should be free of charge.
    4. Forensic medical services should be under the authority of the police or prison system.
    5. Detainees have the right to obtain a second or alternative medical evaluation by a qualified physician during his/her detention.
  5. Clinicians must balance two important requirements in the course of interviewing individuals who allege torture and ill treatment: 1) the need to obtain a detailed accurate account of events, and 2) the importance of respecting the needs of the person being interviewed.
    1. True
    2. False
  6. The gender of the examining clinician should always be the same as the interviewee.
    1. True
    2. False
  7. Which of the following are not accurate statements about the use of interpreters for medical evaluations of torture and ill treatment?
    1. As a rule, family members should not be used
    2. In cases of alleged sexual assault of a woman it is advisable to use a female interpreter if the interviewee does not express a gender preference
    3. The age of the interviewer does not matter
    4. Interviewers should make eye contact with and speak directly to the interviewee
    5. There may be difficulties when the interviewee and the interpreter are from different, ethnic, religious, social, and/or political backgrounds
  8. When a physician is involved in the torture of an individual, he or she may have difficulty trusting the examining clinician. This is an example of:
    1. Transference
    2. Counter-transference
    3. A reaction formation
    4. Traumatic delusion
  9. After listening to the audiotape of the 1996 National Public Radio interview with Sr. Diana Ortiz, consider which of the following emotional reactions that an interviewer is likely to have:
    1. Anger
    2. Helplessness
    3. Fear
    4. Shame
    5. Guilt
    6. All of the above
  10. After listening to the audiotape of the 1996 National Public Radio interview with Sr. Diana Ortiz, identify interview considerations that the interviewer did not adequately address:
    1. Comfort and privacy
    2. Empathy
    3. Appropriate use of open-ended and closed questioning
    4. Allowing the interviewee to have some control over the interview process
    5. All of the above
  11. Before a forensic interview begins, the clinician must inform the interviewee of any limits on the confidentiality of the information he or she provides.
    1. True
    2. False
  12. As a clinician who provides care to survivors of torture and/or conducts medical evaluations of alleged victims of torture and ill treatment, what strategies do you consider to be effective in managing and limiting secondary trauma and “burn out?”
    1. Debriefing with colleagues and seeking counseling if needed
    2. Discussing your emotional reactions with the survivor/alleged victim
    3. Limiting your exposure to traumatic cases
    4. Awareness to, reflection on and modulation of your emotional reactions to interviews with survivors of torture and ill treatment
    5. All of the above
  13. Initially, interview questions should be open-ended, allowing a narration of the trauma with minimal interruptions.
    1. True
    2. False
  14. The accuracy of information obtained in a medical evaluation can be improved by:
    1. Clarifying details
    2. Summarising key points periodically
    3. Scheduling a follow-up interview to address outstanding questions or any inconsistencies
    4. Using cognitive techniques such as “You were telling me about being suspended; can you tell me what happened just before that?”
    5. All of the above
  15. Which of the following may affect an individual’s ability to recall and recount torture and ill treatment?
    1. Disorientation during torture, blindfolding, drugging, and lapses of consciousness
    2. Neurological or psychological memory disturbances
    3. Feelings of guilt or shame
    4. Cultural differences in the perception of time
    5. Lack of trust in the examining clinician and/or interpreter
    6. Fear of reprisals
    7. Lack of privacy during the interview
    8. All of the above
  16. Which of the following are appropriate steps for clinicians to take to assess inconsistencies?
    1. Ask the individual for further clarification
    2. Identify other sources of corroborating information
    3. Identify possible reasons for exaggeration or fabrication
    4. Schedule an additional interview to discuss inconsistencies
    5. Refer the individual to another clinician for a second opinion
    6. All of the above
  17. In medical evaluations of torture and ill treatment it is not appropriate to ask questions about prior political activities and/or social beliefs and attitudes?
    1. True
    2. False
  18. In obtaining information on specific methods of torture and ill-treatment, the clinician should note for each form of abuse: body position, methods of restraint, nature of contact, the duration, frequency, and anatomical location of the alleged abuse, and the subsequent effects of the alleged abuse, i.e. pain, bleeding, loss of consciousness, disabilities, etc.
    1. True
    2. False
  19. The ethical principles of beneficence and non-malfeasance require that clinicians’ conclusions regarding torture and ill treatment be consistent with the least harmful legal outcome.
    1. True
    2. False
  20. In the course of documenting medical evidence of torture and ill-treatment, physicians have an ethical duty of identifying and making appropriate referrals for medical and social needs.
    1. True
    2. False

The primary purpose of a medical evaluation of torture and ill treatment is to assess the degree to which physical and psychological findings correlate with individual allegations of abuse. True False Which of the following will aid clinicians in earning … Continue reading →

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Self-Assessment and Quiz

  1. In what ways do torturers try to conceal the consequences of their actions?
    1. Using narrow, sharp objects for beatings
    2. The use of wet towels with the electric shocks
    3. Detaining victims until obvious signs of abuse have resolved
    4. Leaving the victim’s shoes on during falanga (beating the soles of the feet)
    5. All of the above
  2. Torturers have been known to change their practices based on the effective documentation of torture by clinicians.
    1. True
    2. False
  3. Which of the following is true of falanga?
    1. It can cause acute pain, swelling and hematoma formation
    2. It can be associated with chronic pain, sensory disturbances and impaired walking
    3. A closed compartment syndrome may develop in the foot
    4. The above findings are considered pathognomonic for falanga
  4. Prompt examination is necessary to detect tympanic membrane ruptures less than 2 millimetres in diameter, which may heal within 10 days.
    1. True
    2. False
  5. “Palestinian” suspension results in posterior hyperextension of the arms and traction on the lower roots of the brachial plexus. This may result in damage to the long thoracic nerve and cause:
    1. Sensory deficit over the scapula
    2. A “winged” scapula: diminished vertebral border when hands are pressed against a wall with outstretched arms
    3. Sensory deficit in the deltoid region
    4. A “winged” scapula: prominent vertebral border when hands are pressed against a wall with outstretched arms
    5. Sensory deficit in the ulnar distribution
  6. Positional forms of torture leave few, if any, external marks or radiological findings, despite subsequent, frequently severe chronic disability.
    1. True
    2. False
  7. Which of the following may be observed with crushing and stretch injuries?
    1. Contusions
    2. Incisions
    3. Abrasions
    4. Chronic musculoskeletal pain and/or disabilities
    5. Rhabdomyolysis and acute renal failure
    6. All of the above
  8. Regarding burn injuries, which of the following statements are accurate?
    1. The pattern of scarring gives a clue to the method used
    2. Caustic or acid burns may leave a trail indicating the victim’s posture
    3. Heated metal rods, branding irons or electrically heated devices such as smoothing irons or soldering irons often leave scars of distinctive shape and, if in multiples, they make accidental injury most unlikely.
    4. Cigarettes are a particularly common torture weapon. The scars they leave depend on the way the cigarettes were applied to the skin. If they were touched lightly or simply brushed against the skin they may leave no scar or something that is indistinguishable from a scar from acne, chicken pox or insect bite. On the other hand, if the cigarettes were deliberately stubbed out and held immobile on the skin, the scar is often characteristically circular about one centimetre in diameter, with a hyperpigmented periphery (usually with a relatively indistinct periphery) and an atrophic, hypopigmented, “tissue paper” centre.
    5. All of the above
  9. Electrical injuries can cause:
    1. Severe pain without subsequent physical signs
    2. Dislocations of joints
    3. Arrhythmias leading to sudden death
    4. Urination and/or defecation
    5. All of the Above
  10. Electric shock torture may result in characteristic physical findings, but often do not.
    1. True
    2. False
  11. Various forms of asphyxiation may cause:
    1. No findings at all
    2. Conjunctivitis or otitis media
    3. Anoxic brain injury
    4. Acute broncho-pulmonary infections
    5. All of the above
  12. Waterboarding may not be considered a method of torture because it has been used successfully in survival training of military personnel.
    1. True
    2. False
  13. Violent shaking can result in:
    1. Cerebral edema and subdural hematoma leading to death
    2. Cognitive impairment
    3. Chronic headaches, disorientation and mental status changes
    4. Neck trauma including cervical spine fracture resulting in quadriplegia
    5. All of the above
  14. Which of the following are true statements about sexual assault?
    1. The term sexual assault should not be used unless an individual has been raped
    2. Sexual assaults are often accompanied by direct or implied threats
    3. Rape is always associated with the risk of developing sexually transmitted diseases, including human immunodeficiency virus (HIV)
    4. Ideally, medical evaluations of alleged sexual assault should include a team of experienced clinical experts.
    5. All of the above
  15. Which of the following are considered torture by the UN Committee Against Torture and/or the Special Rapporteur on Torture?
    1. Prolonged isolation and/or sensory deprivation
    2. Sleep deprivation
    3. Temperature manipulation
    4. Threats of harm
    5. Sensory bombardment
    6. Sexual humiliation
    7. All of the above
  16. Which of the following is/are true about the psychological sequelae of torture and ill treatment?
    1. Everyone who has been tortured develops at least some form of diagnosable mental illness
    2. Major Depression and PTSD are the most common diagnoses among survivors of torture and ill treatment
    3. For many that have survived torture, the symptoms of Major Depression and PTSD may persist and fluctuate for many years
    4. Torture and ill treatment can create a sense of complete confusion, powerlessness, and loss of control which can bring about a shattered understanding of one’s self, of any meaningful existential system and of the predictability of the world
    5. All of the above
  17. An examining clinician should not assume that all forms of torture and ill treatment have the same or similar outcomes because the psychological consequences of torture and ill treatment develop in the context of personal meaning and personality development.
    1. True
    2. False
  18. Standardized instruments and quantitative measurement should be used in all medical evaluations of psychological evidence of torture and ill treatment as they are superior to descriptive methods in establishing correlations between allegations of abuse and the subsequent development of psychological symptoms.
    1. True
    2. False
  19. Psychological outcomes can be influenced by many interrelated factors that include but are not limited to the following:
    1. Circumstances, severity and duration of the torture
    2. Age and developmental phase of the victim
    3. Genetic and biological vulnerabilities of the victim
    4. Perception and interpretation of torture by the victim
    5. Community values and attitudes
    6. Political factors
    7. Prior history of trauma
    8. Pre-existing personality
    9. All of the above
  20. Risk factors for developing mental illness among survivors of torture who are also refugees include:
    1. Migration factors (loss of home, loved ones, possessions, etc)
    2. Acculturation
    3. Poverty
    4. Cultural and linguistic isolation
    5. Absence of adequate support systems
    6. Unemployment or underemployment
    7. All of the above

In what ways do torturers try to conceal the consequences of their actions? Using narrow, sharp objects for beatings The use of wet towels with the electric shocks Detaining victims until obvious signs of abuse have resolved Leaving the victim’s … Continue reading →

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Essential information

In all cases, in addition to the medical evidence and information, the following non-medical details should be viewed as useful and often crucial information regardless of the purpose of documentation:

  • Identity of the victim. This should include full name, gender, age, occupation, and address. Date of birth is a useful identifier when the name is a common one; often the year is known although it might not correspond to the age given. Additional useful information would be a description of appearance, a photograph, and any relevant records that may exist on the individual, such as medical files from the time before the alleged abuse.
  • Identity of the perpetrators. This might include the identification of a particular individual or individuals. However, to establish responsibility of the state for a violation, it might be enough to show the connection with the state. Relevant information would detail whether they were members of a specific security force such as police or military and, if possible, their names and rank. If unsure, then a description of uniforms, vehicles, weapons or any identifying characteristics will assist in the determination. Note, for legal and human rights reasons, great care should be taken in making allegations that particular individuals have been involved in torture. These are, after all, allegations of serious criminality.
  • Description of how the individual came into the hands of the perpetrators. This should include whether the person was officially arrested, what reason was given for taking the person into custody, the time and date this took place, and whether there was use of violence or restraints.
  • Description of the location where the abuse took place. This may have been a prison, a police detention facility, a military installation, or any other institution or location, even an outdoor space. Additional useful information would be a description of the conditions in which the individual was held, including size, content of the room, lighting, hygiene, presence of others, and access to lawyers, visitors, and medical care.
  • Description of the form of abuse. Where did it occur? What happened? When? By whom? How often? How long did it last? And what effects did it have on the immediately and later? There should be a detailed description of exactly what occurred, and how frequently. Presence of anyone else in the room during the interview, whether detainees, security personnel or others, should be mentioned. Any instruments used should be noted. What were the immediate and long-term effects of the abuse? If the alleged victim received medical attention, or requested it and the request was denied, directly before, during, or after the abuse, this should all be detailed.
  • Possible witnesses. Were there others present at the time of the abuse. Who were they? What was their role (for example, other detainees)? Did others see the individual immediately after the ill-treatment (for example, cellmates or prison medical staff)?

In all cases, in addition to the medical evidence and information, the following non-medical details should be viewed as useful and often crucial information regardless of the purpose of documentation: Identity of the victim. This should include full name, gender, … Continue reading →

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