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Torture

Safety and Security

Clinicians should carefully consider the context in which they are working, take necessary precautions and provide safeguards accordingly. If interviewing people who are still imprisoned or in similar situations in which reprisals are possible, all precautions should be taken to ensure that they do not place the detainee in danger (or in additional difficulty). Promises must not be made, for example, to provide security for the witness or for relatives who might be at risk, unless the interviewer is certain that they can be fulfilled. Witnesses might believe that international organisations or others investigating allegations of torture have more power to protect them than is the case. It is part of the informed consent process that individuals are aware of all the issues before they agree for a clinician to make a formal report. If the risk of harm from reprisals is a virtual certainty, conducting a medical evaluation may be considered unethical even if informed consent is obtained. This may be the case in the context of documenting human rights violations in places of ongoing conflict.

Whether or not certain questions can be asked safely will vary considerably and depends on the degree to which confidentiality and security can be ensured. When necessary, questions about forbidden activities should be avoided.

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 (see Procedural Safeguards below).

An interviewer will make notes of the interview, and may use other recording devices. The reasons for this should be explained to the interviewee who should be reassured as to how the notes and other records will be used and asked for consent. The way in which any records of such interviews are stored can be important in protecting the security of the interviewer and the interviewee. In many countries where torture is prevalent, the police have been known to raid clinics and search or confiscate medical records. In order to protect patients, therefore, in such conditions records should have no obvious identifying information on any document inside (such as initials or date of birth), and the files themselves being numbered with a register kept in a secure place elsewhere. Patients can be given cards with the identifying number so that treatment can be continued even if the register is not available. In some circumstances it may be necessary to hold records at a different location or even in a third country to ensure their security.

If information about an individual needs to be transmitted to another body, fax transmission is generally safer than e-mail as a copy of the latter may be stored on the sending computer or held on the server of the internet service provider. In some countries the authorities routinely screen all outgoing messages.

Clinicians should carefully consider the context in which they are working, take necessary precautions and provide safeguards accordingly. If interviewing people who are still imprisoned or in similar situations in which reprisals are possible, all precautions should be taken to … Continue reading →

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Module 5 Presentation: Physical Evidence of Torture and Ill-Treatment


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Download Module 5: Physical Evidence of Torture and Ill Treatment (PowerPoint Presentation) (ppt)

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Assessments of Physical and Psychological Evidence

The content of interviews varies among clinicians who conduct separate medical evaluations of physical and psychological evidence of torture. Additional interview considerations for these components of a medical evaluation are included in Modules 5 and 6.

The content of interviews varies among clinicians who conduct separate medical evaluations of physical and psychological evidence of torture. Additional interview considerations for these components of a medical evaluation are included in Modules 5 and 6.

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Violent Shaking

Violent shaking may be haphazard or, as in the case of Israel, systematic and planned. In such cases, bruising may be found on the chest or shoulders where the victim was seized but otherwise there are few outward signs. In the acute phase there is usually headache, disorientation and often a changed mental state. The most severe cases demonstrate all the features, potentially fatal, that have been well documented in shaken infant syndrome – cerebral oedema, subdural haematoma and retinal haemorrhage, the last being the major sign that makes possible a diagnosis before death. It has been named the shaken adult syndrome.

Non-fatal brain trauma from violent shaking can potentially result in more subtle but clinically significant cognitive impairment possibly due to diffuse axonal injury, injury to the brain cells themselves. Non-fatal consequences of shaking may also include recurrent headaches, disorientation and mental status changes, all of which can become chronic. Violent shaking can also produce neck trauma, producing a whiplash mechanism of cervical strain. Cervical spine fracture with spinal cord compression may also occur, resulting in quadriplegia.

Violent shaking may be haphazard or, as in the case of Israel, systematic and planned. In such cases, bruising may be found on the chest or shoulders where the victim was seized but otherwise there are few outward signs. In … Continue reading →

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Module 8: Case Example #02

Objectives:

  • To conduct a complete medical evaluation of an alleged torture victim using Istanbul Protocol standards, including assessments of physical and psychological evidence of torture
  • To develop essential interview skills including: effective communication, earning trust, balancing empathy and objectivity, applying appropriated questioning techniques, obtaining informed consent, ensuring procedural safeguards, providing an appropriate and comfortable setting, respecting gender considerations, taking steps to avoid re-traumatisation
  • To understand the relevant transference and counter-transference issues that may arise in the course of conducting medical evaluations of alleged torture victims
  • To identify possible reasons for difficulties recalling and recounting the story and/or inconsistencies in the story of the alleged victim
  • To provide a well-reasoned interpretation of findings and conclusions regarding torture and ill-treatment.
  • To appreciate the possible difficulties that may arise during an interview with an alleged torture victim
  • To identify and address individual interviewing strengths and weaknesses in conducting an interview

Content

  • See Introduction and Preliminary Considerations and Materials below
  • Review of Case Summary #02 by students
  • Interview of individual role-player (alleged torture victim) by students or instructors (NOTE: role-players use Case Narrative #02 to act their parts)
  • Instructor supervision/demonstration of interview(s) using Guidelines for Instructors Case #02 (see Guidelines for Instructors file)
  • Debriefing between interviewers and role-players
  • Class discussion
  • Assignment: Ask students (individuals or groups) to write up a medical report of evaluation findings to be used in Module #9

Discussion Topics

  • Interviewing skills: How did the interviewers feel they performed? What observations/comments can the instructor and/other students share?
  • Interview content: was the interview complete? Was there any relevant components left out?
  • Role-players should share their reactions to the interview, followed by the interviewers
  • Discuss strategies to effectively address transference and counter-transference issues that arise in the course of interviewing survivors of torture.
  • Discuss your most significant concerns in conducting a psychological evaluation. Discuss how you can address them.

Teaching Formats

  • Group Activity:
    • See Introduction and Preliminary Considerations and Materials below
    • See Discussion Topics above
  • Individual Research/Assignment:
    • Discuss your most significant concerns in conducting a psychological evaluation. Discuss how you can address them
  • Journal Entry: (Instructor to assign Write a few paragraphs — no more than a page)
    • Consider how transference and counter-transference reactions may affect routine medical encounters between patients and clinicians.
    • What are your most significant concerns in conducting a psychological evaluation? Discuss how you can address them.

Primary Resources

  • The Istanbul Protocol
  • Case Example #02 (Case Summary, Narrative and Guidelines for Instructors)

Objectives: To conduct a complete medical evaluation of an alleged torture victim using Istanbul Protocol standards, including assessments of physical and psychological evidence of torture To develop essential interview skills including: effective communication, earning trust, balancing empathy and objectivity, applying … Continue reading →

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Consent and confidentiality

It is a principle of ethical practise that patients must understand what is happening to them and consent to it. This is extremely important in working with torture survivors who have been in the situation of having no control over any aspect of their lives. It is essential that they do not feel powerless in the subsequent clinical setting. This is particularly true of medico-legal work in which the documentation will be in the public domain. As stated above, for consent to be valid, the patient must understand how the data gained from the examination will be used, how it will be stored and who will have access to it.

While all statements emphasise the obligation to act in the best interests of the individual being examined or treated, this presupposes that health professionals know what the patient’s interests are. A fundamental idea in modern medical ethics is that patients are the best judges of their own interests. This requires that health professionals should normally give precedence to the competent adult patient’s wishes. Where the patient is unconscious or otherwise incapable of giving valid consent, health professionals must make a judgement about how that person’s best interests can be protected and promoted. Nurses and doctors are expected to act as advocates of their patients’ well-being and this is made clear in professional statements.

Conflicts arise where health professionals are pressured or required by law to disclose information to third parties about patients without consent. This may include an obligation to report torture or serious crimes (possibly including torture itself). A health professional may receive an allegation of torture on the patients’ understanding that they are only seeking treatment and that the information will not be disclosed to others for fear of reprisals or other reasons. 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. Health professionals should make clear to any authority requesting information that they are bound by professional duties of confidentiality. Health professionals responding in this way are entitled to the support of their professional association and colleagues.

The Geneva Conventions give particular protection to doctor-patient confidentiality in periods of international armed conflict, for example, requiring that doctors should not be compelled to disclose information about their patients to the opposing side.

It is a principle of ethical practise that patients must understand what is happening to them and consent to it. This is extremely important in working with torture survivors who have been in the situation of having no control over … Continue reading →

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Self-Assessment and Quiz

  1. Most physical methods of torture result in characteristic, acute and chronic lesions.
    1. True
    2. False
  2. Physicians who conduct medical evaluations of physical evidence of torture should:
    1. Always conduct a complete physical examination
    2. Always conduct a directed physical examination (pursuit of pertinent positive and negative findings)
    3. Conduct a complete physical examination unless the allegations of torture are limited and there is no history of loss of consciousness or neurological or psychological symptoms that may affect recall of torture allegations.
    4. Conduct an examination which focuses on positive physical findings since pertinent negative finding are not necessary in medico-legal cases
  3. Which of the following forms of historical information may be useful in correlating practices of torture with individual allegations of abuse
    1. Descriptions of torture devices
    2. Body positions
    3. Methods of restraint
    4. Descriptions of acute or chronic wounds and disabilities
    5. Identifying information about perpetrators and places of detention
    6. All of the above
  4. A 38 year-old man alleges that he was detained on suspicion of harboring terrorists. He explains that soon after being detained he was beaten, but does not elaborate further. Which of the following questions would be most appropriate at this time?
    1. What kind of physical symptoms and injuries resulted?
    2. What were your thoughts and emotional reactions at the time?
    3. Can you tell me more about what happened?
    4. Who did this to you?
    5. Do you have any scars from the torture?
  5. In addition to location, size, shape, and color, which of the following should be included in clinical descriptions of skin lesions?
    1. Surface texture
    2. Periphery of the lesion
    3. Extent of demarcation
    4. Level in relation to surrounding skin
    5. All of the above
  6. Lacerations 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.
    1. True
    2. False
  7. A 32 year-old man alleges that he was beaten with a police baton. On physical examination, you observe the following:

    [Courtesy of Amnesty International, The Netherlands.]

    How would you describe the level of consistency between the allegation of abuse and the findings on physical examination?

    1. Not consistent
    2. Consistent
    3. Highly consistent
    4. Virtually diagnostic
    5. Proof of torture
  8. Which of the following are true about contusions?
    1. The extent and severity of a contusion is related to the amount of force applied, and the vascular structures affected
    2. Deep contusions should be re-examined 1 to 2 days after the alleged injury
    3. The color of the bruise can be used to determine the age of the contusion
    4. Sometimes the shape of the bruise helps to identify the shape of the blunt instrument that caused the injury
    5. All of the above
  9. Which of the following statements about scars are true?
    1. Wounds that heal by secondary intention are generally smaller than those that heal by primary intention
    2. Scars related to self-inflicted injuries are generally superficial and within easy reach of the dominant hand
    3. The location and presence of multiple scars may help to distinguish intentional vs. accidental injuries
    4. Post-inflammatory hyperpigmentation may result from contusions and abrasions
    5. All of the above
  10. A 30 year-old man states that he lost consciousness while he was suspended. When he awoke some time later in his cell, he noted a painful, red blister on his left torso which took several weeks to heal. You conduct a medical evaluation for asylum 2 years after the alleged injury. Bases on the photographic information below, what is the most likely cause of the scar?
    [Courtesy of Amnesty International, The Netherlands.]

    1. Electric shock
    2. Burn with a heated instrument
    3. Beating with a police baton
    4. Striae Distinsae
    5. None of the above
  11. Which of the following is the most likely cause of the scars in the photograph below?

    < [Courtesy of Alejandro Moreno, MD, JD.]

    1. Abrasions
    2. Incisions
    3. Lacerations
    4. Burns
    5. Electric shock
  12. Which of the following is the most likely cause of the scar in the photograph below?

    [Courtesy of Alejandro Moreno, MD, JD.]

    1. Abrasion
    2. Incision
    3. Laceration
    4. Burn
    5. Electric shock
  13. Which of the following is the most likely cause of the scars in the photograph below?

    [Courtesy of Alejandro Moreno, MD, JD.]

    1. Abrasions
    2. Incisions
    3. Lacerations
    4. Burns
    5. Electric shock
  14. Which of the following is the most likely cause of the scars in the photograph below?
    [Courtesy of the Human Rights Foundation of Turkey.]

    1. Striae Distensae
    2. Contact dermatitis
    3. Whipping with an electrical wire
    4. Shock baton
  15. What is the most likely cause of the findings in the following photograph?

    [Courtesy of the Human Rights Foundation of Turkey.]

    1. Abrasions
    2. Incisions
    3. Lacerations
    4. Burns
    5. Electric shock
  16. Which of the following statements are true about medical examinations of women alleging sexual assault?
    1. The examination should be performed by an expert in documenting sexual assault
    2. A thorough physical examination should be performed
    3. It is rare to find any physical evidence when examining female genitalia more than one week after an assault
    4. Refusal to consent to a genital examination is a strong indication of false allegations of rape
    5. All of the above
  17. Which of the following statements are true about genital examination of men?
    1. Individuals who were subjected to scrotal torture may suffer from chronic urinary tract infection, erectile dysfunction or atrophy of the testes
    2. Symptoms of PTSD are not uncommon
    3. In the chronic phase, it may be impossible to distinguish between scrotal pathology caused by torture and that caused by other disease processes
    4. Failure to discover any physical abnormalities on full urological examination suggests that urinary symptoms, impotence or other sexual problems may be explained on psychological grounds
    5. Scars on the skin of the scrotum and penis may be very difficult to visualize. For this reason, the absence of scarring at these specific locations does not demonstrate the absence of torture. On the other hand, the presence of scarring usually indicates that substantial trauma was sustained
    6. All of the above
  18. Perianal examinations findings are generally non-specific. When scars are observed out of the midline (i.e. not at 12 or 6 o’clock), they may be an indication of rectal tears associated with penetrating trauma.
    1. True
    2. False
  19. If a camera is available, it is better to take poor quality photographs than to have no photographs at all.
    1. True
    2. False
  20. In general, diagnostic tests should be obtained whenever possible for medical evaluations of torture and ill treatment because:
    1. They are generally inexpensive and readily available
    2. They often provide the evidence needed to prove torture allegations
    3. Their diagnostic value nearly always outweighs their cost
    4. Their reliability and specificity for specific torture is well documented
    5. None of the above

Most physical methods of torture result in characteristic, acute and chronic lesions. True False Physicians who conduct medical evaluations of physical evidence of torture should: Always conduct a complete physical examination Always conduct a directed physical examination (pursuit of pertinent … Continue reading →

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The Perpetrators

State Actors (those who act on behalf of the state)

As is emphasized above, the legal definition of torture implies that the behavior in question be carried out by, or with the apprival of, a representative of the authority in power. Considering the common purposes of torture, which may be to obtain information during an interrogation, or sometimes, to intimidate the population as a whole in the face of insurrection or disturbance, it is unsurprising that the principal perpetrators are those officials involved in the criminal investigation provess, and those responsible for the security of the state.

This means that those most likely to be involved in torture and other forms of ill-treatment include:

  • The police
  • The gendarmerie (in countries where this institution exists)
  • The military
  • State intelligence agents
  • Paramilitary forces or other armed groups acting in connection with official forces
  • State-controlled conter-insurgency forces
  • Prison officers
  • Private contractors carrying out any of the above activities
  • Co-detainees or other members of the general population acting with the acquiescence of or on the orders of public officials.

Health professionals even those not directly employed by t he state may also be involved in actts of torture and other ill-treatment. Doctors, psychiatrists or nurses might participate in torture either by direct involvement (be it through medical monitoring of the torture, certifying someone fit for interrogation, or even using medical knowledge to design or refine methods of torture or other ill-treatment), by assisting in a cover-up (for example, by issuing misleading medical reports), or by omission (such as failing to give necessary treatment). As noted earlier, torture is a crime, and any involvement in torture can lead to criminal charges being brought against those involved, including health professionals.

Non-state actors

In addition, torture often occurs in the context of armed conflicts, particularly internal conflicts involving forces in opposition to the recognized authorities, and which exercise effective power. In such circumstances, torture and other forms of ill-treatment may also be inflicted, for example by opposition forces, who are also bound by customary international law and Geneva Convention standards to refrain from torture.

Furthermore, if an organized group, whether or not it is a party to an armed conflict, engages in acts of torture or other ill-treatment against a civilian population, on a systematic widespread scale, it can be guilty international law of violating the prohibition of torture and other ill-treatment.

Protection from Third Parties

The main focus of this Curriculum is on torture and other ill-treatment by state agents, particularly law enforcement officials. However, there is also a growing acceptance of the importance of safeguarding people from similar treatment carried out by private groups or individuals. States are responsible for safeguarding the rights of everyone within their jurisdiction and may under some circumstances be held accountable for acts carried out by private individuals if it supports or tolerates them, or fails in other ways to provide effective protection in law andin practice against them.

State Actors (those who act on behalf of the state) As is emphasized above, the legal definition of torture implies that the behavior in question be carried out by, or with the apprival of, a representative of the authority in … Continue reading →

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Procedural Safeguards for Detainees

Ensuring procedural safeguards for detainees is essential for the safety and security of detainees, to earn the detainees trust, respect his or her privacy, and ensure confidentiality (See Procedural Safeguards for Detainees, Module 2). Disregard for certain procedural safeguards may not only result in inaccurate medical evaluation, but also the possibility of administrative and/or criminal santions against the medical expert responsible for forensic documentation of torture and ill-treatment. As described in Module 2, procedural safeguards for detainees can be summarised as follows:

  • Forensic medical evaluation of detainees should be conducted in response to official written requests by public prosecutors or other appropriate officials.
  • Detainees themselves, their lawyers or relatives have an independent right to request a medical evaluation to seek evidence of torture and ill-treatment.
  • 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.
  • The detainee should be taken to the forensic medical examination by officials other than soldiers or police working in the unit where the detainee is held.
  • The officials who supervise the transportation of the detainee should be responsible to the public prosecutors and not to other law enforcement officials.
  • The detainee must be:
    • independently and thoroughly examined by a qualified doctor, and, without any police officer being present.
  • 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.
  • Medico-legal evaluations of detainees should include the use of a standardized medical report form.
  • The report must include the story, details of injuries and psychological findings that may be attributable to torture or ill-treatment together with explanations of the patient and the opinion of the doctor.
  • Under no circumstances should a copy of the medical report be transferred to law enforcement officials; instead it should be transmitted to the official requesting the report, generally the public prosecutor.
  • If the forensic medical examination supports allegations of torture or ill-treatment, the detainee should not be returned to the place of detention, but should instead be presented to the competent prosecutor or judge for purposes of determining the detainee’s legal disposition.
  • Access to the lawyer should be provided at the time of the medical examination.
  • The medical examination should be free of charge.
  • Forensic medical services should be under judicial or an independent authority and not under the same governmental authority as the police and prison system.
  • Detainees have the right to obtain a second or alternative medical evaluation by a qualified physician also during his/her detention.

Ensuring procedural safeguards for detainees is essential for the safety and security of detainees, to earn the detainees trust, respect his or her privacy, and ensure confidentiality (See Procedural Safeguards for Detainees, Module 2). Disregard for certain procedural safeguards may … Continue reading →

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Physical Examination

The physical examination, and any related photographs of physical findings, is usually conducted after all other interview components, including the psychological evaluation if the examiner is conducting both the physical and psychological assessments. Information on the physical examination is included in Module 5.

The physical examination, and any related photographs of physical findings, is usually conducted after all other interview components, including the psychological evaluation if the examiner is conducting both the physical and psychological assessments. Information on the physical examination is included … Continue reading →

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