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Torture

Physical Evidence of Torture

Witness and survivor testimony are necessary components in the documentation of torture. To the extent that physical evidence of torture exists, it may provide important confirmatory evidence that a person was tortured. Torture victims may have injuries that are substantially different from other forms of trauma. Although acute lesions may be characteristic of the alleged injuries, most lesions heal within about six weeks of torture, leaving no scars or, at the most, non-specific scars. This is often the case when torturers use techniques that prevent or limit detectable signs of injury. Under such circumstances, the physical examination may be within normal limits, but this in no way negates allegations of torture. As the Istanbul Protocol makes clearly, the absence of such physical evidence should not be construed to suggest that torture did not occur, since such acts of violence against persons frequently leave no marks or permanent scars. A detailed account of the patient’s observations of acute lesions and the subsequent healing process often represent an important source of evidence in corroborating specific allegations of torture or ill-treatment.

A medical evaluation for legal purposes should be conducted with objectivity and impartiality. The evaluation should be based on the physician’s clinical expertise and professional experience. The ethical obligation of beneficence demands uncompromising accuracy and impartiality in order to establish and maintain professional credibility. When possible, clinicians who conduct evaluations of detainees should have specific essential training in forensic documentation of torture and other forms of physical and psychological abuse. They should have knowledge of prison conditions and torture methods used in the particular region where the patient was imprisoned and the common after-effects of torture. The medical report should be factual and carefully worded. Jargon should be avoided. All medical terminology should be defined so that it is understandable to lay persons.

In addition, the physician should not assume that the official requesting a medico-legal evaluation has related all the material facts. It is the physician’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.

Witness and survivor testimony are necessary components in the documentation of torture. To the extent that physical evidence of torture exists, it may provide important confirmatory evidence that a person was tortured. Torture victims may have injuries that are substantially … Continue reading →

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Module 5 Answers

  1. Answer: B

    Although acute lesions may be characteristic of the alleged injuries, most lesions heal within about six weeks of torture, leaving no scars or, at the most, non-specific scars.

  2. Answer: C

    A complete physical examination is recommended unless the allegations of torture are limited and there is no history of loss of consciousness or neurological or psychological symptoms that may affect recall of torture allegations. Under such circumstances, a directed examination may be appropriate in which only pertinent positive and negative evidence is pursued on examination.

  3. Answer: F

    All of the forms of historical information listed may be useful in correlating regional practices of torture with individual allegations of abuse.

  4. Answer: C

    Inquiries should be structured to elicit an open-ended, chronological account of events experienced during detention.

  5. Answer: E

    In addition to location, size, shape and color, each of the factors listed above should be included in clinical descriptions of skin lesions.

  6. Answer: B

    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 and/or abraded. Tissue bridges may be present. 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.

  7. Answer: C or D

    The photograph shows a large 4 cm x 6 cm contusion with underlying edema and/or hematoma formation. There are a series of parallel linear abrasions that correspond to the ridges of a police baton (see photo below). These physical findings should be considered “highly consistent” with or “virtually diagnostic” of the alleged injury since it is very unlikely they were caused by any other mode of injury or pathophysiological process. “Proof” of torture implies 100% certainty and should be avoided unless it can be supported by the evidence. In this case the injury may have been inflicted in the context of “resisting arrest.”
    [Courtesy of Amnesty International, The Netherlands.]

  8. Answer: A, B, D

    Contusions cause blood to leak from small vessels. If the skin and subcutaneous tissues are thin, the bruise becomes apparent relatively quickly and may take the shape of the weapon used. The extent and severity of a contusion are related to the amount of force applied, but more importantly vascular structures affected. 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. As the extravasated red cells are destroyed, the aging bruise goes through variable colour changes. Speculative judgments should be avoided in the evaluation of the nature and age of blunt traumatic lesions.

  9. Answer: B, C, D

    Full thickness wounds 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. 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. Scars related to self-inflicted injuries are generally superficial and within easy reach of the dominant hand. Contusions and abrasions may cause hyperpigmented scars, especially in darker skins, due to post-inflammatory hyperpigmentation. Also scars of distinctive shape and if in multiples suggest intentional injuries rather than those caused accidentally.

  10. Answer: B

    The photograph shows an oval scar above the left hip that is approximately 7 cm x 4 cm. It is a macular lesion with a depigmented, atrophic center, lacking normal skin accessories (hair). The periphery shows a hyperpigmented zone about 1 cm. wide. This scar is most consistent with a 2nd degree burn from a heated instrument.

  11. Answer: A

    This scar is the result of an abrasion injury as the individual was dragged across a rough surface.

  12. Answer: C

    This man sustained blunt trauma to the right supraorbital region which resulted in a typical laceration scar. The appearance of the scar is the result of the healing of irregular wound edges and tissue bridges.

  13. Answer: B

    The photograph shows 2 linear incisions resulting from slashes with a knife. The biconvex appearance of the scars suggest that they healed by secondary intention. These scars are most consistent with incisions because of the sharp, well-demarcated appearance of the scars.

  14. Answer: C

    The multiple linear, scars are most consistent with lacerations from whipping with an electrical wire.

  15. Answer: D

    The photograph shows evidence of multiple cigarette burns 7 days following the injury.

  16. Answer: A, B, C

    Whenever possible, the examination of women alleging rape 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. A thorough physical examination should be performed, including meticulous documentation of all physical findings. It is rare to find any physical evidence when examining female genitalia more than one week after 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. It is unwise to draw conclusions about a refusal to consent to genital examination. If the alleged victim refuses consent, the doctor should record any relevant observations on the alleged victim’s demeanour, such as embarrassment or fear, or cultural considerations.

  17. Answer: F

    All of the statements listed are true.

  18. Answer: A

    Rectal tears with or without bleeding may be noted. Disruption of the rugal pattern may manifest as smooth fan-shaped scarring. When these scars are seen out of midline (i.e. not at 12 or 6 o’clock), they can be an indication of penetrating trauma.

  19. Answer: A

    Poor quality photographs are better than none, but they should be followed up with professional photographs as soon as possible.

  20. Answer: E

    In some cases, the use of diagnostic tests may aid in corroborating allegations of torture. Before obtaining such tests, however, clinicians should carefully consider the potential value of such tests and their inherent limitations in light of the level of “proof” needed in a particular case, the potential adverse consequences for the individual, and any resource limitations. Generally, diagnostic tests are not warranted unless they are likely to make a significant difference to a medico-legal case.

Answer: B Although acute lesions may be characteristic of the alleged injuries, most lesions heal within about six weeks of torture, leaving no scars or, at the most, non-specific scars. Answer: C A complete physical examination is recommended unless the … Continue reading →

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Types of questions

If possible, the individual should be asked to give a chronological account of the incident(s) in question. Generally, open-ended questions should be used, for example: ‘Can you tell me what happened?’ or ‘Tell me more about that.’ The individual should be allowed to tell his or her story with as few interruptions as possible. Further details can be elicited with appropriate follow-up questions, such as: ‘How big was the cell?’, ‘Was there any lighting?’ and ‘How could you go to the toilet?’ Asking too many questions too quickly might confuse the individual, or even remind him or her of being interrogated.

Leading questions are avoided wherever possible, because individuals may answer with what they think the health professional wants to hear. This is especially important when interviewing for medico-legal purposes, where the testimony may be challenged in court. Closed questions, which provide the interviewee with a limited number of options and, particularly, list questions, can cause confusion in the individual and might create unnecessary inconsistencies. For example, an individual might be asked, ‘Were you arrested by the police or the army?’ limiting the answer to a choice between the two. If he or she was arrested by a special task force of soldiers and policemen working together, it would be difficult to give an accurate answer without appearing to contradict the health professional. This could in turn create inconsistencies between statements.

The pace of the interview must be dictated by the individual. Even if there is limited time for the interview (such as in a police station or prison), the interviewee should not feel rushed. It is better to focus on a few specific points than to try to cover too much ground in too little time. If there are many interviewees to be seen over several days, each should be seen once or twice for a substantial period of time, rather than several shorter sessions.

In a clinical setting, the interviewer should allow enough time between appointments to allow for this and for sufficient time to write up his or her notes. It is good practise to write up the notes of each interview at the end of that session, as various aspects of the individuals’ accounts may become confused if the interviewer attempts to write up all the interviews in a later single session, and details may be forgotten.

If possible, the individual should be asked to give a chronological account of the incident(s) in question. Generally, open-ended questions should be used, for example: ‘Can you tell me what happened?’ or ‘Tell me more about that.’ The individual should … Continue reading →

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Medical history

As stated in Module 3 [1], the pysician should obtain a complete medical history, including information about prior medical, surgical or psychiatric problems. S/he should:

  • Be sure to document any history of injuries, medical conditions and surgery before the period of detention and any possible after­effects;
  • Avoid leading questions;
  • Structure inquiries to elicit an open-ended, chronological account of the events experienced during detention.

Specific historical information may be useful in correlating regional practices of torture with individual allegations of abuse. Examples of useful information include descriptions of torture devices, body positions, methods of restraint, descriptions of acute or chronic wounds and disabilities and identifying information about perpetrators and places of detention. While it is essential to obtain accurate information regarding a torture survivor’s experiences, open-ended interviewing methods require that a patient disclose these experiences in their own words using free recall. An individual who has survived torture may have trouble expressing in words his or her experiences and symptoms. In some cases, it may be helpful to use trauma event and symptom checklists or questionnaires. If the interviewer believes it may be helpful to use trauma event and symptom checklists, there are numerous questionnaires available; however, none are specific to torture victims. All complaints of a torture survivor are significant. Although there may be no correlation with the physical findings, they should be reported. Acute and chronic symptoms and disabilities associated with specific forms of abuse and the subsequent healing processes should be documented.

Acute Symptoms

The individual should be asked to describe any injuries that may have resulted from the specific methods of alleged abuse. For example, bleeding, bruising, swelling, open wounds, lacerations, fractures, dislocations, joint stress, haemoptysis (coughing up blood), pneumothorax (lung puncture), tympanic membrane perforation, genitourinary system injuries, burns (including colour, bulla or necrosis according to the degree of burn), electrical injuries (size and number of lesions, their colour and surface characteristics), chemical injuries (colour, signs of necrosis), pain, numbness, constipation and vomiting. The intensity, frequency and duration of each symptom should be noted. The development of any subsequent skin lesions should be described and whether or not they left scars. Ask about health on release; was he or she able to walk, confined to bed? If confined, for how long? How long did wounds take to heal? Were they infected? What treatment was received? Was it a physician or a traditional healer? Be aware that the detainee’s ability to make such observations may have been compromised by the torture itself or its after-effects and should be documented. It is important to note that acute lesions are often characteristic since they may show a pattern of inflicted injury that differs from non-inflicted injuries, for example by their shape, repetitiveness, and distribution on the body.

Chronic Symptoms

Elicit information of physical ailments that the individual believes were associated with torture or ill-treatment. Note the severity, frequency and duration of each symptom and any associated disability or need for medical or psychological care. Even if the after-effects of acute lesions are not observed months or years later, some physical findings may still remain, such as electrical current or thermal burn scars, skeletal deformities, incorrect healing of fractures, dental injuries, loss of hair and myofibrosis. Common somatic complaints include headache, back pain, gastrointestinal symptoms, sexual dysfunction and muscle pain. Common psychological symptoms include depressive affect, anxiety, insomnia, nightmares, flashbacks and memory difficulties (see Module 6 [2]).

Quelle

  • [1] https://phrtoolkits.org/toolkits/istanbul-protocol-model-medical-curriculum/module-3-interview-considerations/
  • [2] https://phrtoolkits.org/toolkits/istanbul-protocol-model-medical-curriculum/module-6-psychological-evidence-of-torture-and-ill-treatment/

As stated in Module 3, the pysician should obtain a complete medical history, including information about prior medical, surgical or psychiatric problems. S/he should: Be sure to document any history of injuries, medical conditions and surgery before the period of … Continue reading →

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Module 6 Answers

  1. Answer: E

    Detailed psychological evaluations should be included in all medical evaluations for all of the reasons listed.

  2. Answer: E

    All of the items listed are true about psychological sequelae of torture and ill treatment.

  3. Answer: B

    Torture may not only have profound effects on individuals, but on families and society as well. It can terrorize entire populations and create an atmosphere of pervasive fear, terror, inhibition, and hopelessness. It can break or damage the will and coherence of entire communities. It often results in disruptions in family dynamics and may be associated with considerable family dysfunction.

  4. Answer: E

    All of the items listed may explain why survivors of torture and ill treatment may not trust examining clinicians.

  5. Answer: H

    When listening to individuals speak of their torture, clinicians should expect to have personal reactions and emotional responses themselves including avoidance and defensive indifference in reaction to being exposed to disturbing material, disillusionment, helplessness, hopelessness that may lead to symptoms of depression or “vicarious traumatisation,” grandiosity or feeling that one is the last hope for the survivor’s recovery and well-being, feelings of insecurity in one’s professional skills in the face of extreme suffering, guilt over not sharing the torture survivor’s experience, or even anger when the clinician experiences doubt about the truth of the alleged torture history and the individual stands to benefit from an evaluation.

  6. Answer: B, C, E

    According to DSM IV criteria, the diagnosis of PTSD requires that:

    A) A person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others; and the person’s response involved intense fear, helplessness, or horror.

    B) One or more re-experiencing symptoms are present following the trauma.

    C) Three or more avoidance symptoms are present following the trauma.

    D) Two or more hyperarousal symptoms are present following the trauma.
    E) The duration of symptoms in Criteria B, C, and D) is more than 1 month.

    F) The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  7. Answer: E

    PTSD symptoms commonly occur under all of the circumstances listed above. Anniversary dates and interactions with police or security forces often serve as direct reminders of past traumatic experiences. Recalling traumatic experiences prior to, during, and following a medical evaluation often results in re-traumatisation. In gaining asylum, survivors of torture are often reminded of the loss of family, friends, job, language, etc. and/or may experience feelings of guilt in “abandoning” others who may still be detained.

  8. Answer: L

    Symptoms of Major Depression include all of the symptoms listed above. Depressive states are very common among survivors of torture. Depressive disorders may occur as a single episode or be recurrent. They can be present with or without psychotic features.

  9. Answer: G

    In addition to all of the items listed, other possible diagnoses include: generalized anxiety disorder, panic disorder, acute stress disorder, bipolar disorder, delusional disorder, disorders due to a general medical condition, (possibly in the form of brain impairment with resultant fluctuations or deficits in level of consciousness, orientation, attention, concentration, memory and executive functioning), and phobias such as social phobia and agoraphobia.

  10. Answer: B

    Somatiform disorders manifest as repeated presentations of physical symptoms in the absence of physical findings. If any physical disorders are present, they do not explain the nature and extent of the symptoms or the distress and preoccupation of the patient.

  11. Answer: A

    Neuropsychology has long been recognised as useful in discriminating between neurological and psychological conditions and in guiding treatment and rehabilitation of patients suffering from the consequences of various levels of brain damage. Neuropsychological evaluations of torture survivors are performed infrequently, but may be useful in evaluating individuals suspected of having brain injury and in distinguishing brain injury from PTSD. Neuropsychological assessment may also be used to evaluate specific symptoms, such as problems with memory that occur in PTSD and related disorders.

  12. Answer: G

    All topics listed are components of the mental status examination with the exception of G, cranial nerve assessment.

  13. Answer: B

    Significant psychological symptoms may not be present among survivors of torture for a number of reasons. Clinicians may fail to consider diagnostic possibilities especially if they simply focus on the most common psychological diagnoses. Survivors may not have significant psychological symptoms due to effective coping strategies, social supports and/or a positive meaning assigned to their experiences (i.e. suffering for an important cause). Under such circumstances the reasons for symptom mitigation can and should be explained in the clinician’s medical evaluation.

  14. Answer: A

    The first step in addressing inconsistencies is to ask the individual for further clarification.

  15. Answer: B

    Pre-torture psycho-social information is highly relevant to the interpretation of psychological evidence as it is provides a context for understanding individual behaviour and the meaning assigned to torture experiences.

  16. Answer: D

    The administration of psychological instruments is up the discretion of the examining clinician. There are numerous questionnaires available. Though they may add complementary value to a clinical evaluation, routine use is not recommended. Caution must be exercised in the interpretation of responses and scores because established norms do not exist for many countries. The Istanbul Protocol makes clear that psychological instruments should not be given more weight than the clinical evaluation.

  17. Answer: A

    The clinician should attempt to understand mental suffering in the context of the survivor’s circumstances, beliefs, and cultural norms rather than rush to diagnose and classify. Awareness of culture specific syndromes and native language-bound idioms of distress is of paramount importance for conducting the interview and formulating the clinical impression and conclusion. When the interviewer has little or no knowledge about the alleged victim’s language and culture, the assistance of an interpreter is essential.

  18. Answer: G

    Interpretation of the clinical findings is a complex task. According to the Istanbul Protocol, all of the concerns listed should be included in clinical interpretations of psychological evidence of torture and ill treatment.

  19. Answer: A

    In the course of documenting psychological evidence of torture clinicians are not absolved of their ethical obligations. Those who appear to be in need of further medical and/or psychological care should be referred to appropriate services. Clinicians should be aware of local rehabilitation and support services.

  20. Answer: F

    All of the considerations listed are true about the effects of torture on children.

Answer: E Detailed psychological evaluations should be included in all medical evaluations for all of the reasons listed. Answer: E All of the items listed are true about psychological sequelae of torture and ill treatment. Answer: B Torture may not … Continue reading →

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Brief History

The Istanbul Protocol 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 who represented 40 organisations and institutions from 15 countries, including the International Rehabilitation Council for Torture Victims (IRCT). The development of the Istanbul Protocol was initiated and coordinated by Physicians for Human Rights-USA (PHR), the Human Rights foundation of Turkey (HRFT), and Action for Torture Survivors (HRFT-Geneva). The project was conceived in March, 1996, after an international symposium on “Medicine and Human Rights” held at the Department of Forensic Medicine, Cukurova University Medical Faculty, in Adana, Turkey by the Turkish Medical Association. The drafting process culminated at a meeting in Istanbul in March, 1999, when the manual reached its final form and subsequently submitted to the United Nations High Comissioner for Human Rights (OHCHR) on the 9th of August 1999. In 2001, the Office of the OHCHR published the Istanbul Protocol in its Professional Training Series in the six official UN languages.

The Istanbul Protocol 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 who represented 40 organisations and institutions from 15 countries, including the International … Continue reading →

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Cognitive Techniques

Psychological research has shown that the ability to recall important incidents can be enhanced by using some basic cognitive techniques. Having established rapport with the individual, he or she should be allowed to give a free narrative about the events. The interviewer should allow the individual, as much as possible, the time to describe what happened in his or her own words. Clarification of points is permissible but not direct questioning which might break the individual’s recall. Only after the individual has finished his or her narrative should direct questions be asked to clarify points. The survivor of torture should know that it is acceptable to say: ‘I don’t understand the question,’ or ‘I don’t know the answer.’

The quality of the information gained can be improved by some specific techniques. Firstly, in a clinical setting in which time allows it, the individual should be told to describe everything surrounding the time of ill-treatment (for instance describing the events and process of being taken into detention), even if it does not appear directly relevant to him or her. This might relate to events that could be more important than the individual realises. Secondly, as he or she relates them, this can bring other events that are more relevant into his or her mind. It helps if he or she is encouraged to recall the context in which the events happened.

Having encouraged the interviewee to describe the events in a free narrative, in chronological order, the interviewer can seek more detail by asking questions in a different order. For example, by reversing the order: ‘You were telling me …, what happened just before that?’

Another tool is changing the perspective, which means trying to describe the events from another point of view, for example if the interviewee is sufficiently well-educated the interviewer could ask: ‘How would a tailor describe what the man was wearing?’ or ‘When you were arrested at the demonstration, what would a spectator have seen?’

It is important to remember that different cultures have different concepts of what is normal behaviour in an interview. In some societies it is considered polite not to look directly into the eyes of someone in a position of relative authority (such as an interviewer), whereas in other cultures such behaviour is considered to be a sign of dishonesty. People from some cultures find constant hand movements a normal part of communication, whereas those from others find them distracting. Personal space varies between and within cultures, and what might be normal between colleagues could feel too close in an interview setting. This could make the individual feel anxious, and behave in a way that the interviewer perceives as uncooperative.

Psychological research has shown that the ability to recall important incidents can be enhanced by using some basic cognitive techniques. Having established rapport with the individual, he or she should be allowed to give a free narrative about the events. … Continue reading →

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The Physical Examination

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

As mentioned in Module 2 [1], it is essential to obtain the individual’s informed consent prior to the physical examination. The physical examination must be conducted by a qualified physician. Whenever possible, the patient should be able to choose the gender of the physician and, where used, interpreter. If the doctor is not the same gender as the patient, a chaperone who is of the same gender as the patient should be used unless the patient objects. The patient must understand that he or she is in control and has the right to limit the examination or to stop at any time (see Module 3 [2]). A complete physical examination is recommended unless the allegations of torture are limited and there is no history of loss of consciousness or neurological or psychological symptoms that may affect recall of torture allegations. Under such circumstances, a directed examination may be appropriate in which only pertinent positive and negative evidence are pursued on examination.

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

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

Quelle

  • [1] https://phrtoolkits.org/toolkits/istanbul-protocol-model-medical-curriculum/module-2-istanbul-protocol-standards-for-medical-documentation-of-torture-and-medical-ethics/
  • [2] https://phrtoolkits.org/toolkits/istanbul-protocol-model-medical-curriculum/module-3-interview-considerations/
  • [3] https://phrtoolkits.org/downloads/?did=22

The physical examination is usually the last component of a medical evaluation of an alleged torture victim, after the acquisition of all background information, allegations of abuse, acute and chronic symptoms and disabilities, and after the psychological evaluation, if, in … Continue reading →

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Resources

As mentioned above, 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, to supplement the Istanbul Protocol, including extensive training materials developed by the IRCT and partner organisations, the Human Rights Foundation of Turkey (HRFT) and Physicians for Human Rights (PHR) for the Prevention through Documentation (PtD) Project. Selected materials were excerpted and adapted from these resources to develop a comprehensive curriculum for health professionals in the course of their training. The primary resources used for the development of the Model Curriculum include:

Each Module contains a list of the primary resources used for its development. It is important to note that clinicians who conduct forensic medical evaluations of alleged victims of torture and ill-treatment should be familiar with the entire content of the Istanbul Protocol, especially if they refer to the application of Istanbul Protocol standards in their medico-legal report(s).

Quelle

  • [1] https://phrtoolkits.org/downloads/?did=34
  • [2] https://phrtoolkits.org/toolkits/istanbul-protocol-model-medical-curriculum/module-7-case-example-01/materials/
  • [3] https://phrtoolkits.org/toolkits/istanbul-protocol-model-medical-curriculum/module-8-case-example-02/materials/
  • [4] http://www.essex.ac.uk/torturehandbook/
  • [5] http://www.essex.ac.uk/combatingtorturehandbook/
  • [6] https://phrtoolkits.org/downloads/?did=22
  • [7] http://physiciansforhumanrights.org/library/reports/examining-asylum-seekers-manual-2005-1.html
  • [8] http://www.preventingtorture.org
  • [9] http://www.preventingtorture.org
  • [10] http://www.irct.org/resources/irct-electronic-library/trainers-materials/presentations.aspx
  • [11] http://www.irct.org/Files/Filer/TortureJournal/16_2_2006/4_dermatological_findings.pdf
  • [12] http://www.irct.org/Admin/Public/DWSDownload.aspx?File=%2fFiles%2fFiler%2fIPIP%2ftraining2009%2fmedical+materials+for+practitioners%2fmedical_en_web_red.pdf
  • [13] http://www.irct.org/Files/Filer/publications/psychological_en_web_red.pdf
  • [14] http://www.redress.org/downloads/publications/PhilippinesManualNov07.pdf
  • [15] http://www.irct.org/Admin/Public/DWSDownload.aspx?File=%2fFiles%2fFiler%2fIPIP%2ftraining2009%2fmedical+materials+for+trainers%2fTrainers-Guidelines-Health-Professionals-ToU-final_password.pdfhttp://www.irct.org/Admin/Public/DWSDownload.aspx?File=%2fFiles%2fFiler%2fIPIP%2ftraining2009%2fmedical+materials+for+trainers%2fTrainers-Guidelines-Health-Professionals-ToU-final_password.pdf
  • [16] http://www.irct.org/resources/irct-electronic-library/trainers-materials/presentations.aspx

As mentioned above, 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, to supplement the Istanbul Protocol, … Continue reading →

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Head and Neck

Lesions on the face are particularly distressing for survivors of torture because they are a frequent reminder of the episode. Most traumatic scars on the face tend to be relatively small, and scars from acne and chickenpox, and tribal markings, must not be mistaken for them.

Lesions are common over bony points, especially the eyebrows and the cheekbones. These may be associated with a fracture of the malar bone (cheekbone). Bruises and scars in the scalp can be difficult to find, especially if the hair is thick. Bruises will normally be tender to touch. Broken or missing teeth are often shown by individuals as evidence of assault, but where the general oral hygiene is poor this usually makes this sign unhelpful. Petechiae of the palate may be evidence of forced oral intercourse. Slaps to the ear can sometimes damage the eardrum. However, the finding of scars of the tympanic membrane (eardrum) does not exclude childhood infections.

Eyes

Conjunctival hemorrhage, lens dislocation, subhyeloid hemorrhage, retrobulbar hemorrhage, retinal hemorrhage, and visual field loss may all be observed following torture. Referral to an ophthalmologist is recommended whenever there is a suspicion of ocular trauma or disease.

Ears

Blunt trauma to the external ear may result in haematoma. Cartilage necrosis and infection are likely sequelae if the ear is left untreated. Lacerations of the pinna vary from those of minor significance to complete amputation. Rupture of the tympanic membrane is a frequent consequence of harsh beatings. Prompt examination is necessary to detect tympanic membrane ruptures less than 2 mm in diameter, as they can heal within 10 days. About 80% of traumatic tympanic membrane perforations diagnosed within 14 days of injury will have healed spontaneously.

The short and long term sequelae of significant injury to the middle and inner ear are hearing loss, vertigo, tinnitus, unsteadiness and, less commonly, facial nerve paralysis. An audiogram should be performed to assess injury to the ossicles and inner ear. A conductive hearing loss is usually due to a tear in the tympanic membrane and blood in the middle ear. A hearing loss of less than 40 dB suggests an ossicular chain dislocation. Sensorineural loss indicates cochlear or retrocochlear damage.

Fluid may be observed in the middle and/or external ear. If otorrhea is confirmed by laboratory analysis to be CSF (cerebrospinal fluid), then MRI or CT should be performed, if possible, to determine the fracture site. The radiographic examination of fractures of the temporal bone or disruption of the ossicular chain is best determined by CT, then hypocycloidal tomography, and lastly linear tomography.

Nose

The nose should be evaluated for alignment, crepitation, and deviation of the nasal septum. Initially soft tissue swelling may make interpretation difficult and it may be necessary to re-examine nose after 48 hours when this has subsided. Frequently there is an associated deviation of nasal septum which may result in nasal obstruction. For simple nasal fractures, standard nasal radiographs should be sufficient. Sometimes the fracture of the nasal bone includes the frontal process of the maxilla, and sometimes it extends to include ethmoid labyrinth. For complex nasal fractures and when the cartilaginous septum is displaced, and when rhinorrhea is present, CT and/or MRI are recommended.

Jaw, Oropharynx and Teeth

The oral cavity must be carefully examined. During the application of electric current to the mouth, the tongue, gingiva or lips may be bitten. Lesions might also be produced by forcing objects or materials into the mouth. Temporomandibular joint syndrome can be caused by electric current and blows to the face. It will produce pain in the temporomandibular joint, limitation of jaw movement, and in some cases subluxation of this joint.

A careful dental history should be taken and, if dental records exist, these should be requested. The patient should be referred to a dentist if there is any damage to the teeth. Mandibular fractures, avulsions or fractures of the teeth, broken prostheses, swelling of the gums, bleeding, pain, or loss of fillings from teeth can all result from direct trauma or electric shock torture. Dental caries and gingivitis should also be noted. Poor quality dentition may be due to conditions in detention, or may have preceded it. X-rays and MRI are suggested for determining the extent of soft tissue, mandibular and dental trauma.

Lesions on the face are particularly distressing for survivors of torture because they are a frequent reminder of the episode. Most traumatic scars on the face tend to be relatively small, and scars from acne and chickenpox, and tribal markings, … Continue reading →

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