Module 4: Torture Methods and their Medical Consequences

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Some degree of restraint is clearly necessary and legitimate at the time of arrest or during transfer in order to prevent a detainee from escaping. However, once detention has been secured, there can be no legitimate need for artificial restraint. The use of shackles or leg irons is specifically forbidden by Rule 33 of the UN Standard Minimum Rules for the Treatment of Prisoners. In spite of this ruling, extreme and prolonged measures are very often taken. Sometimes an attempt is made to justify its use as preventing escape but usually they are applied to cause humiliation or as a punishment. The restraint may be continued for days or even weeks, far longer than needed for legitimate purposes.

Handcuffs, wrist or ankle ties leave no mark if they are applied properly, and in some countries officers take care to prevent damage. In India, for instance, police often use the detainee’s turban cloth to bind the wrists or ankles. Conversely, restraints may cause abrasions or bruising even after a short time if they are of rough or harsh material or are applied too tightly. Thin ligatures tightly applied may cause deep wounds after a few hours. This type of handcuff, which automatically continues to tighten if the prisoner struggles, is particularly dangerous and can cause characteristic lesions.

The use of leg irons is widespread in police stations and prisons. Pakistani prisons are particularly notorious for its use, often for long periods of time. They are used as punishment, as a means of extorting bribes and intimidating or humiliating prisoners. Often the rings round the ankles are roughly finished and cause severe abrasions and scarring which may be highly consistent with allegations of abuse.

There are many forms of positional torture, all of which tie or restrain the victim in contorted, hyperextended or other unnatural positions, which cause severe pain and may produce injuries to ligaments, tendons, nerves and blood vessels. Characteristically, these forms of torture leave few, if any, external marks or radiological findings, despite subsequent frequently severe chronic disability.

Positional torture is directed towards tendons, joints and muscles. The ‘five-point tie’ is a technique of trussing up a captive used in several African countries. A single fine rope is tied round the wrists, ankles and neck or mouth, holding the trunk tightly in extreme extension. An attempt to relieve the pain by moving one limb tightens it more around the others. If this type of restraint is continued for any length of time there is almost certain to be permanent scarring and perhaps peripheral nerve or vascular lesions.

In China, many forms of shackling are used as punishment and are given nicknames to disguise the appallingly painful methods used. For instance, Su Qin bei jian (literally, ‘Su Qin carries a sword on his back’) describes the shackling of one arm pulled over the shoulder to the other which is twisted behind the back. Another is liankao, describing various methods of shackling the hands and feet behind the back.

Cramped or distorted postures or prolonged standing are used routinely in many countries. An example is Israel, where ‘moderate physical pressure’ is permitted by law. Several techniques have been devised by the General Security Service (Shin Bet) and routinely used to put detainees under undue stress. In shabeh the victim is shackled for hours to a low chair whose front legs have been shortened so that the detainee must constantly struggle to avoid sliding off. Shabeh is usually combined with methods of abuse, i.e. placing an often filthy sack over the victim’s head, exposing him or her to loud music and sometimes to extreme temperatures and sleep deprivation.

In gambaz the detainee is forced to crouch on his toes in the ‘frog’ position for long periods. In kas’at tawila the subject is made to kneel with his back up against a table and his cuffed arms resting on the table behind him while the interrogator’s legs push against his shoulders. A small chamber nick-named ‘the refrigerator’ is used to keep the victim immobile for hours or days.

The UN Committee against Torture has determined that restraining detainees in very painful positions is by itself an act of both torture and cruel, inhuman or degrading treatment.^[1] It recently determined that the use of “short shackling” by US (United States) personnel constitutes either torture or cruel, inhuman or degrading treatment and has recommended that the method be prohibited.^[2] In a review of US practises, the UN Special Rapporteur on Torture has condemned the use of stress positions on detainees by the United States as violating the Convention Against Torture.^[3]

^[1] Hashemian F, Crosby S, Iacopino V, Keller A, Nguyen L, Ozkalipici O, et, al. Broken Laws, Broken Lives: Medical Evidence of Torture by US Personnel and It’s Impact. Physicians for Human Rights. June, 2008. pp. 100. (Hereafter: Broken Laws, Broken Lives)

^[2] Broken Laws, Broken Lives pp. 100.

^[3] Broken Laws, Broken Lives pp. 100

Some degree of restraint is clearly necessary and legitimate at the time of arrest or during transfer in order to prevent a detainee from escaping. However, once detention has been secured, there can be no legitimate need for artificial restraint. … Continue reading →

There are three complimentary approaches for understanding the psychological impact of torture. The personal approach is the individual’s story as told through testimony, oral history, literature, and art. The clinical approach utilizes a medical and psychological paradigm and relies on clinical history, physical exam, and mental status exam. The community approach involves epidemiological studies of traumatised groups and populations. In combination these approaches provide a broad and deep understanding of the impact of torture on human beings. Each approach requires consideration of the context of torture. Torture has unique cultural, social and political meanings for each individual. These meanings will influence an individual’s ability to describe and speak about their experiences. Similarly, these factors contribute to the impact that the torture inflicts psychologically and socially. Descriptive methods, therefore, are the best approaches when attempting to evaluate psychological or psychiatric reactions and disorders because what is considered disordered behaviour or a disease in one culture may not be viewed as pathological in another. While some psychological symptoms may be present across differing cultures, they may not be the symptoms that concern the individual the most. Therefore, the clinician’s inquiry has to include the individual’s beliefs about their experiences and meanings of their symptoms, as well as an evaluating the presence or absence of symptoms of trauma-related mental disorders. For example, intrusive memories may be interpreted as a supernatural experience. Therefore the health professional’s inquiry has to include the individual’s beliefs about their experiences and meanings of their symptoms.

Torture is powerful enough on its own to produce mental and emotional consequences, regardless of the individual’s pre-torture psychological status. Nevertheless, torture has variable effects on people because the social, cultural and political contexts vary widely. Outcomes can be influenced by many interrelated factors that include but are not limited to the following:

• Circumstances, severity and duration of the torture
• Cultural meaning of torture/trauma and cultural meaning of symptoms
• Age and developmental phase of the victim
• Genetic and biological vulnerabilities of the victim
• Perception and interpretation of torture by the victim
• The social context before, during and after the torture
• Community values and attitudes
• Political factors
• Prior history of trauma
• Pre-existing personality

The psychological impact of ill-treatment clearly depends on the individual (see risk factors listed below). For example, someone who is politically active might be able to undergo substantial torture without necessarily developing persistent psychological symptoms because he or she could have anticipated the experience, and put the episode into a personal and political context. However, someone who was arrested simply as a result of being in the wrong place at the wrong time might not suffer much ill-treatment, but could still be devastated by the experience, because the incident was not anticipated and the person was not sustained by a political ideology or religious faith.

Similarly, the consequences are different for a young woman who is raped during torture and is from a culture that attaches a severe negative stigma of impurity to a woman who has been raped, compared with a former military officer who is captured and suffers long-term solitary confinement and multiple beatings. It goes without saying that both types of torture are extremely severe, yet the impact on the individual’s life is vastly different. The young woman might be socially ostracized and condemned even by her own family and community. The former military officer may have brain damage from beatings to the head with resultant long-term disability.

There are three complimentary approaches for understanding the psychological impact of torture. The personal approach is the individual’s story as told through testimony, oral history, literature, and art. The clinical approach utilizes a medical and psychological paradigm and relies on … Continue reading →

Suspension is a common form of torture that can produce extreme pain, but which leaves little, if any, visible evidence of injury. A person still in custody may be reluctant to admit to being tortured, but the finding of peripheral neurological deficits, diagnostic of brachial plexopathy, virtually proves the diagnosis of suspension torture. Suspension may last from 15 to 20 minutes to several hours. Suspension can be applied in various forms:

• Cross suspension or “crusifixion.” Applied by spreading the arms and tying them to a horizontal bar;
• Butchery suspension. Applied by fixation of hands upwards, either together or one by one;
• Reverse butchery suspension. Applied by fixation of feet upward and the head downward;
• “Palestinian” suspension. Applied by suspending the victim with the wrists or forearms bound together behind the back and tied to a horizontal bar or rope.
• “Parrot perch” suspension. Applied by suspending a victim by the flexed knees from a bar passed below the popliteal region, usually while the wrists are tied to the ankles.

“Palestinian” suspension may produce permanent brachial plexus injury in a short period. There is such an unnatural strain on all the muscles and ligaments of the shoulder girdle that one or both shoulders may dislocate. Victims complain for several days afterwards of inability to raise the arms above the head and sometimes of numbness and weakness of the fingers. For years afterwards they may experience pain on raising the arms, lifting weights or combing the hair. On examination there is usually tenderness in the muscles around the shoulders and scapulae and severe pain on passive movements, especially extension and internal rotation of the shoulders. There is occasionally winging of the scapulae (prominent vertebral border of the scapula) caused by traction on the long thoracic nerve, easily missed unless specially looked for by asking the subject to press against a wall with outstretched arms, and there may be permanent deficit of the lower roots of the brachial plexus, as shown by sensory deficit in an ulnar distribution.

The “parrot perch” (pau de arara, the chicken, the bar) is another form of suspension which causes immediate severe pain. It has been commonly used in many Latin American countries but is also seen in Africa. The wrists are bound together in front of the body, the arms passed over the knees and a pole thrust behind the knees. The result may be rupture of the cruciate ligaments of the knees or sensory or vascular damage below the knees. Victims will often be beaten while suspended or otherwise abused. In the chronic phase, it is usual for pain and tenderness around the shoulder joints to persist, as the lifting of weight and rotation, especially internal, will cause severe pain many years later.

There are many other methods of suspension including hanging by the ankles or with the arms tied to a cross-bar as in ‘crucifixion’. Whether there will be any immediate or later ill-effects depends on the method used, the posture of restraint and the distribution of bonds, which may have been not only at the wrists and ankles but at any point of the arms, legs or trunk.

Suspension by the hair can avulse the scalp leading to an immediate cephal­haematoma which may persist and be palpable for months or even years as a boggy swelling. In any event, the scalp is likely to remain tender, sometimes with the scalp attached unnaturally firmly to the underlying skull.

In general, complications in the acute period following suspension include weakness of the arms or hands, pain and parasthesias, numbness, insensitivity to touch, superficial pain and tendon reflex loss. Intense deep pain may mask muscle weakness. In the chronic phase, weakness may continue and progress to muscle wasting. Numbness and, more frequently, parasthesia are present. Raising the arms or lifting weight may cause pain, numbness or weakness. In addition to neurologic injury, there may be tears of the ligaments of the shoulder joints, dislocation of the scapula and muscle injury in the shoulder region.

Various forms of suspension can result in neurologic injury which is usually asymmetrical in the arms. Brachial plexus injury manifests itself in motor, sensory and reflex dysfunction.

• Motor examination. Asymmetrical muscle weakness, more prominent distally, is the most expected finding. Acute pain may make the examination for muscle strength difficult to interpret. If the injury is severe, muscle atrophy may be seen in the chronic phase;
• Sensory examination. Complete loss of sensation or parasthesias along the sensory nerve pathways is common. Positional perception, two-point discrimination, pinprick evaluation and perception of heat and cold should all be tested. If at least three weeks later, deficiency or reflex loss or decrease is present, appropriate electrophysiological studies should be performed by a neurologist experienced in the use and interpretation of these methodologies;
• Reflex examination. Reflex loss, a decrease in reflexes or a difference between the two extremities may be present. In “Palestinian” suspension, even though both brachial plexi are subjected to trauma, asymmetric plexopathy may develop due to the manner in which the torture victim has been suspended, depending on which arm is placed in a superior position or the method of binding. Although research suggests that brachial plexopathies are usually unilateral, that is at variance with experience in the context of torture, where bilateral injury is common.

Among the shoulder region tissues, the brachial plexus is the structure most sensitive to traction injury. “Palestinian” suspension creates brachial plexus damage due to forced posterior extension of the arms. As observed in the classical type of “Palestinian” suspension, when the body is suspended with the arms in posterior hyperextension, typically the lower plexus and then the middle and upper plexus fibers, if the force on the plexus is severe enough, are damaged, respectively. If the suspension is of a “crucifixion” type, but does not include hyperextension, the middle plexus fibers are likely to be the first ones damaged due to hyperabduction. Brachial plexus injuries may be categorized as follows:

• Damage to the lower plexus. Deficiencies are localized in the forearm and hand muscles. Sensory deficiencies may be observed on the forearm and at the fourth and fifth fingers of the hand’s medial side in an ulnar nerve distribution;
• Damage to the middle plexus. Forearm, elbow and finger extensor muscles are affected. Pronation of the forearm and radial flexion of the hand may be weak. Sensory deficiency is found on the forearm and on the dorsal aspects of the first, second and third fingers of the hand in a radial nerve distribution. Triceps reflexes may be lost;
• Damage to the upper plexus. Shoulder muscles are especially affected. Abduction of the shoulder, axial rotation and forearm pronation-supination may be deficient. Sensory deficiency is noted in the deltoid region and may extend to the arm and outer parts of the forearm.

Assessing physical evidence following suspension may be complicated by the fact that suspension is often accompanied by beating, so it is impossible to generalise, but if the examiner asks the subject to describe or mime the particular posture and stress he was subjected to, it is possible to decide what areas of skin, joints and muscle groups to concentrate on during physical examination. This entails a detailed search of the skin for marks of bonds, the joints for limitation of movement by pain or, occasionally, tendency to subluxation, and muscle groups for abnormal tension and tenderness as well as a neurological examination for peripheral nerve lesions and the extremities for vascular changes. Abnormalities are likely to be easily found in the immediate aftermath but usually fade with time. Unless the full thickness of skin has been destroyed by tight bonds there is unlikely to be any permanent scarring where bonds have been applied though they must be searched for. Their absence does not negate the allegation. In most cases all signs on the skin fade after a few days, but if abrasions are deep or become infected, there may be permanent scarring, changes in pigmentation or occasionally, only depilation (hair loss). Lesions are usually linear and transverse and most marked over bony prominences. These are suggestive, but only if they are almost completely circumferential round the limbs are they are virtually diagnostic of restraint. Though usually situated at the level of the wrists or ankles, they may be found further up the limbs because bonds may be applied higher or ride higher up. In many cases joint movements remain limited and painful for months or years and tenderness of muscle groups is often persistent. Motor or sensory changes tend to improve with time.

The sooner after injury that treatment can be instituted the better, but it is rare for any professional care to be possible until long after the events. Victims often say that they were treated by traditional methods of massage and exercise, with relief of pain on their release from detention. Late treatment concentrates on physiotherapy with massage, graduated exercises and postural re-education. At first, the therapist must be extremely careful to respect the patient’s fear of contact and may not even be able to touch him until a satisfactory rapport has been established.

Suspension is a common form of torture that can produce extreme pain, but which leaves little, if any, visible evidence of injury. A person still in custody may be reluctant to admit to being tortured, but the finding of peripheral … Continue reading →

In considering who may be at heightened risk for developing psychological problems, one must evaluate both general/overall risk factors as well as those risk factors specific to traumatised populations including how trauma affects family and social relationships and other natural supports. The general risk factors for developing mental illness are based on age, sex, education, social class, divorced/widowed status, history of mental illness, and family history of mental illness. Additional risk factors for torture survivors include torture, war, political oppression, imprisonment, witnessing or experiencing atrocities, loss of family and/or separation from family, and distortion of social relationships. If the torture survivor is also a refugee or asylum seeker, he/she has the further risk factors of migration (loss of home, loved ones, possessions, etc), acculturation, poverty, prejudice, cultural beliefs and traditional roles, cultural and linguistic isolation, absence of adequate support systems, and unemployment or underemployment. The multiple layers of increasing risk present a clinical picture that has been described by as one of “cumulative synergistic adversity.”

In considering who may be at heightened risk for developing psychological problems, one must evaluate both general/overall risk factors as well as those risk factors specific to traumatised populations including how trauma affects family and social relationships and other natural … Continue reading →

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 →

Objectives

• To provide in-depth information on specific torture methods, how they are applied and possible acute and chronic physical findings associated with them
• To develop an understanding of the extent to which physical findings corroborate specific allegations of torture and ill-treatment
• To be able to describe and identify physical findings, likely causes of injury and opinion regarding the possibility of torture/ill-treatment
• To understand common psychosocial consequences of torture and ill-treatment
• To be familiar with factors which may affect the variability of psychological evidence of torture and ill-treatment

Content

• The subjective element of suffering
• Torture methods
• Beating
• Falanga
• Ear trauma
• Eye trauma
• Restraint, shackling and positional torture
• Suspension
• Crushing and stretch Injuries
• Burning
• Electrical injuries
• Aspyxiation
• Violent shaking
• Sexual assault
• Sexual humiliation
• Prolonged isolation and sensory deprivation
• Sleep deprivation
• Temperature manipulation
• Sensory bombardment
• Threats of harm
• Psychological consequences of torture
• The Paradox of Psychological Consequences of Torture
• The Psychological Consequences of Torture
• Social, Political and Cultural Context
• Risk factors for Trauma and Torture-Related Disorders
• Psychological Symptoms

Discussion Topics

• Students should work in groups or individually on answering questions contained in Self-Assessment 4
• Additional Discussion Topics:
• Discuss the overall value of physical evidence of torture and limitations thereof
• Consider relationships between physical and psychological evidence of torture. Provide 92 examples of interrelated findings.
• What patterns of physical injury support the allegation of torture?
• Discuss possible interpretations of the absence of physical evidence of torture and ill treatment

Teaching Formats

• Group Activity:
• Divide the class into several groups and have each group work on answering questions contained in Self-Assessment 4
• A facilitator should be identified to moderate the discussion and rapporteur should be identified to record the group’s findings and report them when the class reconvenes.
• After 20-30 minutes of group discussion, the entire class should reconvene
• Rapporteurs should briefly report on their group’s findings
• Open class discussion
• Alternative Option:
• Divide the class into several groups and assign each group with one or more (or all) of the Discussion Topics
• Follow the usual sequence for conducting group activities as outlined above
• Individual Research/Assignment:
• Individual students should answer all questions contained in Self-Assessment 4
• Journal Entry: (Instructor to assign Write a few paragraphs — no more than a page)
• Respond to one or more of the Discussion Topics

Primary Resources

• The Istanbul Protocol, Chapters V and VI
• The Medical Documentation of Torture
• Medical Investigation and Documentation of Torture: A Handbook for Health Professionals
• Examining Asylum Seekers
• Medical Physical Examination of Alleged Torture Victims: A Practical Guide to the Istanbul Protocol for Medical Doctors
• Dermatologic Findings after Alleged Torture (PowerPoint file). Lis Danielsen and Ole Vedel Rasmussen, IRCT 2004-2005.
• Torture Methods (PowerPoint file). Ole Vedel Rasmussen, IRCT 2004-2005.
• Işkence Atlaı: Işkencenin Tibbi Olarak Belgelendirilmesinde Muayene ve Tanısal Inceleme Sonuclarının Kullanılması
• Trainers’ Guidelines for Health Professionals: Training of Users

Objectives To provide in-depth information on specific torture methods, how they are applied and possible acute and chronic physical findings associated with them To develop an understanding of the extent to which physical findings corroborate specific allegations of torture and … Continue reading →

Many torturers injure their victims by stamping on their hands or feet with heavy boots, leaving scarring and fractures of the digits, which may give a good indication of how the injuries were inflicted. However, it is not usually possible to differentiate nails damaged by trauma from the subjects of previous chronic infection.

“Cheera” is the Punjabi word for tearing. It is the nickname given to a technique common in the northwest of the Indian subcontinent. The victim is seated on the floor, often with an officer behind him with a knee in his back and pulling the head back by the hair. The legs are stretched apart, either suddenly or gradually, until they reach as much as 180 degrees. There is often a sound and sensation of tearing and, of course, the pain is excruciating. Often there is the additional trauma of kicks aimed at the inner aspect of the thighs or the genitals. In extreme cases the femur may fracture. The usual immediate result is the appearance of extensive haematomata in the groins or lower on the inner aspect of the thighs depending on whether the adductors have been torn off their origins or the bellies of the muscles have been disrupted. Naturally, walking is almost impossible for a long time. The late findings are pain on walking long distances, tenderness over the origins or bellies of the muscles and extreme limitation of abduction of the hips by pain. If the legs have been kicked, there are sometimes circular or irregular scars on the inner aspect of the thighs, an unusual site for accidental trauma. It may be impossible to squat, kneel or sit cross-legged for months or years afterwards.

In the same part of the world the ghotna is routinely used in police stations and interrogation centres. It is a traditional domestic implement, a pole about four feet long and four inches in diameter used for grinding corn or spices. In many police stations implements specially made of metal are used instead. These may be filled with concrete and are extremely heavy. The most common method is, with the victim seated or lying supine on the floor, for the ghotna to be rolled up and down the front of the thighs with one or more of the heaviest policemen standing on it. Occasionally, with the victim prone, it is rolled over the buttocks and back of the thighs or calves, but it is usual for bony areas like the shins to be avoided. The immediate effects are extensive bruising and inability to walk and even years later there is usually pain on walking far. On examination there is marked tenderness on palpation of the thigh muscles. Occasionally areas of fat necrosis can be palpated. If a rough or angular log has been used, there may be some scarring of the skin. Sometimes scars are found over the anterior superior spine, the patellae or the shins.

Another way for the ghotna to be used is, with the victim lying prone, the ghotna to be placed behind the knees and then the legs bent forcibly over it, straining and possibly disrupting the cruciate ligaments. The late effects of this depend on the amount of internal damage to the knee joints that has been caused. If severe, there may be permanent difficulty in walking, tenderness on palpating the joint margins and marked limitation by pain of flexion of the knees. Squatting, kneeling or sitting cross-legged may be extremely painful and impossible to maintain for long periods.

Many torturers injure their victims by stamping on their hands or feet with heavy boots, leaving scarring and fractures of the digits, which may give a good indication of how the injuries were inflicted. However, it is not usually possible … Continue reading →

For a detailed discussion of psychological symptoms and assessment of psychological evidence, see Module 6. Despite the variability due to personal, cultural, social and political factors, certain psychological symptoms and clusters of symptoms have been observed among survivors of torture and other types of violence. The diagnosis of Posttraumatic Stress Disorder (PTSD) has been applied to an increasingly broad array of individuals suffering from the impact of widely varying types of violence. Although the utility of this diagnosis in non-western cultural groups has not been clearly established, evidence suggests that there are high rates of PTSD and depression symptoms among traumatised refugee populations from multiple different ethnic and cultural backgrounds.

The core symptoms and signs of severe trauma and torture across cultures have become increasingly clear. Many are physiological reactions that can persist for years. The main psychiatric disorders associated with torture are PTSD and Major Depression. One does not have to be tortured to develop PTSD and/or Major Depression because these disorders appear in the general population. Similarly, everyone who has been tortured does not develop PTSD and Major Depression.

The course of Major Depression and PTSD varies over time. There can be asymptomatic intervals, recurrent episodes, and episodes during which an individual is extremely symptomatic. Therefore, when conducting an evaluation of a torture survivor, one must consider the following questions:

• What is the timeframe of onset of symptoms; did symptoms occur immediately following the traumatic events or were they delayed for weeks, months or even years?
• Is there a history of recurring episodes of symptomatology?
• How do problems and symptoms emerge over time?
• Where is the survivor in the recovery process at the time of the assessment?

For a detailed discussion of psychological symptoms and assessment of psychological evidence, see Module 6. Despite the variability due to personal, cultural, social and political factors, certain psychological symptoms and clusters of symptoms have been observed among survivors of torture … Continue reading →

The application of heat is frequently employed by torturers. It produces immediate and long-term effects that are similar to those caused accidentally, but it is often possible to determine the deliberate nature of the injury if it is widely distributed in different parts of the body or if there are numerous similar lesions. For this reason it is important to take a detailed history in order to learn the nature of the agents used, the situation and posture of the subject and the duration of the application. Of course, if the victim was blindfolded or hooded during torture, he may not be able to describe the method of burning. In late cases, it is important to enquire as to the immediate effects and appearance of the wounds and how long they took to heal. If there was merely initial erythema or blistering and no infection supervened, it is likely that there will be no permanent scarring but if there was infection, sloughing and delay in healing for a month or more, recognisable scarring would be expected.

The pattern of scarring gives a clue to the method used. Flame burns caused by setting clothing alight leave different patterns from the application of blowlamps or other flames.

Caustic or acid burns may leave a trail indicating the victim’s posture. Scarring tends to be more florid, perhaps with keloid formation than similarly-configured scars caused by scalding with boiling water.

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.

Melted candle wax or plastic give a characteristic pattern of scarring which indicate the flow of the hot liquid, and burning rubber tyres such as are placed round the neck in “necklacing”, leave burns over the whole upper body.

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. The feature that corroborates allegations of deliberate infliction of the burns is the presence of patterns on a part of the skin surface that the history indicates would be exposed. Thus, if the victim was strapped to a chair, there may be a line of scars on the knuckles, up the forearms or on the front of the thighs.

The application of heat is frequently employed by torturers. It produces immediate and long-term effects that are similar to those caused accidentally, but it is often possible to determine the deliberate nature of the injury if it is widely distributed … Continue reading →