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Istanbul Protocol Model Medical Curriculum

Educational Resources for Health Professional Students

Role of the health professional in the team

Health professionals who encounter survivors of torture may do so in different capacities, and they may thus have slightly different but convergent duties:

  • The health professional who is asked to examine an individual expressly for the purpose of providing a medical opinion in a report for a court or other judicial body will be fulfilling a forensic (medico-legal) role.
  • A health professional who is acting as a care giver to an individual and who in the course of routine work notes signs and symptoms of ill-treatment, or to whom the individual complains of being previously subjected to ill-treatment, may need to make an accurate medical record of the findings in the medical notes.
  • A health professional who forms part of a team visiting places of detention may record findings of ill-treatment in individuals, but this information may be used more generally in a report on the place of detention without actually forming part of a medico-legal report.
  • Health professionals in primary care or emergency departments to whom the individual complains of ill-treatment or who note signs of torture. In such cases the health professional may not necessarily have to write a report, but may just need to know how to make a proper examination and a good set of medical notes, which document the care.
  • Health professionals in hospitals or clinics who may be asked by, for example, police or military, to examine a detainee.
  • Health professionals examining individuals in a specialist centre for survivors of torture

The first and foremost concern for the health professional is the immediate health and well-being of the torture survivor. Health professionals may have a therapeutic role in treating the patient, or a forensic role in establishing the possible causes and origins of injuries and trauma. There are concerns that having a dual role may create the perception of bias in the reporting. The health professional should therefore ensure that the individual is receiving any necessary medical care, taking into account that:

  • Care includes immediate treatment and long-term rehabilitation for survivors of torture.
  • Forms of torture may be used that are psychological or otherwise leave no persisting physical signs. It must always be emphasised that the absence of physical or psychological findings can never be considered to be evidence that ill-treatment did not occur.
  • A psychological assessment of the individual should take place, noting any psychological effects that may be the result of torture or other ill-treatment.
  • The strongest evidence supporting the allegation of torture is often of a medical or psychological nature. The health professional should record any external or physical evidence of injury or abuse and any psychological symptoms and signs.

Health professionals who encounter survivors of torture may do so in different capacities, and they may thus have slightly different but convergent duties: The health professional who is asked to examine an individual expressly for the purpose of providing a … Continue reading →

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International Codes

Many UN documents address the specific ethical obligations of doctors and other health professionals, for example in Principles of Medical Ethics Relevant to the Role of Health Personnel, Particularly Physicians, in the Protection of Prisoners and Detainees Against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment; Body of Principles for the Protection of All Persons under Any Form of Detention or Imprisonment; Standard Minimum Rules for the Treatment of Prisoners; and the Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (The Istanbul Protocol). These documents stress that it is a gross contravention of health care ethics to participate, actively or passively, in torture or other ill-treatment, or condone it in any way. Medical services must be provided for all patients without discrimination. They reinforce the ethical obligations of health professionals to act in the best interests of patients.

Many UN documents address the specific ethical obligations of doctors and other health professionals, for example in Principles of Medical Ethics Relevant to the Role of Health Personnel, Particularly Physicians, in the Protection of Prisoners and Detainees Against Torture and … Continue reading →

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Summarising and clarifying

During the interview, it is often helpful to clarify points, in order to ensure that the information is accurate. For example: ‘When you say that you were suspended by your arms, in what position were they?’ Alternatively the individual can be asked to recreate the position, but it should be borne in mind that doing so could provoke uncomfortable feelings or other reactions in the individual.

At the end of each session, it generally helps to summarise the key points, to ensure that they are clear. This sometimes has the additional benefit of getting the individual to remember details that add to the narrative.

In medico-legal cases, it may be helpful to have an opportunity to meet with the individual again to review any questions or inconsistancies. This also provides an opportunity to follow up any clinical problems that may have been identified in the evaluation.

During the interview, it is often helpful to clarify points, in order to ensure that the information is accurate. For example: ‘When you say that you were suspended by your arms, in what position were they?’ Alternatively the individual can … Continue reading →

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Regional Mechanisms

A number of regional human rights treaties have also been developed within the Council of Europe (CoE), the Organisation of American States (OAS) and the African Union (AU).[1] The rights protected by these treaties derive from, and are similar to, those of the Universal Declaration of Human Rights, but each treaty has developed unique approaches when seeking to implement them. The principal instruments referred to here are:

  • the European Convention on Human Rights
  • the European Convention for the Prevention of Torture and Inhuman and Degrading Treatment or Punishment
  • the American Convention on Human Rights
  • the Inter-American Convention to Prevent and Punish Torture
  • the African Charter on Human and Peoples’ Rights.

The European Court of Human Rights, the Inter-American Commission on Human Rights, the Inter-American Court of Human Rights, the African Commission on Human Rights and the (soon to be established) African Court on Human Rights are responsible for monitoring state-compliance with their respective treaties. These bodies examine allegations of torture on the same level as other alleged human rights violations. However, the CoE has also created a specific body for preventing torture in its member states.

The European Committee for the Prevention of Torture (CPT) was set up under the 1987 Council of Europe European Convention for the Prevention of Torture and Inhuman and Degrading Treatment or Punishment. It is composed of as many independent and impartial members as there are states parties to the Convention and may be assisted by ad hoc experts. Currently all members of the CoE have also ratified the European Convention for the Prevention of Torture. The CPT conducts periodic and ad hoc visits in any places under the jurisdiction of a contracting state where persons are deprived of their liberty by a public authority. States parties are obliged to provide the CPT with access to its territory and the right to travel without restriction; full information on the places where persons deprived of their liberty are being held; unlimited access to any place where persons are deprived of their liberty, including the right to move inside such places without restriction; and other information which is necessary for the CPT to carry out its task.[2] The CPT is also entitled to interview, in private, persons deprived of their liberty and to communicate freely with anyone whom it believes can supply relevant information. The report on the visit and detailed recommendations sent to the government are confidential unless the government concerned decides that they can be published. In practise, most reports have been made public.

[1] Formerly the Organisation for African Unity (OAU).

[2] Article 8, European Convention for the Prevention of Torture and Inhuman and Degrading Treatment or Punishment 1987.

A number of regional human rights treaties have also been developed within the Council of Europe (CoE), the Organisation of American States (OAS) and the African Union (AU).[1] The rights protected by these treaties derive from, and are similar to, … Continue reading →

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International Recognition of the Istanbul Protocol

The Istanbul Principles have been recognised by a number of human rights bodies as a point of reference for measuring the effectiveness of torture investigations. Such recognition represents a significant factor in the widespread use and acceptance of Istanbul Protocol standards in medico-legal contexts.

Both the UN General Assembly and the then UN Commission on Human Rights (since 2006, the UN Human Rights Council) have strongly encouraged states to reflect upon the Principles in the Protocol as a useful tool to combat torture in their resolutions 55/89 on the 4th of December 2000, following the recommendation of the United Nations Special Rapporteur on Torture during the fifty-sixth session, on the 2nd of February 2000.

The UN Special Rapporteur on Torture stressed in his General Recommendations of 2003 the importance of the Istanbul Principles in the context of establishing independent national authorities for investigation; promptness and independence of investigations; independence of forensic medical services by governmental investigatory bodies and obtaining forensic evidence.

On the 23rd of April 2003, the UN Commission on Human Rights, in its resolution on human rights and forensic science, drew the attention of governments to these principles as a useful tool in combating torture. Likewise, reference was made to the Istanbul Protocol in the resolution on the competence of national investigative authorities in preventing torture.

In addition to recognition by the UN system, the Istanbul Protocol has also been adopted by several regional bodies.

The African Commission on Human and Peoples’ Rights deliberated on the importance of the Istanbul Protocol during its 32nd ordinary session in October 2002 and concluded that investigations of all allegations of torture or ill-treatment, shall be conducted promptly, impartially and effectively, and be guided by the Istanbul Principles.

The European Union has referred to the Istanbul Protocol in its Guidelines to EU Policy towards Third Countries on Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment adopted by the General Affairs Council in 2001. The EU guidelines mention that states should “conduct prompt, impartial and effective investigations of all allegations of torture in accordance with the Istanbul Rules annexed to CHR resolution 2000/43” and should “establish and operate effective domestic procedures for responding to and investigating complaints and reports of torture and ill-treatment in accordance with the Istanbul Rules.”

Other institutions and organisations have reiterated the UN and other bodies’ recommendations in their reports, statements, and comments (including the Advisory Council of Jurists and the Asia Pacific Forum of National Human Rights Institutions). These references can roughly be summarised into three categories”

  • References that cite the Istanbul Protocol as a useful tool in the efforts to combat torture and strongly encourage governments to reflect upon the principles contained in the Protocol;
  • References that stress that all investigations and documentation of torture allegations should be conducted promptly, impartially and effectively, and be guided by the Istanbul Principles;
  • References that say that states should establish and operate effective domestic procedures for the investigation and documentation of torture allegations in accordance with the Istanbul Protocol.

The Istanbul Principles have been recognised by a number of human rights bodies as a point of reference for measuring the effectiveness of torture investigations. Such recognition represents a significant factor in the widespread use and acceptance of Istanbul Protocol … Continue reading →

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Chest and Abdomen

Examination of the trunk, in addition to noting lesions of the skin, should be directed toward detecting regions of pain, tenderness or discomfort that would reflect underlying injuries of the musculature, ribs or abdominal organs. The examiner must consider the possibility of intramuscular, retroperitoneal and intra-abdominal hematomas, as well as laceration or rupture of an internal organ. Ultrasonography, CT scans and bone scintigraphy should be used, when realistically available, to confirm such injuries. Routine examination of the cardiovascular system, lungs and abdomen should be performed in the usual manner. Pre-existing respiratory disorders are likely to be aggravated in custody, and new ones may develop. Near asphyxiation often leaves no marks and may cause acute and chronic respiratory problems as well as other complications.

Victims can be exposed in a confined space to smoke or tear gas. Many survivors will give an account of a persistent dry cough for a few days or weeks afterwards, probably as a result of inhalation pneumonitis (inflammation of the lungs). Some survivors say that they have been asthmatic since such an incident, but it would be very difficult to demonstrate causation. Examination of the lungs, and respiratory function tests are usually normal.

Rib fractures are a frequent consequence of beatings to the chest. If displaced, they may be associated with lacerations of the lung and possible pneumothorax. Fractures of the vertebral pedicles may result from direct blunt force. Fractures of the lower right ribs carry approximately a 10% risk of hepatic injury.

Following acute abdominal trauma, the physical examination must seek evidence of damage to abdominal organs or the urinary tract, but this examination is often negative. Gross haematuria is the most significant indication of kidney contusion. Organ injury may present on investigation as free air, extraluminal fluid, and areas of low attenuation, which may represent oedema, contusion, haemorrhage or a laceration. Peripancreatic edema is one of the signs of acute traumatic and non-traumatic pancreatitis. Ultrasound is particularly useful in detecting subcapsular hematomas of the spleen. Peritoneal lavage may detect occult abdominal haemorrhage, but free abdominal fluid detected subsequently on CT scan might be from the lavage or haemorrhage; thus invalidating the finding. Acute renal failure due to crush syndrome may be seen acutely following severe beatings.

Examination of the trunk, in addition to noting lesions of the skin, should be directed toward detecting regions of pain, tenderness or discomfort that would reflect underlying injuries of the musculature, ribs or abdominal organs. The examiner must consider the … Continue reading →

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Materials

Case Summary/Referral #01

(distribute to students who conduct the interviews)

(Weak physical evidence, strong psychological evidence and strong historical evidence; medical evaluation 4 months after alleged torture)

Note: This case example is written specifically for a female role-player. All names included in the narrative are fictitious.

  • Name: Mrs. Asha Ali Yousif
  • Date Reporting to the Center: dd/mm/yyyy (today’s date)
  • Date of Birth: dd/mm/yyyy (age 35)
  • Age: 35 years-old
  • Marital Status/Children: Married, widow, 13 year-old daughter
  • Religion: Muslim
  • Ethnic Group: Fur
  • Profession: Teacher
  • Political/Social Affiliation: None
  • Date and Place of Detention/Assault: dd/mm/yyyy (4 months prior to the exam date) in a field 2 Km east of Kalma Camp; dd/mm/yyyy (2 days following the alleged assault) at Nyala Wasat (Central) police station.
  • Period of Detention: Less than 2 hours on both occasions
  • Trauma History: On dd/mm/yyyy (4 months prior to the exam date), at approximately 2:00pm, Mrs. Yousif, her 13 year-old daughter, and two other women were attacked by armed men in military uniforms whilst fetching firewood several miles from Kalma camp. They were all beaten and raped. One of the women, Fatima Ibrahim (22 yrs), was shot and killed while attempting to escape. Several days later, Mrs. Yousif reported the incident to police at Nyala Wasat (Central) Police Station. Police refused to file a case. One of the police officers, Omer Mohamed Suliman, beat and sexually assaulted her. She then went to Nyala Hospital, but was refused a medico-legal evaluation since she did not have Police Form 8 (medico-legal form for treatment of injuries caused by a criminal act), formerly a requirement under Sudanese Law. A friend in Kalma was worried about her and insisted that she get help. The friend also suggested that Mrs. Yousif and her daughter take legal action against their perpetrators.
  • Alleged Perpetrators: Men in military uniform, also, police officer Omer Mohamed Suliman from Nyala Wasat (Central) Police Station.
  • Reasons for visit: Mrs. Yousif indicated that she would like to get help for her daughter and herself, but she was not sure about taking legal action against their perpetrators.
  • Effects of Torture: Insomnia, nightmares, inability to concentrate, profound sadness, frequent headaches and decreased appetite. She is also very troubled about her daughter’s health and future.

Case Narrative #01

(distribute to role-players only)

Note: This case example is written specifically for a female role-player. All names included in the narrative are fictitious.

Case Summary/Referral Information

  • Name: Mrs. Asha Ali Yousif
  • Date Reporting to the Center: dd/mm/yyyy (today’s date)
  • Date of Birth: dd/mm/yyyy (age 35)
  • Age: 35 years-old
  • Marital Status/Children: Married, widow, 13 year-old daughter
  • Religion: Muslim
  • Ethnic Group: Fur
  • Profession: Teacher
  • Political/Social Affiliation: None
  • Date and Place of Detention/Assault: dd/mm/yyyy (4 months prior to the exam date) in a field 2 Km east of Kalma Camp; dd/mm/yyyy (2 days following the alleged assault) at Nyala Wasat (Central) police station.
  • Period of Detention: Less than 2 hours on both occasions
  • Trauma History: On dd/mm/yyyy (4 months prior to the exam date), at approximately 2:00pm, Mrs. Yousif, her 13 year-old daughter, and two other women were attacked by armed men in military uniforms whilst fetching firewood several miles from Kalma camp. They were all beaten and raped. One of the women, Fatima Ibrahim (22 yrs), was shot and killed while attempting to escape. Several days later, Mrs. Yousif reported the incident to police at Nyala Wasat (Central) Police Station. Police refused to file a case. One of the police officers, Omer Mohamed Suliman, beat and sexually assaulted her. She then went to Nyala Hospital, but was refused a medico-legal evaluation since she did not have Police Form 8 (medico-legal form for treatment of injuries caused by a criminal act), formerly a requirement under Sudanese Law. A friend in Kalma was worried about her and insisted that she get help. The friend also suggested that Mrs. Yousif and her daughter take legal action against their perpetrators.
  • Alleged Perpetrators: Men in military uniform, also, police officer Omer Mohamed Suliman from Nyala Wasat (Central) Police Station.
  • Reasons for visit: Mrs. Yousif indicated that she would like to get help for her daughter and herself, but she was not sure about taking legal action against their perpetrators.
  • Effects of Torture: Insomnia, nightmares, inability to concentrate, profound sadness, frequent headaches and decreased appetite. She is also very troubled about her daughter’s health and future.

Identification Information

My name is Asha Ali Yousif, and I am 35 years-old.

Additional Information:

  • Date of Birth: dd/mm/yyyy (age 35)
  • Citizenship: Sudanese
  • Marital Status/Children: Married, widow, 13 year-old daughter
  • Place of Birth: A village east of Nyala
  • Place of Residence: Kalma IDP Camp, 17 Km. east of Nyala, southern Darfur state
  • Highest Level of Education: completed high school
  • Occupation: Former teacher, currently unemployed
  • Religion: Muslim
  • Identification Document Presented: None
  • Ethnic Group: Darfurian, Fur Tribe
  • Physician Examiner’s Name and License #: (To be filled out by the examining physician)
  • Individuals Present in the Examination Room and Reason for Presence: (To be filled out by the examining physician)
  • Language Spoken: Fur
  • Name of Interpreter: None (To be filled out by the examining physician)
  • Restrictions Noted: (To be filled out by the examining physician)
  • Detainee Status: No (To be filled out by the examining physician)

Past Medical/Surgical History and Psychosocial History

Past Medical/Surgical History

Before my encounters with soldiers and police, I had no medical problems, no major illnesses or injury, no surgery, broken bones or head injury. I am not on any medications, except aspirin for headaches and pains in my body. I have never used any illegal drugs and I do not drink alcohol. I do not smoke either.

Psychosocial History

I never had any mental problems, nor has anyone in my family. I am the oldest of four children. Although my family was very poor, we were able survive with the money that my parents made working odd jobs. I was able to go to school and become a teacher. My husband was also a teacher, but he and my father were killed about a year ago, when the Sudanese Army and Janjaweed militia burned my village to the ground. After that, my daughter and I went to Kalma camp.

Prior Medical Evaluation

I went to Nyala Hospital after my daughter and I were attacked by soldiers, but the doctors refused to examine me because I did not have official papers from the police. On the same day, I visited a clinic in Kalma, and they gave me some aspirin for my headaches. I was planning to tell them about what happened to me, but I was too afraid after my experience with the police.

Trauma History

NOTE: Provide information in parentheses only if specifically asked by the interviewer.

About a year ago, the army and militia came to our village and burned it to the ground. They accused us of supporting the SLA and shot some of the men including my husband and father right in front of us. My daughter and I have been living in Kalma for about one year. Since I lost my husband, my home and my job, we don’t have enough to survive. Sometimes we cut grass in nearby fields to sell. We also have go outside the camp to wash our clothes and collect firewood. We know this is dangerous, but we do not have a choice. My daughter and I have been through a lot. When they burned our village to the ground, they threatened to rape the women. This happened to some of the women in our village, but we were lucky that day. Since then, I thought it was safer for my daughter and me to be together. Now I know this is not true.

On dd/mm/yyyy (4 months prior to the exam date), I went to fetch firewood with my daughter and two other women from Kalma. We had done this many times without any problems, but on that day, we were attacked by 10 men in military uniforms. They had guns and threatened to kill us if we tried to run away. They started insulting us, calling us slaves and saying that this land did not belong to us. I pleaded with them not to hurt my daughter, Salwa. One of them said: “Don’t worry she will soon be the mother of an Arab child.” Salwa was very frightened and began to cry. They slapped her and told her to take off her clothes, but she did not. I tried to wrap my arms around her to protect her, but they pulled her away from me. I was stuck [above my left eye] with the butt of a gun and fell to the ground They continued to punch and kick me. One of the other women, Fatima Ibrahim, who was also from our village, tried to run away, but they shot her in the back. She was not moving. One of the men walked over to her and shot her in the head. “This is what happens when you do not obey your masters,” he said. One of the men started raping me while several others threatened me with their guns. I could hear my daughter screaming, but could do nothing. After the third one had raped me, he spit on me and kicked me very hard on the right side of my face. Later I noticed it was very swollen [in front of my right ear] and I was unable to move the right side of my face [or close my right eye] for about 2 weeks. They said nothing else and left us there naked. My daughter was badly bruised on her face and there was blood running down her legs. I tried to reassure her, but we both just wept for a long time.

After 2 days, I decided to go to the police station in Nyala to make a complaint. I waited a long time and then was placed in a room with a police officer. His name was, Omer Mohamed Suliman. I told him what happened and he laughed. “I find this hard to believe,” he said. Who were the men that you say did this?” he asked. I told him that I did not know, but that they were in military uniforms. He refused to believe me and said: “You know nothing and have no witnesses. If you were raped, then show your injuries. His tone began to change and insisted I take off my clothes. He slapped my face and called me a liar. He grabbed me and started pulling off my clothes. He touched my breasts and between my legs. I yelled for help. He stopped when another police officer peered in through the door. After that, be began beating me with a hose on my back and arms. He said, “If you tell anyone, your daughter will find you dead.”

From the police station, I went to Nyala Hospital. I told the doctor what happened in the field. I was too afraid to tell him about what happened at the police station. He said there was nothing he could do, since I did not have official papers from the police requesting an examination.

A few days later, I visited a clinic in Kalma and they gave me some aspirin for my headaches and a bandage for the cuts I had above my left eye and on the back of my left hand. I was planning to tell them about what happened to me, but I was afraid to after my experience with the police.

Recently, a friend in Kalma insisted that my daughter and I get some help. She can see that we are very troubled. She also suggested we take legal action against those who hurt us.

Review of Torture Methods

The following history should be revealed only on further questioning, unless asked in the context of the trauma history:

  • Sexual Assault:
    • Condoms were not used by any of the perpetrators.
    • No anal intercourse
    • No menstrual period for the past three months
    • [History of infibulation prior to marriage and reinfibulation after the birth of her child.]
  • Head trauma: handgun butt to the left side of her face, just above the left eyebrow, no loss of consciousness. There was blood on my face and a cut above my left eyebrow. The area was very tender and swollen for about one to two weeks.
  • Laceration injury to the dorsum (backside) of the left hand: I am not sure how or when this happened but I noticed that it had bled. The injury became infected, swollen and drained pus about a week later. I was treated as an outpatient with antibiotics. The doctors opened it and packed it with gauze. Eventually it healed.
  • The review of torture methods is negative for the all other torture methods, physical and psychological.

Physical Symptoms (Acute and Chronic) and Disabilities

Acute Symptoms
  • Blood in the urine for about 3 days following the incident, then it resolved completely. No vaginal discharge, no menstrual period since the assault.
  • Unable to move the right side of my face [or close my right eye] for about 2 weeks.
  • Observed bruises where beaten, black and blue marks that resolve after about 2 weeks. [IF ASKED, RESPOND: Some of the bruises on the back and chest were long in shape, like the hose that was used to beat her. Each of the bruises had two parallel lines about 1-2 cm wide and a clear area in the middle of the lines.]
Chronic Symptoms
  • Chronic headaches [IF ASKED, RESPOND: in the front of the head, throbbing, lasts a few hours, once to a few times per day, improved with acetaminophen, similar headaches in the past with stress, but only occasionally.]
  • Difficulty concentrating and irritable
  • Having problems sleeping (see psychological evaluation below)
Disabilities
  • None noted

Psychological Evaluation and Mental Status

Mental Status

Mrs. Yousif was appropriately dressed and groomed and looked her stated age. She was alert, fully oriented, pleasant and cooperative throughout the evaluation. There were no gross abnormalities in movement or posture on observation. She appeared to possess average intellectual ability, with good insight and judgment. Her speech was clear and fluent. There was no evidence of delusions, hallucinations or psychotic thought processes. Memory was intact. Attention and concentration appeared intact. Her mood and affect conveyed a watchfulness and some apprehension, and were congruent, but she was open enough to be able to describe her experiences willingly. At times, she wept when she was discussing emotionally painful aspects of her experience. There was no evidence of suicidal or homicidal ideation.

Psychological Findings
  1. Symptoms of Post-traumatic Stress Disorder:
    • Persistent Re-experiencing of Traumatic Events and Avoidance Behaviour: Mrs. Yousif reported frequent nightmares from which she awakens in a sweat with her heart pounding. The nightmares usually refer to a grave threat to herself and her daughter. The content of her dreams includes trauma-related material to varying degrees but usually not precise repetitions of actual events. For example, the night prior to the examination she dreamt that thieves had entered her domicile carrying knives, beating her with sticks, and threatened her and her daughter. She awakens from her nightmares gripped with fear and finds it difficult to fall asleep again. She often experiences intrusive recollections of the sexual assault that she experienced. Mrs. Yousif indicated that she has a profound sense of guilt over what happened to her daughter and is often preoccupied with thoughts of what she should have done differently. Sometimes when she sees police or security forces, she feels anxious and starts thinking about what happened to them. She tries to avoid intrusive recollections through prayer. Also, she avoids talking to her daughter and others about what happened to them as it often precipitates recollections of her abuse and makes it difficult to fall asleep.
    • Persistent Symptoms of Increased Arousal: As mentioned above, Mrs. Yousif suffers from difficulties falling asleep and from poor sleep throughout the night, often waking up hourly throughout the night. In the morning, she often feels exhausted. She also startles easily, feeling very jumpy in response to any kind of sudden noise. She indicated that: “Sometimes when I am in a room like this, I feel that someone may just storm in.” She feels that her concentration is impaired since being raped. For example, she used to like to read and talk to friends, but now has difficulty following conversations and reading. Often she forgets that she has already taken her headache medicine and subsequently takes a second dose. She misplaces things and sometimes takes days to find them. She is no longer good with directions and indicated that she cannot find her way even after a second time. “I have trouble following what is said in conversation and forget names of people I know, or what I had eaten the previous night,” she said. She sometimes feels irritable and has outbursts of anger without a clear reason. Her daughter has been unable to speak since the rapes; she spends hours alone staring straight ahead and she seems to be unaware of her surroundings. Mrs. Yousif is worried that her daughter is losing her mind. She tries to coax her daughter to eat and talk with her and she tries hard to keep her own despair secret in order to reassure her daughter. Nevertheless, Mrs. Yuosif finds that she has outbursts of anger and crying that she cannot prevent. Somatic Complaints: Mrs. Yousif suffers from frequent headaches that respond well to aspirin.
  2. Major Depression: Mrs. Yousif demonstrated symptoms of major depression, including depressed mood, diminished interest or pleasure in activities, decreased appetite resulting in weight loss [IF ASKED, RESPOND: about 4 Kilos], insomnia, fatigue and loss of energy, frequent crying and difficulty concentrating. She denied suicidal ideation and suicide attempts. Mrs. Yousif explained that her sadness stems largely from her inability to protect her daughter and what this means for her future. Though she wants justice for what has been done to them, she is afraid to take legal action.  In the days after she had been raped, she spent hours bathing herself to cleanse herself of the shame she felt. Mrs. Yousif blames herself for what happened. She regrets not insisting that her daughter stay in the camp. She also expressed considerable anger over the camp-related security issues. She asked, “Why do we have to go where it is dangerous to get what we need?”

Physical Examination

(All photos taken on the day of examination)

NOTE: Images of “virtual physical examination” findings will be presented in a separate room using PPT slides.

  • Slide #1: Note 1 cm hyperpigmented, linear scar above left eyebrow consistent with an old laceration injury.
  • Slide #2: Note complex, atrophic scar, approximately 4 x 6 cm over the dorsum of the left hand associated with hypopigmentation and subcutaneous fibrosis.

Interpretation and Conclusion

Per trainee’s assessment

Case Summary/Referral #01 (distribute to students who conduct the interviews) (Weak physical evidence, strong psychological evidence and strong historical evidence; medical evaluation 4 months after alleged torture) Note: This case example is written specifically for a female role-player. All names … Continue reading →

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Glossary

Medical Terms

Axilla
Armpit.
Brachial plexus
The nerves running from the spine into the arm.
Callus
An area of thickening of bone at the place of healing.
Cerebral oedema (edema)
Swelling of the brain.
Cognitive impairment
Partial impairment of memory, thinking, perception or mood.
Counter-transference
Potential emotional reaction of the clinical evaluator toward the alleged torture victim.
Depigmentation
Complete loss of pigment from a patch of skin.
DSM
Diagnostic and Statistical Manual (American Psychiatric Association).
Haematuria
Blood in the urine.
Hyperpigmentation
Increase in pigmentation of an area of skin.
Hypopigmentation
Partial loss of pigment from an area of skin.
Intrusive memories
Involuntary, unpleasant and recurrent memories of an incident.
Ischemia
Decreased blood flow.
Laceration
A wound in which the skin is torn by blunt force.
Medical Evaluation
An assessment of physical and/or psychological evidence by a clinician.
Medical history
An individual’s personal account of a health problem.
Medico-legal
Relating to that branch of medicine that assists the courts.
Necrotic
Devitalized (death of) body tissues.
Neuropathy
Nerve damage.
Oedematous (edematous)
Swollen.
Parasthesias
A skin sensation such as burning, itching, tingling, with no apparent casuse.
Pathognomonic
A pathological finding that has only one cause.
Perianal
Around the anus.
Petechiae
Clusters of very small bruises.
Psychosomatic symptoms
Apparently physical symptoms that have a psychological cause.
Retinal haemorrhage
Bleeding into the back of the eye.
Sequelae
The consequences of a medical problem.
Striae distensae
Stretch marks of the skin.
Subdural bleeding
Bleeding between certain layers of fibrous tissue covering the brain.
Tonic-clonic fits
The common form of epileptic convulsions or seizures.
Transference
Feelings that a survivor of torture has towards the clinician that relate to past experiences, but which are misunerstood and towards the clinician personally.
Urethral meatus
The aperture at the end of the penis through which urine is voided.

Legal Terms

Allegation
A claim (as yet neither proved nor disproved) that an incident of torture has occurred.
Applicant
Person making an application under an individual complaint procedure.
Application
Submission asking a judicial body to consider a case under an individual complaint procedure.
Arrest
The act of apprehending a person for the alleged commission of an offence or by the action of an authority.
Asylum
Asylum is sought by individuals who do not wish to return to a country, usually their own, where they are at risk. If granted, it means being allowed to remain in a country which is not their own. It may be temporary or permanent.
Corroboration
Evidence which supports or confirms the truth of an allegation.
CPT
Council of Europe’s Committee for the Prevention of Torture.
Declaration
A particularly formed resolution, usually of the United Nations General Assembly, which is not as such legally-binding, but sets out standards which states undertake to respect.
Derogate
To temporarily suspend or limit.
Detention
Depriving a person of personal liberty except as a result of conviction for an offence.
Domestic law or legal system
National law or legal system; law or legal system which is specific to a particular country.
Enforcement (of obligations)
Making the obligations effective; ensuring that they are respected.
Fact-finding
Carrying out an investigation to discover the facts.
Incommunicado detention
Being held by the authorities without being allowed any contact with the outside world.
Individual complaint
A complaint relating to a specific set of facts affecting an individual or individuals.
Instrument
A general term to refer to international law documents, whether legally binding or not.
Judicial procedure
A procedure before a judicial body.
NGO
Non-governmental organisation.
Perpetrator
The person who has carried out an act.
Reparation
Measures to repair damage caused, eg. compensation.
Sanction
A penalty imposed for a state’s failure to respect its legal obligation.
State responsibility
Holding a state accountable under international law.
Treaty
International law document which sents out legally-binding obligations for states.
War Crimes
Grave breaches of the Geneva Conventions 1949, committed in the course of an armed conflict against persons or property protected by the Conventions, and other criminal violations of the rules of war.

Clarifications of Terms

Use of the term “patient”
Individuals who allege torture and ill treatment are sometimes referred to as “patients” even in the context of medico-legal evaluations.
Physicians/Clinicians
The terms “physician” and “clincician” are often used interchangably in this Curriculum. Keep in mind that psychological evidence may be evaluated by physicians, psychologists and clinical social workers. Physical evidence, however, is evaluated by physicians (medical doctors) only.

Medical Terms AxillaArmpit.Brachial plexusThe nerves running from the spine into the arm.CallusAn area of thickening of bone at the place of healing.Cerebral oedema (edema)Swelling of the brain.Cognitive impairmentPartial impairment of memory, thinking, perception or mood.Counter-transferencePotential emotional reaction of the clinical … Continue reading →

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Neurological Examination

The neurological examination should include both the central and peripheral nervous systems. Particular attention should be paid to assessment of both motor and sensory neuropathies and cranial nerves. Performing examination of reflexes is important. Radiculopathies, other neuropathies, cranial nerve deficits, hyperalgesia, parasthesiae, hyperaesthesia, change in position and temperature sensation, motor function, gait and coordination may all result from trauma associated with torture. In patients with a history of dizziness and vomiting, vestibular examination should be conducted, and evidence of nystagmus noted.

The neurological examination should include both the central and peripheral nervous systems. Particular attention should be paid to assessment of both motor and sensory neuropathies and cranial nerves. Performing examination of reflexes is important. Radiculopathies, other neuropathies, cranial nerve deficits, … Continue reading →

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