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Istanbul Protocol Model Medical Curriculum

Educational Resources for Health Professional Students

Materials

Case Summary/Referral #02

(distribute to students who conduct the interviews)

(Strong physical, moderate psychological and strong historical evidence; medical evaluation 7 days after alleged torture)

Note: This case example #02 is written for male role-player. All names included in the narrative are fictitious.

  • Name: Mr. Hassan Bashir Adam
  • Date Reporting to the Center: dd/mm/yyyy (today’s date)
  • Date of Birth: dd/mm/yyyy (age 25)
  • Age: 25 yrs
  • Marital Status/Children: Single, no children
  • Religion: Muslim
  • Ethnic Group: Darfurian, Zagawa tribe
  • Profession: Student, Khartoum University
  • Political/Social Affiliation: Member of Student Democratic Front (SDF)
  • Date of Detention: dd/mm/yyyy (7 months prior to the exam date)
  • Place of Detention: XXX police station
  • Period of Detention: 3 days
  • Trauma History: On dd/mm/yyyy (7 months prior to the exam date), Mr. Adam as arrested by four officers from the NSA. He was placed in a truck with blackened windows, blindfolded and taken to a police station. His mobile phone and ID card were confiscated. His hands were restrained and he was punched, kicked and beaten with black water hoses and electric wires. They suspended him by his wrists and applied electric shocks to his genitals.
  • Alleged Perpetrators: Security personnel from the NSA, including Abdel Salih, and Kaleel Rahim, also 2 perpetrators referred to as Rasoul and Mujahid.
  • Reasons for Visit: Treatment for problems related to torture and to take legal action against the perpetrators. The client has already met with SOAT legal advisors, and they have requested a medical evaluation of the client’s allegations of torture.
  • Effects of Torture: Musculoskeletal pain, multiple bruises and burns.

Case Narrative #02

(distribute to role-players only)

Note: Case example #02 is written for male role-players. All names included in the narrative are fictitious.

Case Summary/Referral Information

  • Name: Mr. Hassan Bashir Adam
  • Date Reporting to the Center: dd/mm/yyyy (today’s date)
  • Date of Birth: dd/mm/yyyy (age 25)
  • Age: 25 yrs
  • Marital Status/Children: Single, no children
  • Religion: Muslim
  • Ethnic Group: Darfurian, Zagawa tribe
  • Profession: Student, Khartoum University
  • Political/Social Affiliation: Member of Student Democratic Front (SDF)
  • Date of Detention: dd/mm/yyyy (7 months prior to the exam date)
  • Place of Detention: XXX police station
  • Period of Detention: 3 days
  • Trauma History: On dd/mm/yyyy (7 months prior to the exam date), Mr. Adam as arrested by four officers from the NSA. He was placed in a truck with blackened windows, blindfolded and taken to a police station. His mobile phone and ID card were confiscated. His hands were restrained and he was punched, kicked and beaten with black water hoses and electric wires. They suspended him by his wrists and applied electric shocks to his genitals.
  • Alleged Perpetrators: Security personnel from the NSA, including Abdel Salih, and Kaleel Rahim, also 2 perpetrators referred to as Rasoul and Mujahid.
  • Reasons for Visit: Treatment for problems related to torture and to take legal action against the perpetrators. The client has already met with SOAT legal advisors, and they have requested a medical evaluation of the client’s allegations of torture.
  • Effects of Torture: Musculoskeletal pain, multiple bruises and burns.

Identification

My name is Hassan Bashir Adam. I live in Khartoum, and I am 25 years-old.

Additional Information:

  • Date of Birth: dd/mm/yyyy (age 25)
  • Citizenship: Sudanese
  • Marital Status/Children: I am single, and I do not have children.
  • Place of Birth: Nyala
  • Place of Residence: Khartoum
  • Highest Level of Education: Currently a student at Khartoum University.
  • Occupation: Student
  • Religion: Muslim
  • Identification: ID confiscated
  • Ethnic Group: Darfurian, Zagawa tribe
  • Physician Examiner Name and License #: Fill out
  • Individuals Present in the Examination Room and Reason for Presence: Fill out
  • Language Spoken: Zagawa
  • Name of Interpreter: None
  • Restrictions Noted: This depends on the response of the interviewer.
  • Detainee Status: Detained by police and released

Past Medical/Surgical History and Psychosocial History

Past Medical/Surgical History

Before I was arrested, I had no medical problems, no major illnesses or injury, no surgery, broken bones or head injury. I never had any mental problems, nor has anyone in my family. I am not on any medications. I do not use any illegal drugs or drink alcohol. I smoke about one pack of cigarettes per day.

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

Psychosocial History Pre-Arrest

I was born in Nyala and have two younger brothers. My father owns a small grocery store in Nyala and my mother helps him out at the store. I was good in school and decided to go to Khartoum University for business studies. I have had various part-time jobs, but I have never worked for my parents. My plan was to have a good job with a large company in the future. I have been an active member of the SDA (Student Democratic Front) for the past two years. Many of my friends and I were detained after the student elections last year. I was beaten, but not as bad as the others. One of my brothers was killed by security forces in Darfur about 9 months ago. My parents worry about me, because they know I am an active member of the SDF and they do not approve.

Trauma History

NOTE: At the time of arrest, there was no arrest warrant or subpoena order, search warrant, or resistance by the accused.

On dd/mm/yyyy (7 months prior to the exam date), at about 10:00 pm, four officers from the NSA came to the flat that I share with two other students. They told me that they needed to ask me some questions. I asked them if I was being charged with a crime. One of them, Abdel Salih, told me “Keep your mouth shut if you know what’s good for you.” Another one of them was named Kaleel Rahim.

I was placed in a truck with blackened windows and taken to XXX police station.

They took my mobile phone and ID card. When we arrived, they locked me in a room, about one meter by one meter and a half in size. The room was filthy and smelled of urine. There were no light and the ventilation in the room was very poor. During the time that I was detained, I had difficulty sleeping and was given only a small amount of poor quality food.

Later that night, they took me to an interrogation room and started asking questions about members of the SDF, who I knew and worked with and the nature of our work. I had made a speech recently on the situation in Darfur and they told me, “You may think you are free to criticize us, but we are free to do anything we like. We could kill you tonight and no one would care.” They tied my hands with rope and started beating me with punches, kicks, black water hoses and electric wires. This went on for more than an hour. One of them, “Rasoul,” put a plastic bag over my head and I was gasping for air. He repeated this 3 or 4 more times and I passed out.

When I woke up, they started beating me again (punches, kicks, and hoses). They forced me to take off all of my clothes. My hands were tied behind my back with a rope that was hanging from the ceiling. They lifted me off the ground; the pain was unbearable. They continued beating me while I was suspended. Then they sprayed cold water over me with a hose and forced it in my mouth and nose so I had trouble breathing. One of the agents attached a clip with some wires to my penis and my right foot. He said insulting things (Like “you won’t be needing this anymore.”). My whole body cramped violently when they shocked me. I lost consciousness after they shocked me about five or six times. When I woke up, I was on the floor. I felt several burning sensations on my right forearm. One of them had a lit cigarette in his hand. He burned my arm again and again. One of them told me, “You better stop making speeches or you will end up like your brother.” I was locked in a cell for two days before I was released. I am not guilty of anything, and no one should be treated this way. That is why I had the courage to take legal action against the people who tortured me.

Review of Torture Methods

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

  • The review of torture methods is negative for the all other torture methods, physical and psychological.

Symptoms (Acute and Chronic) and Disabilities

Acute Symptoms
  • Multiple bruises over my arms, legs and back, no injuries to the head. The bruises are red and swollen and still visible on my body. (No cuts or bleeding)
  • Pain in the shoulders, arms and wrists.
  • A number of burn marks on my right forearm, which took about 2-3 weeks to heal.
  • I did not observe any lesion on the penis where they shocked me.
  • Difficulty lifting objects due to pain in my arms and numbness in my right arm for a few months, but this resolved.
Chronic Symptoms
  • Scars noted on right forearm from cigarette burns.
  • Difficulty having erections, i.e. not able to perform sexually but has noted erections upon waking for sleep.
Disabilities
  • None noted

Psychological Evaluation and Mental Status

Mental Status

Mr. Adam was appropriately dressed and groomed and looked his stated age. He was alert, fully oriented, pleasant and cooperative throughout the evaluation. There were no gross abnormalities in movement or posture on observation. Sensory functions and motor functions appeared to be intact. He appeared to possess above average intellectual ability, with good insight and judgment. His speech was clear and fluent. There was no evidence of delusions, hallucinations or psychotic thought processes. Memory was intact. Attention and concentration appeared intact. His mood was apprehensive in the presence of the police officer who escorted him to my office, but then calm during the evaluation. There was no evidence of suicidal or homicidal ideation.

Psychological Findings

Mr. Adam did not admit to any symptoms of post-traumatic stress disorder or major depression. Though his affect was calm throughout most of the interview, he expressed considerable anger toward those who tortured him and the loss of his brother. Mr. Adam indicated that since being tortured, he is less sure of his future plans. He is now considering altering his career path to become more active politically. His parents have expressed strong disapproval, however; they consider his political activity to be “foolish and dangerous.” This has resulted in considerable discord between them. He and his father have not spoken to one another in the past several weeks.

Physical Examination

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

  • Slide #1 and #2 (day of exam): Hyperpigmented, circumferential scars above both wrists, highly consistent with wrist abrasions from alleged restraint with rope and suspension
  • Slide #3 and #4 (day of exam): Multiple hyperpigmented circular scars (about 1 cm in diameter) with indistinct margins and no central palor or atrophy. The characteristics of the lesions and location on one arm only are highly consistent with the alleged cigarette burns.
  • Slides #5 and #6 (6 days following alleged torture): Linear “tram-track” lesions with peripheral echymosis and central palor, consistent with acute signs of beating to the back with a water hose.

Interpretation and Conclusion

Per trainee’s assessment

Case Summary/Referral #02 (distribute to students who conduct the interviews) (Strong physical, moderate psychological and strong historical evidence; medical evaluation 7 days after alleged torture) Note: This case example #02 is written for male role-player. All names included in the … Continue reading →

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Module 1: International Legal Standards (Overview)

Objectives

  • To understand basic definitions of torture and other forms of cruel, inhuman and degrading treatment or punishment.
  • To familiarize students with the international legal standards on the prohibition of torture and ill-treatment
  • To obtain a clear understanding of the torture practises in the world today and relevant country-specific practises.
  • To be familiar with international and regional monitoring mechanisms.
  • To understand basic torture prevention and accountability measures, including specific safeguards for those deprived of their liberty.
  • To identify international and country specific needs for prevention and accountability measures, including specific safeguards for those deprived of their liberty.
  • To identify country-specific challenges in preventing torture and holding perpetrators accountable including effective remedial measures in this regard.

Content

  • Definition of torture and ill-treatment
  • Brief review of the purpose of torture and its history
  • Review of relevant international standards for torture prevention
  • Torture in the world today, including practises, the role of state and non-state actors, common situations for allegations
  • Review of country-specific legal standards and torture practises [to be provided by Instructors]
  • Overview of prevention and accountability measures
  • International and regional monitoring mechanisms and formal inspections of detention facilities
    • Human Rights Committee
    • UN Committee against Torture
  • Regional monitoring mechanisms
  • Other monitoring mechanisms
    • The UN Special Rapporteur
    • International criminal courts and tribunal
    • The International Committee of the Red Cross (ICRC)
  • Safeguards against torture for those deprived of their liberty
    • Notifying people of their rights
    • Use of officially recognised places of detention
    • Humane conditions of detention
    • Limits on interrogation
    • Access to a doctor
    • The right to challenge the lawfulness of detention
  • Safeguards for special categories of detainees
    • Women in detention
    • Juvenile detainees
    • People with mental health problems

Discussion Topics

  • Compare and contrast similarities and differences between international standards and national legislation
  • Develop a 10-12 point country-specific plan for torture prevention and accountability
  • Discuss how international, regional and national organisations can work together for the effective investigation and prevention of torture.
  • Discuss the role of health professionals in torture prevention and accountability.
  • Discuss the relationship between human rights and human security in general, and specifically with regard to national anti-terror policies/practises and torture.

Teaching Formats

  • Group Activity:
    • Divide the class into several groups and assign each group with one or more (or all) of the Discussion Topics listed above.
    • 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
  • Individual Research/Assignment(s):
    • Conduct literature research on the psychology of abuse and write a two-page essay analyzing different theories. Provide your opinion with supporting information
    • Develop a 10-12 point, country-specific plan for torture prevention and accountability
    • Develop a country-specific list of organisations and bodies relevant to torture and ill-treatment
  • Journal Entry: (Instructor to assign students to write a few paragraphs — no more than a page on one or more of the following)
    • Respond to one or more of the Discussion Topics
    • Why do you think health professionals should or should not be concerned about torture and ill-treatment?

Primary Resources

  • The Istanbul Protocol, Chapters I and III, Annex I
  • The Torture Reporting Handbook
  • Action Against Torture: A Practical Guide to the Istanbul Protocol for Lawyers
  • Medical Investigation and Documentation of Torture: A Handbook for Health Professionals
  • Combating Torture: A Manual for Judges and Prosecutors
  • The Torture Reporting Handbook

Objectives To understand basic definitions of torture and other forms of cruel, inhuman and degrading treatment or punishment. To familiarize students with the international legal standards on the prohibition of torture and ill-treatment To obtain a clear understanding of the … Continue reading →

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Physical Evidence of Torture

Indispensable to compliance with the guidelines prescribed in the Istanbul Protocol is an understanding that “the absence of…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.” As a matter of fact, survivors of torture and/or ill-treatment often to not have physical evidence of torture as most lesions heal in approximately 6 weeks. As stated in the Istanbul Protocol, “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.” (IP, §171) Physical manifestations of torture may involve all organ systems. Some effects are typically acute while other may be chronic. Symptoms and physical findings will vary in a given organ system over time, though psychosomatic and neurologic symptoms are typically chronic findings. Musculoskeletal symptoms are commonly present in both acute and chronic phases. A particular method of torture, its severity, and the anatomical location of injury often indicate the likelihood of specific physical findings. For example:

  • Beating the soles of the feet (falanga) may result in subcutaneous fibrosis and a compartment syndrome of the feet.
  • The use of electricity and various methods of burning may also leave highly characteristic skin changes.
  • Whipping may also produce a highly characteristic pattern of scars.
  • Different forms of body suspension and stretching of limbs may result in characteristic musculoskeletal and nerve injuries.
  • Other forms of torture may not produce physical findings, but are strongly associated with other conditions. For example, beatings to the head that result in loss of consciousness are particularly important to the clinical diagnosis of organic brain dysfunction. Also, trauma to the genitals is often associated with subsequent sexual dysfunction.

Before conducting the physical examination, the Istanbul Protocol states that health professionals should interview individuals in an effort to compile background information, asking individuals to describe both acute and chronic symptoms and/disabilities. Health professionals should ask examinees about any injuries resulting from the alleged abuse, documenting instances where the examinees’ ability to describe injuries may be compromised by any after-effects of the torture. Typical acute symptoms include bleeding, bruising, burns from cigarettes, heated instruments or electricity, musculoskeletal pain, numbness, weakness, and loss of consciousness. Some common chronic systems are headache, back pain, gastrointestinal symptoms, sexual dysfunction, and muscle pain. In addition, many alleged victims suffer from chronic psychological effects, which can include depression, anxiety, insomnia, nightmares, flashbacks, and memory difficulties. Physicians should inquire about the intensity, frequency, as well as duration of each reported symptom.

After gathering background information, forensic experts should conduct a physical examination looking for findings or the lack of them that correlate with the allegations of torture and/or ill-treatment.In general, these examinations include an assessment of the following organs or systems: a) skin, b) face, c) chest and abdomen, d) musculoskeletal system, e) genitourinary system, and f) central and peripheral nervous system. The examiner should note all pertinent positive and negative findings, using body diagrams and photographs to record the location and nature of all injuries. Although genital exams can provide crucial corroborating evidence, these are to be performed only with the alleged victim’s consent. In the case that the physician differs in gender from the alleged victim, a chaperone must be present in the examination room. While diagnostic tests are not an essential part of the clinical assessment, there are some circumstances in which such tests may provide valuable supporting evidence.

Indispensable to compliance with the guidelines prescribed in the Istanbul Protocol is an understanding that “the absence of…physical evidence should not be construed to suggest that torture did not occur, since such acts of violence against persons frequently leave no … Continue reading →

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The Psychological Consequences of Torture

The potential effects of torture include cumulative traumatic experiences on individual, family and community levels.

On the individual level

Torture is a dynamic process that begins at the moment of losing liberty, and involves a sequence of traumatic events that may take place at different times and places, ending with the release or demise of the victim. Sometimes this cascade of events may start again within a short time-frame, without leaving any time for the individual to recover. The person experiences complete lack of control, inability to escape, and is also challenged by the unpredictability of the torturer.

Generally torture has an extremely threatening and painful character, and can induce immediate reactions of panic and fear, including significant fear of death, with a very high level of tension and, sometimes subsequently, of emotional numbness. These feelings may be accompanied by 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. Torture can damage individuals on a number of levels:

  • physical and psychological integrity and entity,
  • cognitive, emotional, behavioural, social well-being,
  • personality,
  • identity,
  • autonomy,
  • self-actualisation,
  • self-respect or self-esteem ,
  • sense of safety and survival,
  • dreams, hopes, aspirations for the future,
  • belief system,
  • system of meaning about him/herself and the world,
  • attachment,
  • connectedness, and
  • trust.

The aim of torture is often not only the intentional destruction of the victim, but of his or her economic, social, and cultural worlds of the victims. Torture also may profoundly affect an individual’s sense of being grounded in a family and in society. It may also cause secondary problems which compromise social, educational and occupational functioning.

On the family level

Torture can profoundly damage intimate relationships between spouses, parents, children and other family members, and relationships between the victims and their communities. Such trauma can lead to various forms of family dysfunction and disruptions including:

  • Other members of the family may also be detained, tortured and ill treated.
  • Other members of the family may suffer from the secondary traumatisation.
  • The repercussions of the physical and psychological suffering of the tortured person within the family can cause an increased level of stress as well as fear, worry, feelings of being terrorised and threatened, and loss of sense of safety and security, affecting the family system and the other members of the family.
  • Torture may change the roles and relationship patterns in the family; it may result in deterioration in the ability to care for children and loved ones, and in parenting capacity.
  • Torture experiences may also cause substantial disruption of the quality of life in the family due to health problems, forced change of living place, loss of work and diminished social support.

The potential effects of torture include cumulative traumatic experiences on individual, family and community levels. On the individual level Torture is a dynamic process that begins at the moment of losing liberty, and involves a sequence of traumatic events that … Continue reading →

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Avoiding incommunicado detention

International standards do not expressly prohibit incommunicado detention – where a detainee is denied all contact with the outside world – in all circumstances. However, international standards provide and expert bodies have maintained that restrictions and delays in granting detainees access to a doctor and lawyer and to having someone notified about their detention are permitted only in very exceptional circumstances for very short periods of time.

The Human Rights Committee has found that the practise of incommunicado detention is conducive to torture[1] and may itself violate Article 7 or Article 10 of the ICCPR.[2] It has stated that provision should also be made against incommunicado detention as a safeguard against torture and ill-treatment.[3]

The UN Commission on Human Rights has stated that “prolonged incommunicado detention may facilitate the perpetration of torture and can in itself constitute a form of cruel, inhuman or degrading treatment.”[4] The UN Special Rapporteur on Torture has stated that “torture is most frequently practised during incommunicado detention. Incommunicado detention should be made illegal, and persons held incommunicado should be released without delay.”[5]

[1] Preliminary Observations of the Human Rights Committee: Peru, UN Doc. CCPR/C/79/Add.67, paras 18 and 24, 25 July 1996.

[2] Albert Womah Mukong v Cameroon, (458/1991), 21 July 1994, UN Doc. CCPR/C/51/D/458/1991; El-Megreisi v Libyan Arab Jamahiriya, (440/1990), 23 March 1994, UN Doc. CCPR/C/50/D/440/1990

[3] Human Rights Committee General Comment 20, para.11.

[4] Resolution 1997/38, para. 20.

[5] Report of the Special Rapporteur on Torture, UN Doc.A/56/156, July 2001, para. 39(f).

International standards do not expressly prohibit incommunicado detention – where a detainee is denied all contact with the outside world – in all circumstances. However, international standards provide and expert bodies have maintained that restrictions and delays in granting detainees … Continue reading →

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Clinical Considerations

Symptoms of PTSD may appear in children. The symptoms can be similar to those observed in adults but the clinician must rely more heavily on observations of the child’s behaviour than on verbal expression. For example, the child may demonstrate symptoms of re-experiencing as manifested by monotonous, repetitive play representing aspects of the traumatic event, visual memories of the events in and out of play, repeated questions or declarations about the traumatic event and nightmares. The child may develop bedwetting, loss of control of bowel movements, social withdrawal, restricted affect, attitude changes toward self and others and feelings that there is no future. S/he may experience hyperarousal and have night terrors, problems going to bed, sleep disturbance, heightened startle response, irritability and significant disturbances in attention and concentration. Fears and aggressive behaviour that were non-existent before the traumatic event may appear, such as aggressiveness toward peers, adults or animals, fear of the dark, fear of going to the toilet alone and phobias. The child may demonstrate sexual behaviour that is inappropriate for his/her age and may experience somatic reactions. Anxiety symptoms may appear, such as exaggerated fear of strangers, separation anxiety, panic, agitation, temper tantrums and uncontrolled crying. The child also may develop eating problems.

Symptoms of PTSD may appear in children. The symptoms can be similar to those observed in adults but the clinician must rely more heavily on observations of the child’s behaviour than on verbal expression. For example, the child may demonstrate … Continue reading →

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Follow-up

Many infectious diseases can be transmitted by sexual assault, including sexually transmitted diseases such as gonorrhoea, chlamydia, syphilis, HIV, hepatitis B and C, herpes simplex and Condyloma acuminatum (venereal warts), vulvovaginitis associated with sexual abuse, such as trichomoniasis, Moniliasis vaginitis, Gardnerella vaginitis and Enterobius vermicularis (pinworms), as well as urinary tract infections.

Appropriate laboratory tests and treatment should be prescribed in all cases of sexual abuse. In the case of gonorrhoea and chlamydia, concomitant infection of the anus or oropharynx should be considered at least for examination purposes. Initial cultures and serologic tests should be obtained in cases of sexual assault, and appropriate therapy initiated. Sexual dysfunction is common among survivors of torture, particularly among victims who have suffered sexual torture or rape, but not exclusively. Symptoms may be physical or psychological in origin or a combination of both and include:

  • Aversion to members of the opposite sex or decreased interest in sexual activity;
  • Fear of sexual activity because a sexual partner will know that the victim has been sexually abused or fear of having been damaged sexually. Torturers may have threatened this and instilled fear of homosexuality in men who have been anally abused. Some heterosexual men have had an erection and, on occasion, have ejaculated during non-consensual anal intercourse. They should be reassured that this is a physiological response;
  • Inability to trust a sexual partner;
  • Disturbance in sexual arousal and erectile dysfunction;
  • Dyspareunia (painful sexual intercourse in women) or infertility due to acquired sexually transmitted disease, direct trauma to reproductive organs or poorly performed abortions of pregnancies following rape.

Many infectious diseases can be transmitted by sexual assault, including sexually transmitted diseases such as gonorrhoea, chlamydia, syphilis, HIV, hepatitis B and C, herpes simplex and Condyloma acuminatum (venereal warts), vulvovaginitis associated with sexual abuse, such as trichomoniasis, Moniliasis vaginitis, … Continue reading →

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Apendix I: Sample Psychological Evaluations

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Conclusions

At the end of the report, the health professional must give his or her opinion of the totality of his or her findings, both physical and mental. He or she can say how strongly the findings support or do not support the allegations. The report may have corroborative value when it is added to the other evidence in the case.

All the available information should then be brought together in order to prepare the final report, including:

  • Copies of any previous court decisions about the individual
  • Correspondence from other health professionals to whom the patient has been referred
  • Background information about the situation in the country to which the allegations of torture relate (e.g. from the UNHCR (United Nations High Commissioner for Refugees) or Amnesty International)
  • The account of the event(s) as described by the individual
  • Notes on the individual’s description of his or her physical and mental health
  • Records of the psychological and physical findings from the interview(s)
  • The results of any clinical investigations
  • Recommendations for further treatment

This will then allow the health professional to give an opinion of the likelihood that the alleged victim had been tortured in the way that he or she described, to the standard of proof required by the appropriate forum. Ultimately, the court decides whether the individual is credible, but health professionals must not ignore the issue. Credibility is not an all-or-nothing concept – there is a continuum between the absolute truth and the complete fabrication of events, with at least three points in-between:

  1. A mixture of falsehood and truth, e.g. a fabricated history of a recent detention added to a genuine one in the past
  2. Conscious or subconscious exaggeration – saying that the ill-treatment was more frequent and more severe than actually happened
  3. Genuine errors arising from mistakes and misunderstandings. The health professional should then make a final statement summarising the opinion.

The components of written reports are elaborated throughout this Curriculum. The following guidelines are based on the Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (the “Istanbul Protocol”), Appendix IV. These guidelines are not intended as a fixed protocol. Rather, they should be applied with due consideration to the purpose of an individual evaluation and a reasonable assessment of available resources. Please note that assessments of physical and psychological evidence of torture and ill-treatment may be conducted by one or more clinicians depending on their qualifications.

Guidelines for Medical Evaluations of Torture and Ill Treatment

(see Istanbul Protocol [1] Annex IV)

Case Information

Date of Evaluation:……………………… Exam. Requested By (Name/Position):…………
Case ID/Report #: ……………………… Duration of Evaluation: ……Hours ……Minutes
Subject’s Given Name:..………………… Birth Date:………… Birth Place………………
Subject’s Family Name:..………………… Gender: female / male
Reason for Exam…………………… Subject’s ID#:……………………………………
Clinician’s Name:……………………….. Interpreter Yes/No: Name:…..……………………
Informed Consent: Yes/No; If “No,” Provide Reason:…..……………………………
Subject Accompanied By (Name/Position):…………………………………..…………………
Person(s) Present During Examination (Name/Position):……………………..…………………
Subject Restrained During Exam: Yes/No; If “Yes,” How/Why?……………………………………….
Medical Report Transferred to (Name/Position/ID#):…………………………………………….
Transfer Date: …………………….. Transfer Time: …………………….
Medical Evaluation/Investigation Conducted without Restriction (For Subjects in Custody): Yes/No
Provide Details of Any Restrictions:…………………………………..……………………

Clinician’s Qualifications (For Judicial Testimonies)

  1. Medical Education and Clinical Training
  2. Psychological/Psychiatric Training
  3. Experience in Documenting Evidence of Torture and Ill-treatment
  4. Regional Human Rights Expertise Relevant to the Investigation
  5. Relevant Publications, Presentations and Training Courses
  6. Provide Curriculum Vitae

Statement Regarding Veracity of Testimony (For Judicial Testimonies)

For example: “I personally know the facts recited below, except as to those stated on information and belief, which I believe to be true. I would be prepared to testify to the above statements based on my personal knowledge and belief.”

Background Information

  1. General Information: (age, occupation, education, family composition, etc.)
  2. Past Medical History
  3. Review of Prior Medical Evaluations of Torture and Ill-treatment:
  4. Psychosocial History Pre-Arrest

Allegations of Torture and Ill-treatment

  1. Summary of Detention(s) and Abuse
  2. Circumstances of Arrest and Detention
  3. Initial and Subsequent Places of Detention: (chronology, transportation, and detention conditions)
  4. Narrative Account of Ill-treatment of Torture: (in each place of detention)
  5. Review of Torture Methods

Physical Symptoms and Disabilities

  1. Describe the development of acute and chronic symptoms and disabilities and the subsequent healing processes.
  2. Acute Symptoms and Disabilities
  3. Chronic Symptoms and Disabilities

Physical Examination

  1. General Appearance
  2. Skin
  3. Face/Head
  4. Eyes/Ears/Nose/Throat
  5. Oral Cavity/Teeth
  6. Chest/Abdomen (including vital signs)
  7. Genitourinary System
  8. Musculoskeletal System
  9. Nervous System (Central and Peripheral)

Psychological History/Examination

  1. Methods of Assessment
  2. Current Psychological Complaints
  3. Post-Torture History
  4. Pre-Torture History
  5. Past Psychological/Psychiatric History
  6. Substance Use and Abuse History
  7. Mental Status Examination
  8. Assessment of Social Functioning
  9. [Psychological Testing]
  10. [Neuropsychological]

Photographs

Diagnostic Test Results (see Appendix I for indications and limitations)

Consultations

Interpretation of Finding

  1. Physical Evidence:
    1. Correlate the degree of consistency between the history of acute and chronic physical symptoms and disabilities with allegations of abuse.
    2. Correlate the degree of consistency between physical examination findings and allegations of abuse. (Note: the absence of physical findings does not exclude the possibility that that torture or ill-treatment was inflicted.)
    3. Correlate the degree of consistency between examination findings of the individual with knowledge of torture methods and their common after-effects used in a particular region.
  2. Psychological Evidence:
    1. Correlate the degree of consistency between the psychological findings and the alleged report of torture.
    2. Provide an assessment of whether the psychological findings are expected or typical reactions to extreme stress within the cultural and social context of the individual.
    3. Indicate the status of the individual in the fluctuating course of trauma-related mental disorders over time; i.e. what is the time frame in relation to the torture events and where in the course of recovery is the individual.
    4. Identify any coexisting stressors impinging on the individual (e.g. ongoing persecution, forced migration, exile, loss of family and social role, etc.) and the impact these may have on the individual.
    5. Mention physical conditions that may contribute to the clinical picture, especially with regard to possible evidence of head injury sustained during torture and/or detention.

Conclusions and Recommendations

  1. Statement of opinion on the consistency between all sources of evidence cited above (physical and psychological findings, historical information, photographic findings, diagnostic test results, knowledge of regional practices of torture, consultation reports, etc.) and allegations of torture and ill-treatment.
  2. Reiterate the symptoms and/or disabilities that the individual continues to suffer as a result of the alleged abuse.
  3. Provide any recommendations for further evaluation and/or care for the individual.

Statement of Truthfulness (For Judicial Testimonies)

For example, “I declare under penalty of perjury, pursuant to the laws of (XX country), that the foregoing is true and correct and that this affidavit was executed on X/X/X at (City), (State or Province).”

Statement of Restrictions on the Medical Evaluation/Investigation (For Subjects in Custody)

For example, “The undersigned clinician(s) personally certify that they were allowed to work freely and independently, and permitted to speak with and examine (the subject) in private, without any restriction or reservation, and without any form of coercion being used by the detaining authorities;” or alternatively: “The undersigned clinician(s) had to carry out his/her/their evaluation/investigation with the following restrictions:…”

Clinician’s Signature, Date, Place

Relevant Appendices

e.g. Clinician’s Curriculum Vitae, Anatomical Drawings for Identification of Torture and Ill-treatment, Photographs, Consultations, and Diagnostic Test Results, among others.

In the process of correlating the degree of consistency between physical and psychological findings and allegations of abuse, it is helpful to use the following terms (adapted from IP, §125):

  • Not consistent: The finding could not have been caused by the trauma described. (If this term is used in a medico-legal report, the writer should explain why the individual’s account is considered to be credible, if that is the case, despite this inconsistency.
  • Consistent with: The finding could have been caused by the trauma described, but it is non-specific and there are common alternative possible causes.
  • Highly consistent: The finding could have been caused by the trauma described and there are few other possible causes. (Depending on the level of proof required by the court, such findings may be sufficient to corroborate the individual’s testimony.)
  • Typical of: This phrase is used for lesions that are ‘highly consistent’ with the attribution and additionally the appearance is one that is usually found with this type of trauma (for example, cigarette burns).
  • Diagnostic of: This finding could not have been caused in any way other than that described. (This is strongly supportive of the individual’s account, but does not, by itself, confirm that torture has occurred because the status of the perpetrator and the purpose of the assault are also relevant.)

Quelle

  • [1] https://phrtoolkits.org/downloads/?did=22

At the end of the report, the health professional must give his or her opinion of the totality of his or her findings, both physical and mental. He or she can say how strongly the findings support or do not … Continue reading →

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Reparation

(i) To ensure that victims of torture have the right to an effective remedy and adequate reparation by:

  • Ensuring that victims of torture have effective procedural remedies, both judicial and non-judicial, to protect their right to be free from torture in law and practice;
  • Guaranteeing that domestic law reflects the different forms of reparation recognized under international law and that the reparations afforded reflect the gravity of the violation(s).

(i) To ensure that victims of torture have the right to an effective remedy and adequate reparation by: Ensuring that victims of torture have effective procedural remedies, both judicial and non-judicial, to protect their right to be free from torture … Continue reading →

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