← Previous Pages
More Pages →

Istanbul Protocol Model Medical Curriculum

Educational Resources for Health Professional Students

Humane conditions of detention

The Human Rights Committee has stated that the duty to treat detainees with respect for their inherent dignity is a basic standard of universal application. States cannot claim a lack of material resources or financial difficulties as a justification for inhumane treatment. States are obliged to provide all detainees and prisoners with services that will satisfy their essential needs. Failure to provide adequate food and recreational facilities constitutes a violation of Article 10 of the ICCPR, unless there are exceptional circumstances. The Committee has also stated that prolonged solitary confinement may amount to a violation of the prohibition against torture and ill-treatment in Article 7 of the ICCPR.[1]

The Basic Principles for the Treatment of Prisoners provide that states should undertake efforts to abolish solitary confinement as a punishment or to restrict its use.[2] The Standard Minimum Rules for the Treatment of Prisoners specify that ‘corporal punishment, punishment by placing in a dark cell, and all cruel, inhuman or degrading punishments shall be completely prohibited as punishments for disciplinary offences.[3] The CPT has stressed that solitary confinement can have “very harmful consequences for the person concerned” and that, in certain circumstances, solitary confinement can “amount to inhuman and degrading treatment” and should, in all circumstances, be applied for as short a period as possible.[4]

[1] Human Rights Committee General Comment 20, para. 6.

[2] Principle 7 of the Basic Principles for the Treatment of Prisoners.

[3] Rule 31.

[4] CPT/Inf/E (2002) 1, p.20 para. 56(2).

The Human Rights Committee has stated that the duty to treat detainees with respect for their inherent dignity is a basic standard of universal application. States cannot claim a lack of material resources or financial difficulties as a justification for … Continue reading →

Toolkit:
Subject:
Issue:
Use:

Role of the Family

The family plays an important dynamic role in persisting symptomatology among children. In order to preserve cohesion in the family, dysfunctional behaviours and delegation of roles may occur. Family members, often children, can be assigned the role of patient and develop severe disorders. A child may be overly protected or important facts about the trauma may be hidden. Alternatively, the child can be “parentified” and expected to care for the parents.

When the child is not the direct victim of torture but only affected indirectly, adults often tend to underestimate the impact on the child’s psyche and development. When loved ones around a child have been persecuted, raped and tortured or the child has witnessed severe trauma or torture, s/he may develop dysfunctional beliefs, such as that he/she is responsible for the bad events or that s/he has to bear the parent’s burdens. These types of beliefs can lead to long-term problems with loyalty conflicts, guilt, personal development and maturing into an independent adult.

The family plays an important dynamic role in persisting symptomatology among children. In order to preserve cohesion in the family, dysfunctional behaviours and delegation of roles may occur. Family members, often children, can be assigned the role of patient and … Continue reading →

Toolkit:
Subject:
Issue:
Use:

Module 8 Presentation: Case Example #02


Download

Download Module 8: Case Example #02 (PowerPoint Presentation) (ppt)

Toolkit:
Subject:
Issue:
Use:

Genital Examination of Women

In many cultures, it is completely unacceptable to penetrate the vagina of a woman who is a virgin with anything, including a speculum, finger or swab. If the woman demonstrates clear evidence of rape on external inspection, it may be unnecessary to conduct an internal pelvic examination. Genital examination findings may include:

  • Small lacerations or tears of the vulva. These may be acute and are caused by excessive stretching. They normally heal completely, but, if repeatedly traumatised, there may be scarring;
  • Abrasions of the female genitalia. Abrasions can be caused by contact with rough objects such as fingernails or rings;
  • Vaginal lacerations. These are rare, but, if present, may be associated with atrophy of the tissues or previous surgery. They cannot be differentiated from incisions caused by inserted sharp objects.

It is rare to find any physical evidence when examining female genitalia more than one week after an assault. Later on, when the woman may have had subsequent sexual activity, whether consensual or not, or given birth, it may be almost impossible to attribute any findings to a specific incident of alleged abuse. Therefore, the most significant component of a medical evaluation may be the examiner’s assessment of background information (for example, correlation between allegations of abuse and acute injuries observed by the individual) and demeanour of the individual, bearing in mind the cultural context of the woman’s experience.

In many cultures, it is completely unacceptable to penetrate the vagina of a woman who is a virgin with anything, including a speculum, finger or swab. If the woman demonstrates clear evidence of rape on external inspection, it may be … Continue reading →

Toolkit:
Subject:
Issue:
Use:

Module 9 Presentation: Report Writing and Testifying in Court


Download

Download Module 9: Report Writing and Testifying in Court (PowerPoint Presentation) (ppt)

Toolkit:
Subject:
Issue:
Use:

Genital Examination of Men

Men who have been subjected to torture of the genital region, including the crushing, wringing or pulling of the scrotum or direct trauma to that region, usually complain of pain and sensitivity in the acute period. Hyperaemia, marked swelling and ecchymosis can be observed. The urine may contain a large number of erythrocytes and leucocytes. If a mass is detected, it should be determined whether it is a hydrocele, haematocele or inguinal hernia. In the case of an inguinal hernia, the examiner cannot palpate the spermatic cord above the mass. With a hydrocele or a haematocele, normal spermatic cord structures are usually palpable above the mass. A hydrocele results from excessive accumulation of fluid within the tunica vaginalis due to inflammation of the testis and its appendages or to diminished drainage secondary to lymphatic or venous obstruction in the cord or retroperitoneal space. A haematocele is an accumulation of blood within the tunica vaginalis, secondary to trauma. Unlike the hydrocele, it does not transilluminate.

Testicular torsion may also result from trauma to the scrotum. With this injury, the testis becomes twisted at its base, obstructing blood flow to the testis. This causes severe pain and swelling and constitutes a surgical emergency. Failure to reduce the torsion immediately will lead to infarction of the testis. Under conditions of detention, where medical care may be denied, late sequelae of this lesion may be observed.

Individuals who were subject to scrotal torture may suffer from chronic urinary tract infection, erectile dysfunction or atrophy of the testes. Symptoms of PTSD are not uncommon. In the chronic phase, it may be impossible to distinguish between scrotal pathology caused by torture and that caused by other disease processes. Failure to discover any physical abnormalities on full urological examination suggests that urinary symptoms, impotence or other sexual problems may be explained on psychological grounds. Scars on the skin of the scrotum and penis may be very difficult to visualize. For this reason, the absence of scarring at these specific locations does not demonstrate the absence of torture. On the other hand, the presence of scarring usually indicates that substantial trauma was sustained.

As with sexual assault of women described above, male victims of sexual violence also need to be assessed for prophylaxis of sexually transmitted diseases, Hepatitis B and HIV.

Men who have been subjected to torture of the genital region, including the crushing, wringing or pulling of the scrotum or direct trauma to that region, usually complain of pain and sensitivity in the acute period. Hyperaemia, marked swelling and … Continue reading →

Toolkit:
Subject:
Issue:
Use:

Self-Assessment and Quiz

  1. In which of the following contexts may expert medical reports and testimony be of value?
    1. Prosecution of alleged perpetrators
    2. Challenging the credibility of statements extracted by torture
    3. Reparations and rehabilitation of alleged victims
    4. Exonerating law enforcement officials accused of torture and ill treatment
    5. Human rights investigations
    6. Medical assessments of asylum applicants
    7. All of the above
  2. Regardless of the context of a medical evaluation, the purpose of written reports and oral testimony by medical experts is to assess the degree to which physical and psychological findings correlate with the individual allegations of abuse.
    1. True
    2. False
  3. Which of the following may be relevant qualifications for medical expertise on physical and/or psychological evidence of torture?
    1. Medical education and clinical training
    2. Psychological/psychiatric training
    3. Experience in documenting evidence of torture and Ill-treatment
    4. Relevant training courses and seminars
    5. Relevant publications and presentations
    6. All of the above
  4. Physicians who are not psychiatrists may qualify as experts on psychological evidence of torture and ill treatment:
    1. True
    2. False
  5. Clinicians should not review the alleged victim’s affidavit as it may create a bias for the evaluating clinician.
    1. True
    2. False
  6. Which of the following are true about written reports and oral testimony?
    1. They require accurate and effective communication skills
    2. They should be factual and carefully worded; jargon should be avoided
    3. They should not include any opinion(s) that cannot be defended under oath or during cross-examination
    4. The quality can only be as good as the interview and examination conducted
    5. All of the above
  7. Which of the following sources of information should not be used as a reference to a medical evaluation or torture and ill treatment?
    1. Client affidavit of alleged torture and ill treatment
    2. NGO (non-governmental organization) Human rights reports
    3. Government reports on torture and ill treatment practices
    4. Medical records following the alleged torture and ill treatment
    5. None of the above
  8. Written reports and oral testimony represent an opportunity for clinicians to educate adjudicators on physical and psychological evidence of torture and ill treatment.
    1. True
    2. False
  9. Clinicians who are conducting their first medical evaluation may enhance the accuracy and credibility of their evaluation by conducting the evaluation under the supervision of, or having it formally reviewed by, a more experienced clinician.
    1. True
    2. False
  10. Historical information such as descriptions of torture devices, body positions and methods of restraint, descriptions of acute and chronic wounds and disabilities, and identifying information about perpetrators and the place(s) of detention may be very useful in corroborating an individual’s allegations of torture.
    1. True
    2. False
  11. The need for medical and/or psychological care should be noted in your medical evaluation only when the alleged torture victim’s attorney requests it.
    1. True
    2. False
  12. The clinician’s interpretation of findings and conclusions, should relate various categories of evidence, i.e., physical and psychological evidence of torture, and historical information as well.
    1. True
    2. False
  13. Which of the following considerations support the clinical assessments of credibility and argue against the possibility of malingering or simulation?
    1. Lack of over-endorsement of physical and/or psychological symptoms
    2. Lack of a suspiciousness or defensiveness
    3. Consistency between the observed affect of the interviewee and the content of the evaluation.
    4. Consistency between an individual’s pre-torture personality and the meaning the individual assigns to his or her torture/ill treatment experiences
    5. Inconsistencies that are attributable to an individual’s torture experience
    6. All of the above
  14. Exaggeration of psychological symptoms usually indicates that the individual’s allegation of torture and ill treatment are false.
    1. True
    2. False
  15. Which of the following may be helpful in explaining inconsistencies in the alleged victim’s account of torture and ill treatment?
    1. Disorientation during torture, blindfolding, drugging, and lapses of consciousness
    2. Neurological or psychological memory disturbances
    3. Feelings of guilt or shame
    4. Cultural differences in the perception of time
    5. Lack of trust in the examining clinician and/or interpreter
    6. Fear of reprisals
    7. Lack of privacy during the interview
    8. All of the above
  16. It is often helpful to include a statement on the veracity of testimony in a written medical report, such as: “I personally know the facts recited below, except as to those stated on information and belief, which I believe to be true.”
    1. True
    2. False
  17. The presence of diagnostic criteria for PTSD or Major Depressive Disorder (MDD) provides stronger evidence of torture and/or ill treatment than sub-threshold symptoms of these diagnoses.
    1. True
    2. False
  18. Which of the following are important considerations for clinicians who provide testimony on torture and ill treatment in court?
    1. Do not “react” to provocative statements.
    2. Clarify questions that you do not understand before providing an answer.
    3. Do not offer opinions on subjects about which you are not qualified to comment.
    4. Speak clearly, slowly, and make eye contact with whomever you are speaking.
    5. All of the above
  19. Which of the following can help to distinguish psychological symptoms caused by torture and ill treatment versus other traumatic experiences or losses?
    1. Temporal relationships between the onset of psychological symptoms and the alleged torture and ill-treatment
    2. Trends in psychological symptoms in relation to external stressors
    3. Content of nightmares and intrusive recollections
    4. Triggers for intrusive recollection, reliving experiences, and avoidance reactions
    5. All of the above
  20. Istanbul Protocol guidelines for medical evaluations of alleged torture and ill treatment include a formal assessment of the individual’s credibility.
    1. True
    2. False

In which of the following contexts may expert medical reports and testimony be of value? Prosecution of alleged perpetrators Challenging the credibility of statements extracted by torture Reparations and rehabilitation of alleged victims Exonerating law enforcement officials accused of torture … Continue reading →

Toolkit:
Subject:
Issue:
Use:

Role of the NGO member in the team

Experience over the past decades has shown that human rights NGOs vary in mandate, focus, and methods, but some can contribute in important ways to the documentation of torture and subsequent legal action:

  • They can assist individuals to gain advice, services and treatment, from the legal and medical professions, through lawyers and health professionals who are part of the NGO or by referral to others.
  • NGOs are often best placed to handle the case of the individual in the international arena, for example by assisting and advising in making complaints to international courts and other mechanisms.
  • The information held by the NGO on other similar cases and the research conducted on torture and other ill-treatment domestically and internationally, can provide valuable support to the case of the individual. Their knowledge of local circumstances can be very important. In certain cases it may be possible to combine a number of cases into joint complaints and petitions.
  • NGOs often have the expertise for any necessary work to be done through public advocacy or with the media.
  • NGOs can assist in the prevention of abuse, for example, by circulating information about those who have been recently arrested.

Although the circumstances vary considerably between countries, generally it is better for an NGO to be open about its activities in helping survivors of torture and to develop links with relevant regional and international bodies; this makes it easier to seek protection from intimidation by the national authorities.

Experience over the past decades has shown that human rights NGOs vary in mandate, focus, and methods, but some can contribute in important ways to the documentation of torture and subsequent legal action: They can assist individuals to gain advice, … Continue reading →

Toolkit:
Subject:
Issue:
Use:

Confidentiality

Clinicians have a duty to maintain confidentiality of information and to disclose information with only the interviewee’s informed consent. The clarification of confidentiality and its limits are of paramount importance for a well-conducted interview. The interviewee should be clearly informed of any limits on the confidentiality of the evaluation and of any legal obligations for disclosure of the information gathered by means of the interview and medical/psychological examination at the beginning of the interview.

Individuals may fear that information revealed in the context of an evaluation cannot be safely kept from being accessed by persecuting governments. Fear and mistrust may be particularly strong in cases where physicians or other health workers were participants in the torture. In many circumstances, the evaluator will be a member of the majority culture and ethnicity, whereas the patient, in the situation and location of the interview, is likely to belong to a minority group or culture. This dynamic of inequality may reinforce the perceived and real imbalance of power and may increase the potential sense of fear, mistrust and forced submission in the interviewee.

Clinicians have a duty to maintain confidentiality of information and to disclose information with only the interviewee’s informed consent. The clarification of confidentiality and its limits are of paramount importance for a well-conducted interview. The interviewee should be clearly informed … Continue reading →

Toolkit:
Subject:
Issue:
Use:

Cruel Inhuman & Degrading Treatment & Punishment (CID)

The exact boundaries between “torture” and other forms of “cruel, inhuman or degrading treatment or punishment” (CID or “ill-treatment”) are often difficult to identify and may depend on the particular circumstances of the case and the characteristics of the particular victim. Both terms cover mental and physical ill-treatment that has been intentionally inflicted by, or with the consent or acquiescence of, the state authorities. The ‘essentialelements’ of what constitutes torture contained in Article 1 of the Convention against Torture include:

  • The infliction of severe mental or physical pain or suffering;
  • By or with the consent or acquiescence of the state authorities;
  • For a specific purpose, such as gaining information, punishment or intimidation.

Cruel treatment, and inhuman or degrading treatment or punishment are also legal terms. These refer to ill-treatment that does not have to be inflicted for a specific purpose, but there does have to be an intent to expose individuals to the conditions which amount to or result in the ill-treatment. Exposing a person to conditions reasonably believed to constitute ill-treatment will entail responsibility for its infliction. Degrading treatment may involve pain or suffering less severe than for torture or cruel or inhuman treatment and will usually involve humiliation and debasement of the victim. The essential elements which constitute ill-treatment not amounting to torture would therefore be reduced to:

  • Intentional exposure to significant mental or physical pain or suffering;
  • By or with the consent or acquiescence of the state authorities

It is often difficult to identify the exact boundaries between the different forms of ill-treatment as this requires an assessment about degrees of suffering that may depend on the particular circumstances of the case and the characteristics of the particular victim. In some cases, certain forms of ill-treatment or certain aspects of detention which would not constitute torture on their own may do so in combination with each other. Ill-treatment is, however, prohibited under international law and even where the treatment does not have the purposive element or, as far as degrading treatment is concerned, is not considered severe enough (in legal terms) to amount to torture, it may still amount to prohibited ill-treatment.[1]

The Human Rights Committee has stated that: ‘The Covenant does not contain any definition of the concepts covered by article 7, nor does the Committee consider it necessary to draw up a list of prohibited acts or to establish sharp distinctions between the different kinds of punishment or treatment; the distinctions depend on the nature, purpose and severity of the treatment applied.[2]”

Over the years a wide variety of abusive acts has been declared by authoritative bodies as violating the prohibition of torture and other ill-treatment. A sample could include:

  • Severe forms of beatings, including beatings on the soles of the feet
  • Suspension by the arms while these are tied behind the back and similar forced positions
  • Infliction of wounds or injuries
  • Cigarette burns, or burns with other instruments or substances
  • Electric shocks
  • Rape or other sexual violence or molestation
  • Near asphyxiation
  • Pharmacological abuse using toxic doses of sedatives, neuroleptics, paralytics, etc
  • Mock executions and mock amputations
  • Forced breach of religious or cultural prohibitions or taboos such as dietary codes
  • Sensory manipulation methods, such as hooding (sensory deprivation) and constant noise (sensory bombardment)
  • Forced to witness torture or atrocities being inflicted on others
  • Prolonged solitary confinement, particularly if combined with incommunicado detention
  • Extremely poor conditions of detention
  • Threats of any of the above being inflicted on the victim or family

[1] Only the practice of the European Court of Human Rights explicitly uses the notion of relative severity of suffering as relevant to the borderline between ‘torture’ and ‘inhuman treatment’. The usual approach is to use the existence or otherwise of the purposive element to determine whether or not the behaviour constitutes torture.

[2] Human Rights Committee, General Comment 20, Article 7 (Forty-fourth session, 1992), Compilation of General Comments and General Recommendations Adopted by Human Rights Treaty Bodies, U.N. Doc. HRI/GEN/1/Rev.1. at 30 (1994), para 4.

The exact boundaries between “torture” and other forms of “cruel, inhuman or degrading treatment or punishment” (CID or “ill-treatment”) are often difficult to identify and may depend on the particular circumstances of the case and the characteristics of the particular … Continue reading →

Toolkit:
Subject:
Issue:
Use:
← Previous Pages
More Pages →