Istanbul Protocol Model Medical Curriculum

1. In what ways do torturers try to conceal the consequences of their actions?
   1. Using narrow, sharp objects for beatings
   2. The use of wet towels with the electric shocks
   3. Detaining victims until obvious signs of abuse have resolved
   4. Leaving the victim’s shoes on during falanga (beating the soles of the feet)
   5. All of the above
2. Torturers have been known to change their practices based on the effective documentation of torture by clinicians.
   1. True
   2. False
3. Which of the following is true of falanga?
   1. It can cause acute pain, swelling and hematoma formation
   2. It can be associated with chronic pain, sensory disturbances and impaired walking
   3. A closed compartment syndrome may develop in the foot
   4. The above findings are considered pathognomonic for falanga
4. Prompt examination is necessary to detect tympanic membrane ruptures less than 2 millimetres in diameter, which may heal within 10 days.
   1. True
   2. False
5. “Palestinian” suspension results in posterior hyperextension of the arms and traction on the lower roots of the brachial plexus. This may result in damage to the long thoracic nerve and cause:
   1. Sensory deficit over the scapula
   2. A “winged” scapula: diminished vertebral border when hands are pressed against a wall with outstretched arms
   3. Sensory deficit in the deltoid region
   4. A “winged” scapula: prominent vertebral border when hands are pressed against a wall with outstretched arms
   5. Sensory deficit in the ulnar distribution
6. Positional forms of torture leave few, if any, external marks or radiological findings, despite subsequent, frequently severe chronic disability.
   1. True
   2. False
7. Which of the following may be observed with crushing and stretch injuries?
   1. Contusions
   2. Incisions
   3. Abrasions
   4. Chronic musculoskeletal pain and/or disabilities
   5. Rhabdomyolysis and acute renal failure
   6. All of the above
8. Regarding burn injuries, which of the following statements are accurate?
   1. The pattern of scarring gives a clue to the method used
   2. Caustic or acid burns may leave a trail indicating the victim’s posture
   3. Heated metal rods, branding irons or electrically heated devices such as smoothing irons or soldering irons often leave scars of distinctive shape and, if in multiples, they make accidental injury most unlikely.
   4. Cigarettes are a particularly common torture weapon. The scars they leave depend on the way the cigarettes were applied to the skin. If they were touched lightly or simply brushed against the skin they may leave no scar or something that is indistinguishable from a scar from acne, chicken pox or insect bite. On the other hand, if the cigarettes were deliberately stubbed out and held immobile on the skin, the scar is often characteristically circular about one centimetre in diameter, with a hyperpigmented periphery (usually with a relatively indistinct periphery) and an atrophic, hypopigmented, “tissue paper” centre.
   5. All of the above
9. Electrical injuries can cause:
   1. Severe pain without subsequent physical signs
   2. Dislocations of joints
   3. Arrhythmias leading to sudden death
   4. Urination and/or defecation
   5. All of the Above
10. Electric shock torture may result in characteristic physical findings, but often do not.
    1. True
    2. False
11. Various forms of asphyxiation may cause:
    1. No findings at all
    2. Conjunctivitis or otitis media
    3. Anoxic brain injury
    4. Acute broncho-pulmonary infections
    5. All of the above
12. Waterboarding may not be considered a method of torture because it has been used successfully in survival training of military personnel.
    1. True
    2. False
13. Violent shaking can result in:
    1. Cerebral edema and subdural hematoma leading to death
    2. Cognitive impairment
    3. Chronic headaches, disorientation and mental status changes
    4. Neck trauma including cervical spine fracture resulting in quadriplegia
    5. All of the above
14. Which of the following are true statements about sexual assault?
    1. The term sexual assault should not be used unless an individual has been raped
    2. Sexual assaults are often accompanied by direct or implied threats
    3. Rape is always associated with the risk of developing sexually transmitted diseases, including human immunodeficiency virus (HIV)
    4. Ideally, medical evaluations of alleged sexual assault should include a team of experienced clinical experts.
    5. All of the above
15. Which of the following are considered torture by the UN Committee Against Torture and/or the Special Rapporteur on Torture?
    1. Prolonged isolation and/or sensory deprivation
    2. Sleep deprivation
    3. Temperature manipulation
    4. Threats of harm
    5. Sensory bombardment
    6. Sexual humiliation
    7. All of the above
16. Which of the following is/are true about the psychological sequelae of torture and ill treatment?
    1. Everyone who has been tortured develops at least some form of diagnosable mental illness
    2. Major Depression and PTSD are the most common diagnoses among survivors of torture and ill treatment
    3. For many that have survived torture, the symptoms of Major Depression and PTSD may persist and fluctuate for many years
    4. Torture and ill treatment can create a sense of complete confusion, powerlessness, and loss of control which can bring about a shattered understanding of one’s self, of any meaningful existential system and of the predictability of the world
    5. All of the above
17. An examining clinician should not assume that all forms of torture and ill treatment have the same or similar outcomes because the psychological consequences of torture and ill treatment develop in the context of personal meaning and personality development.
    1. True
    2. False
18. Standardized instruments and quantitative measurement should be used in all medical evaluations of psychological evidence of torture and ill treatment as they are superior to descriptive methods in establishing correlations between allegations of abuse and the subsequent development of psychological symptoms.
    1. True
    2. False
19. Psychological outcomes can be influenced by many interrelated factors that include but are not limited to the following:
    1. Circumstances, severity and duration of the torture
    2. Age and developmental phase of the victim
    3. Genetic and biological vulnerabilities of the victim
    4. Perception and interpretation of torture by the victim
    5. Community values and attitudes
    6. Political factors
    7. Prior history of trauma
    8. Pre-existing personality
    9. All of the above
20. Risk factors for developing mental illness among survivors of torture who are also refugees include:
    1. Migration factors (loss of home, loved ones, possessions, etc)
    2. Acculturation
    3. Poverty
    4. Cultural and linguistic isolation
    5. Absence of adequate support systems
    6. Unemployment or underemployment
    7. All of the above

In what ways do torturers try to conceal the consequences of their actions? Using narrow, sharp objects for beatings The use of wet towels with the electric shocks Detaining victims until obvious signs of abuse have resolved Leaving the victim’s … Continue reading →

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

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

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

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

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

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

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

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

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

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

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

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

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

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