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Istanbul Protocol Model Medical Curriculum

Educational Resources for Health Professional Students

The United Nations Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment 1984

The UN Convention against Torture was adopted by the UN General Assembly in 1984. One hundred and thirty states were party to the Convention by August 2002. The Convention defines torture and specifies that states parties must prohibit torture in all circumstances. Torture cannot be justified during a state of emergency, or other exceptional circumstances, nor because of superior orders received by an official.[1] The Convention prohibits the forcible return or extradition of a person to another country where he or she is at risk of torture.[2] States must ensure that all acts of torture are offences under its criminal law – including complicity and participation in and incitement to such acts.[3] States must establish jurisdiction over such offences in cases of torture where the alleged offenders are not extradited to face prosecution in another state, regardless of the state in which the torture was committed, or the nationality of the perpetrator or the victim (‘universal jurisdiction’).[4] In exercising universal jurisdiction states are obliged to take suspected perpetrators of torture into custody, to undertake inquiries into allegations of torture and to submit suspected torturers to the prosecuting authorities.[5] States must also co-operate with one another to bring torturers to justice.[6] Statements made as a result of torture may not be invoked in evidence – except against the alleged torturer.[7] Victims of torture also have a right to redress and adequate compensation.[8]

The Convention against Torture also obliges states parties to take effective measures to combat torture. States undertake to train law enforcement, medical personnel, and any other persons who may be involved in the custody, interrogation or treatment of detained individuals, about the prohibition of torture and ill-treatment.[9] Interrogation rules and custody arrangements are to be kept under review to aid in preventing any acts of torture and ill-treatment.[10] States must actively investigate acts of torture and ill-treatment – even if there has not been a formal complaint about it.[11] Individuals have a right to complain about acts of torture and ill-treatment, to have their complaints investigated and to be offered protection against consequent intimidation or ill-treatment.[12] Acts of cruel, inhuman or degrading treatment or punishment that do not amount to acts of torture are also prohibited and the provisions discussed in this paragraph also apply to such acts.[13]

[1] Article 2, the UN Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment.

[2] Article 3 ibid.

[3] Article 4, ibid.

[4] Articles 5, ibid.

[5] Articles 6-8, ibid.

[6] Article 9, ibid.

[7] Article 15, ibid.

[8] Article 14, ibid.

[9] Article 10, ibid.

[10] Article 11, ibid.

[11] Article 12, ibid.

[12] Article 13, ibid.

[13] Article 16, ibid.

The UN Convention against Torture was adopted by the UN General Assembly in 1984. One hundred and thirty states were party to the Convention by August 2002. The Convention defines torture and specifies that states parties must prohibit torture in … Continue reading →

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Self-Assessment and Quiz

  1. The Istanbul Protocol can best be described as:
    1. The duties of states to ensure the effective investigation and documentation of torture and ill treatment
    2. Guidelines for the effective investigation and documentation of torture and ill treatment
    3. International Legal obligations of states to respect The intentional infliction of severe mental or physical pain or suffering
    4. International standards that enable medical and legal experts to prove or disprove allegations of torture and ill treatment
  2. The guidelines contained in the Istanbul Protocol are not designed to be fixed; rather, they represent an elaboration of the minimum standards contained in the Istanbul Principles and should be applied in accordance with a reasonable assessment of available resources.
    1. True
    2. False
  3. The Istanbul Protocol has been recognised by UN and regional human rights bodies as the international standard for the effective investigation and documentation of torture and ill treatment.
    1. True
    2. False
  4. A forensic medical evaluator should avoid conveying empathy during evaluations of alleged torture victims because it may compromise his or her objectivity in the collection of physical and psychological evidence.
    1. True
    2. False
  5. Although there may be considerable variability in the psychological effects of torture and ill-treatment, the effects are often profound and result in long-term psychological disability.
    1. True
    2. False
  6. According to the Istanbul Protocol, what are the most common psychological problems that torture victims suffer from?
    1. There are no common psychological problems
    2. Posttraumatic stress disorder (PTSD) and depression
    3. Paranoia
    4. Sexual dysfunction
  7. Physical evidence of trauma is always of greater legal value than psychological evidence.
    1. True
    2. False
  8. In addition to providing medical evidence of torture and ill treatment, the Istanbul Protocol can be used to exonerate police who are accused of torture and ill treatment of detainees.
    1. True
    2. False
  9. Which of the following are procedural safeguards for detainees?
    1. Police may be in the presence of the detainee when s/he is being examined
    2. The detainee’s lawyer should be present during the request for examination
    3. Prisoners should be examined at the most convenient location
    4. A copy of the examination should not, under any circumstances, be transferred to law enforcement officials
    5. Requests for medical evaluations by police should be considered valid
  10. If the forensic medical examination supports allegations of torture, the detainee should not be returned to the place of detention.
    1. True
    2. False
  11. The presence of police, security forces, and/or other third parties during the examination may be grounds for disregarding a negative medical report.
    1. True
    2. False
  12. The term “medical ethics” refers to the moral framework that each health professional is bound to in their work.
    1. True
    2. False
  13. The use of hoods or blindfolds during any contact between a detainee and a health professional is absolutely unacceptable under any circumstances.
    1. True
    2. False
  14. Which of the following is not a provision under the World Medical Association’s 1975 Tokyo Declaration?
    1. Doctors shall not be present during any procedure during which torture is used
    2. The doctor shall not countenance, condone or participate in the practise of torture or other forms of cruel, inhuman or degrading procedures
    3. The doctor’s fundamental role is to alleviate the stress of his or her fellow man and no motive whether personal, collective, or political shall prevail against this higher purpose
    4. None of the above
  15. Which of the following is not an example of a role that a health professional may play in the participation of torture and ill treatment?
    1. A health professional might be asked to resuscitate a torture victim after he/she has become unconscious
    2. A health professional might provide certain instruments to the torturers/perpetrators
    3. A health professional might be asked to falsify or misrepresent a medical report
    4. A health professional might perform a medical evaluation in order to assess that the victim will be able to withstand torture
    5. A health professional might provide confidential medical information to interrogators
    6. All of the above
  16. Which of the following are essential elements of informed consent?
    1. Mental competence
    2. Full disclosure regarding risks and benefits
    3. The individual understands the information provided
    4. Consent is voluntary and not coerced in any way
    5. The individual provides verbal or written authorization of consent
    6. All of the above
  17. When health professionals are pressured or required by law to disclose information to third parties about patients without consent, they should make clear to any authority requesting information that they are bound by professional duties of confidentiality.
    1. True
    2. False
  18. Under which of the following circumstances would it be appropriate for a physician to feed a hunger striker?
    1. When the physician’s moral beliefs compel him or her to do so
    2. If the hunger striker is already in a comatose state and no prior directives have been established
    3. Immediate family members insist on feeding after the hunger striker became comatose, even though the attending physician documented that the detainee was competent, rational and understood the risk of his actions
    4. None of the above
  19. The ethical duties of medical personnel do not apply in non-clinical encounters with detainees, such as interrogation.
    1. True
    2. False
  20. Effective medical and legal investigations of torture and ill treatment requires obtaining the following essential information?
    1. Identity of the victim
    2. Identity of the perpetrators
    3. Description of how the individual came into the hands of the perpetrators
    4. Description of the location where the abuse took place
    5. Description of the form of abuse
    6. Possible witnesses
    7. All of the above

The Istanbul Protocol can best be described as: The duties of states to ensure the effective investigation and documentation of torture and ill treatment Guidelines for the effective investigation and documentation of torture and ill treatment International Legal obligations of … Continue reading →

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The treatment of prisoners and detainees

The rules of medical ethics and medical professional codes do not allow for discrimination in the provision of health care to prisoners and detainees. Individuals under arrest or any form of detention must have access to a standard of health care and services, and compassionate care, which are equivalent to that of the surrounding general population. This applies to health professionals who work directly in prisons or other detention centres, and equally to health professionals working in the national health services to whom prisoners may be referred. One consequence of neglect of detainee is that they learn to mistrust doctors, leading to them to avoid seeking medical help after imprisonment.[1] There may be other reasons for prisoners not to trust the prison doctor. Doctors working in prisons are often underpaid, ill-considered by their superiors, and receive no training on prison health issues. As a result they are not very motivated in performing their jobs, which leads the prisoners to mistrust their services. Prison doctors in situations where torture is a reality will also be, rightly or wrongly, seen as accomplices of “the system” and also be mistrusted.

Hunger strikes are a particularly difficult situation for doctors to deal with. Most fasting prisoners do so for two or three weeks, and those on strikes rarely suffer any harm. As they go on longer, the risks to the hunger striker increase. In an ideal situation, an independent doctor will have explained the risks of prolonged hunger strike, and taken instructions on what the person wants to happen if he or she ceases to be capable of rational thought. This should happen in an environment where the patient’s confidentiality can be respected, and where he or she can be protected from undue pressure from political colleagues. In cases where prison doctors have been following hunger strikers before and during the fast, and know what the patients’ positions and convictions are, physicians should respect the principles stated in the Declaration of Malta on hunger strikes. This declaration allows physicians to act in the best perceived interests of their patients, while respecting autonomy. If a physician is called upon to take care of a hunger striker already in a comatose state, he or she will have no choice and will have to provide reanimation. A physician should not rely on what amounts to “hearsay” in such cases. The opinions of the immediate family should be taken into consideration, but are not paramount. Neither the opinions of the authorities nor those of the patient’s political colleagues should be given any weight.

[1] Smidt-Nielsen K. The participation of health personnel in torture. Torture, 1998; 8(3):91-94.

The rules of medical ethics and medical professional codes do not allow for discrimination in the provision of health care to prisoners and detainees. Individuals under arrest or any form of detention must have access to a standard of health … Continue reading →

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The International Committee of the Red Cross (ICRC)

The ICRC is an independent and impartial humanitarian body with a specific mandate assigned to it under international humanitarian law, particularly the four Geneva Conventions. It actively provides many forms of protection and assistance to victims of armed conflict, as well as situations of internal strife. In cases of international armed conflict between states party to the Geneva Conventions, the ICRC is authorised to visit all places of internment, imprisonment and labour where prisoners of war or civilian internees are held. In cases of non-international armed conflicts, or situations of internal strife and tensions, it may offer its services to the conflicting parties and, with their consent, be granted access to places of detention. Delegates visit detainees with the aim of assessing and, if necessary, improving the material and psychological conditions of detention and preventing torture and ill-treatment. The visit procedures require access to all detainees and places of detention, that no limit be placed on the duration and frequency of visits, and that the delegates be able to talk freely and without witness to any detainee. Individual follow-up of the detainees’ whereabouts is also part of ICRC standard visiting procedures. Visits and the reports made on them are confidential – although the ICRC may publish its own comments if a state publicly comments on a report or visit.

The ICRC is an independent and impartial humanitarian body with a specific mandate assigned to it under international humanitarian law, particularly the four Geneva Conventions. It actively provides many forms of protection and assistance to victims of armed conflict, as … Continue reading →

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Comparing records

Different members of the team might have notes or memories that emphasise different aspects of the individual’s account. This is particularly true when the team comprises members with different professional backgrounds. Interviews should be reviewed and notes compared before one member is delegated to write up the relevant interview. All notes should be retained. It is important to note that a team approach may be more appropriate for documentation in a therapeutic context than a medico-legal context. In the case of medico-legal documentation, it is advisable to discuss with the client’s attorney potential benefits and liabilities before proceding with a team approach.

As the team comes together, it may be able to identify patterns of a general nature, especially if several teams are working together, and not every team member is aware of the information gathered by the others. Evidence that appeared incomprehensible or implausible might be clarified by the understanding of evidence gathered by other team members or teams. They can then discuss how to take the work forward, for example by de-identifying data and analysing them in groups.

Different members of the team might have notes or memories that emphasise different aspects of the individual’s account. This is particularly true when the team comprises members with different professional backgrounds. Interviews should be reviewed and notes compared before one … Continue reading →

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Review of Symptoms

After eliciting a detailed narrative of the alleged torture and ill-treatment, it is important to document subsequent symptoms and disabilities that may be related to the alleged abuse. The clinician should obtain a detailed review of physical and psychological symptoms and disabilities at the time of the abuse and subsequently, up to the present time. All complaints of the alleged torture victim are of significance; although there may or may not be a correlation with the physical findings, they should be reported. Acute and chronic symptoms and disabilities associated with specific forms of abuse and the subsequent healing processes should be documented. Specific information acute and chronic symptoms and disabilities are included in Module 5 (Physical Evidence of Torture) and Module 6 (Psychological Evidence of Torture).

After eliciting a detailed narrative of the alleged torture and ill-treatment, it is important to document subsequent symptoms and disabilities that may be related to the alleged abuse. The clinician should obtain a detailed review of physical and psychological symptoms … Continue reading →

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Electrical injuries

Electric shocks have been used commonly by torturers for many years because they cause exquisite pain but rarely leave identifiable physical signs. The equipment can be as basic as the magneto of an old military field telephone or a couple of bare wires in an electrical socket to complex stun guns.

Magnetos (generators) are generally hand-cranked devices that provide a direct current (DC) related to the speed at which a rotor is turned – giving an opportunity to threaten the victim further. Main electrical currents can be delivered through bare wires touched against the skin, which might have been previously covered in water. Clips are sometimes used, and these can cause small lacerations when they pull off as the victim jolts with the force of the current. Some torturers have used fixed systems using switches or levers which again can be used to increase the threat of the torture.

Battery operated devices are portable but can still deliver a high voltage which may be alternating current (AC) or DC. Electric shock batons are being superseded by a range of devices including stun shields, remote control stun belts, and tasers, many of which were originally designed for law-enforcement purposes.

Electrical torture uses the property of the electrical current to cause pain: in the body the current travels along nerves and blood vessels as they are the paths of lower resistance. As the current travels, it causes contractions to the muscles involved and severe pain. These contractions can cause dislocation of joints and, if the chest muscles are involved, difficulties in breathing. If the current passes through the heart, arrhythmias (irregular heartbeat) can develop, leading to sudden death. Torturers apply electricity to the most vulnerable and intimate parts of the body. Genitals and breasts are often targeted and the victim is threatened on his or her reproductive capacity. When the current involves the muscles controlling urination and defecation those can occur without the victim being able to exercise control. The mouth also is very sensitive and often targeted.

Areas of reddening may persist for weeks. Occasionally the electrodes can leave small burns, probably from sparking. Both tend to be circular and less than 0.5 cm in diameter. These lesions may create hyperpigmentation. However, as these lesions are small, they may be difficult to find. Although non-specific, they can corroborate allegations of electric shock torture, especially if they are in certain parts of the body. Studies have shown distinctive changes to cells beneath the site of the shock on microscopy, but such investigations should only be performed if they are essential to the legal case.

Electric shocks have been used commonly by torturers for many years because they cause exquisite pain but rarely leave identifiable physical signs. The equipment can be as basic as the magneto of an old military field telephone or a couple … Continue reading →

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The right to challenge the lawfulness of detention

Article 9 (3) of the ICCPR states that: ‘Anyone arrested or detained on a criminal charge shall be brought promptly before a judge or other officer authorized by law to exercise judicial power and shall be entitled to trial within a reasonable time or to release.’ The Human Rights Committee has stated that the right to challenge the legality of detention applies to all persons deprived of their liberty and not just to those suspected of committing a criminal offence.

Article 9 (3) of the ICCPR states that: ‘Anyone arrested or detained on a criminal charge shall be brought promptly before a judge or other officer authorized by law to exercise judicial power and shall be entitled to trial within … Continue reading →

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Diagnostic Tests

In some cases, the use of diagnostic tests may aid in corroborating allegations of torture. Before obtaining such tests, however, clinicians should carefully consider the potential value of such tests and their inherent limitations in light of the level of “proof” needed in a particular case, the potential adverse consequences for the individual, and any resource limitations. Generally, diagnostic tests are not warranted unless they are likely to make a significant difference to a medico-legal case.

Radiologic Imaging

In the acute phase of injury, various imaging modalities may be quite useful in providing additional documentation of both skeletal and soft tissue injuries. Once the physical injuries of torture have healed, however, the residual sequelae generally are no longer detectable by these same imaging methods. This is often true even when the survivor continues to suffer significant pain or disability from his/her injuries.

References have already been made to various radiologic studies in the discussions of the examination of the patient and in the context of various forms of torture. What follows is a summary of the application of these methods, recognizing that the more sophisticated (and expensive) technology is not universally available.

Radiologic and imaging diagnostic examinations include routine radiographs (x-rays), radioisotopic scintigraphy, computerized tomography (CT), nuclear magnetic resonance imaging (MRI), and ultrasonography (USG). Each has its advantages and disadvantages. X-rays, scintigraphy, and CT scanning use ionizing radiation, which may be a concern for pregnant women and children. MRI uses a magnetic field; potential biologic effects on fetuses and children are theoretical, but thought to be minimal. Ultrasound uses sound waves; no biologic risk is known.

X-Rays

X-rays are readily available. They can be very useful when searching for fractures, fissures, deformity and foreign bodies in osseous structures. Excluding the skull, all injured areas should have routine radiographs as the initial examination. While routine radiographs will demonstrate facial fractures, CT is a superior examination as it demonstrates more fractures, fragment displacement and associated soft tissue injury and complications. When periosteal damage or minimal fractures are suspected, bone scintigraphy should be used in addition to x-rays.

The type of fracture can reveal important information on the force and its form of application. In this respect, soft tissue changes adjacent to the fracture or deformity as well as foreign bodies in the vicinity can also contribute information. The awareness of the forms of torture used can specify the cause of a lesion otherwise considered to be non-specific. Extension deformities can be followed up with these approaches during chronic stages.

A percentage of x-rays will be negative even when there is an acute fracture or early osteomyelitis. It is possible for a fracture to heal leaving no radiographic evidence of previous injury; this is especially true in children. Routine radiographs are not the ideal examination for evaluation of soft tissues.

Scintigraphy

Scintigraphy is an examination of high sensitivity but low specificity. Scintigraphy is an economic and effective examination to screen the entire skeleton for disease processes such as osteomyelitis or trauma. Testicular torsion can also be evaluated, but ultrasound is better suited to this task. Scintigraphy is not the appropriate examination to identify soft tissue trauma.

Scintigraphy can detect an acute fracture within twenty-four hours, but generally it takes two to three days and may occasionally take a week or more, particularly in the elderly. Generally the scan returns to normal after two years. However, it may remain positive in both fractures and cured osteomyelitis for years. The use of bone scintigraphy to detect fractures at the epiphysis or metadiaphysis (ends of long bones) in children is very difficult because of the normal uptake of the radiopharmaceutical at the epiphysis. Scintigraphy is often able to detect rib fractures that are not apparent on routine x-ray films.

Scintigraphy is more sensitive in the demonstration of bone tissue lesions than classical radiological techniques. It allows observation of the effects years later. It is more cost effective than MRI which can verify lesions in early stages. Fundamental events in revealing the pathology are osteoblastic activity and increased blood flow in tissues. In trauma not leading to fractures, bone metabolism and thus turnover is increased, and as trauma continues microfractures develop. The contribution of scintigraphy significantly increases in areas such as ribs, spinous processes and the scaphoid bone which are hard to evaluate by direct X-rays. Thus scintigraphy yields better results in trauma directed to thorax. Lesions such as epiphyseal separation or metaphyseal edge fractures which are easily missed can well be differentiated by the shape of epiphyseal plate and its visualisation. Scintigraphy also provides advantages as a screening procedure in multiple traumatic injuries.

Another contribution of scintigraphy is that activity of radioactive material changes in time. In acute stages, positive results are obtained in 80% of the lesions within the first 24 hours and 95% in 72 hours. Increased activity may be observed 1-2 years after the alleged injuries and may sometimes persist for 10-15 years.

Application of Bone Scintigraphy to the Diagnosis of Falanga

Bone scans may be performed either with delayed images at about three hours or as a three-phase examination. The three phases are: 1) radionucleide angiogram (arterial phase); 2) blood pool images (venous phase, which is soft tissue); and 3) delayed phase (bone phase). Patients examined soon after falanga should have two bone scans performed at one-week intervals. A negative first delayed scan and positive second scan indicates exposure to falanga within days before the first scan. In acute cases, two negative bone scans at an interval of one week do not necessarily mean that falanga did not occur, but that the severity of the falanga applied was under the sensitivity level of the scintigraphy. Initially, if three-phase scanning is done, increased uptake in the radionucleide angiogram phase and in blood pool images and no increased uptake in the bone phase indicate hyperemia compatible with soft tissue injury. Trauma in the foot bones and soft tissue can also be detected with MRI.

Ultrasound

Ultrasound is inexpensive and without biologic hazard. The quality of the examination depends on the skill of the operator. In parts of the world where CT is not available, USG is used to evaluate acute abdominal trauma. Tendonopathy can also be evaluated by USG, and it is a method of choice for testicular abnormalities.

Shoulder USG is carried out in acute and chronic periods following suspension torture. In the acute period, edema, fluid collection on and around the shoulder joint, lacerations and hematomas of the rotator cuffs can be observed by USG. The reapplication of USG and subsequent observation that findings from the acute period disappear in time strengthens the diagnosis. In such cases, EMG, scintigraphy and other radiological examinations should be carried out together and their correlation examined. Even lacking positive results from other examinations, USG findings alone are adequate to prove suspension torture.

Although ultrasound is primarily used for evaluation of muscles and joints, especially the shoulder joint, its contributions can be much wider depending on the skill of the applicator administering it. Insufficient documentation increases the possibility of mis-diagnosis as results may appear conclusive. However, results by less experienced operators can well serve as a document for more experienced specialists who evaluate the event later.

Contribution of conventional ultrasound varies according to its capacity for morphological evaluation. At present, high channel probes with multifrequencies between 8 and 15 MHz can be more sensitive than CT and MRI in showing changes in cutaneous, subcutaneous, osseous and soft tissues as well as in muscles and joints. Ultrasound sensitivity to pathology related to shoulder, knee and ankle joints and related lesions of joints, tendons and adjacent soft tissues is usually is higher than MRI. It is possible to demonstrate correctly muscle contusion and haematomas, subcutaneous contusion and haemorrhages, loss of uniformity of subcutaneous fat tissue, soft tissue micro and macro-calcifications and foreign bodies with ultrasound. Traumatic changes and contusions of soft tissue in genitals, breast and perineum can be identified in detail with high resolution probes.

A second contribution is information on the perfusion of tissues identified by Doppler studies. Focal deficits of tissue perfusion and areas of reactive hyperaemia can be identified in injuries especially caused by cold (cold water, cold air). Findings of testicular torsion or of early detorsion can also be successfully demonstrated. It is also possible to demonstrate fracture, fissure, small osseous cortical discontinuities, neovascularisation due to wound healing, or reactive periosteal callus formation in osteochondral injuries earlier and more precisely in comparison to direct X-rays or CT and MRI. However, in cases when there are no cortical injuries, verification of medullary and trabecular osseous changes is possible neither by classic nor by Doppler sonographic studies.

CT scans

CT is excellent for imaging both soft tissue and bone. MRI is better for soft tissue than bone. However, MRI may detect an occult fracture before it can be imaged by either routine radiographs or scintigraphy. Use of open scanners and/or sedation may alleviate anxiety and claustrophobia that are especially prevalent among torture survivors.

CT is also excellent for diagnosing and evaluating fractures, especially temporal bone and facial bones. Other advantages include determining alignment and displacement of fragments, especially spinal, pelvic, shoulder and acetabular fractures. CT cannot identify bone bruising.

CT with and without intravenous infusion of a contrast agent should be the initial examination for acute, subacute and chronic central nervous system (CNS) lesions. If the CT examination is negative, equivocal or does not explain the survivor’s CNS complaints or symptoms, proceed to an MRI.

CT with bone windows and a pre- and post-contrast examination should be the initial examination for temporal bone fractures. Bone windows may demonstrate fractures and ossicular disruption. The pre-contrast examination may demonstrate fluid and cholesteatoma. Contrast is recommended because of the common vascular anomalies that occur in this area. For rhinorrhea, injection of contrast into the spinal canal should follow a temporal bone. MRI may also demonstrate the tear responsible for the leakage of fluid.

When rhinorrhea is suspected, a CT of the face with soft tissue and bone windows should be performed. Then, a CT should be obtained after contrast is injected into the spinal canal.

MRI

MRI is more sensitive than CT in detecting central nervous system (CNS) abnormalities. The time course of CNS hemorrhage is divided into immediate, hyperacute, acute, subacute and chronic phases. The time course of CNS hemorrhage has ranges that correlate with imaging characteristics of the hemorrhage. Thus, the imaging findings may allow estimation of the timing of head injury and correlation to alleged incidents. CNS hemorrhage may completely resolve or produce sufficient hemosiderin deposits that the CT scan will be positive even years later. Hemorrhage in soft tissue, especially in muscle, usually completely resolves leaving no trace, but rarely can ossify. This is called heterotrophic bone formation or myositis ossificans and is detectable on CT scan.

Recently there have been significant advances in demonstration of acute and chronic lesions using MRI. MRI with Turbo STIR sequences, directed to the whole body can demonstrate general body trauma and identify lesions and areas needing detailed evaluation. Unidentified lesions and those not causing any clinical complaints can also be visualized. Early stage cortical and medullary oedema and trabecular destructions can be much more readily demonstrated than CT. Minimal changes identified as bone bruise in pre-oedema stages can also be identified in osseous tissues. New special sequences which can verify these changes within hours are being developed and administered. Small millimetric cortical destructions, minimal oedematous changes of soft tissue, especially in series with fat suppression, and muscle contusion or strain injuries can also be identified.

Biopsy of Electric Shock Injury

Electric shock injuries may, but do not necessarily, exhibit microscopic changes that are highly diagnostic and specific for electric current trauma. The absence of these specific changes in a biopsy specimen does not mitigate against a diagnosis of electric shock torture, and judicial authorities must not be permitted to make such an assumption. Unfortunately, if a court requests that a petitioner alleging electric shock torture submit to a biopsy for confirmation of the allegations, refusal to consent to the procedure or a “negative” result is bound to have a prejudicial impact upon the court. Furthermore, clinical experience with biopsy diagnosis of torture-related electrical injury is limited, and the diagnosis can usually be made with confidence from the history and physical examination alone.

This procedure is therefore one that should currently be done in a clinical research setting, and not promoted as a diagnostic standard. In giving informed consent for biopsy, the individual must be informed of the uncertainty of the results and permitted to weigh the potential benefit against the impact upon an already traumatised psyche.

Rationale for biopsy

There has been extensive laboratory research measuring the effects of electric shocks on the skin of anaesthetized pigs. This work has shown that there are histologic findings specific for electrical injury that can be established by microscopic examination of punch biopsies of the lesions. However, further discussion of this research, which may have significant clinical application, is beyond the scope of this publication. The reader is referred to the above cited references for further information.

Few cases of electric shock torture of humans have been studied histologically. Only in one case, where lesions were excised probably 7 days after the injury, were alterations in the skin believed to be diagnostic of electrical injuries observed (deposition of calcium salts on dermal fibers in viable tissue located around necrotic tissue). Lesions excised a few days after alleged electrical torture in other cases have shown segmental changes and deposits of calcium salts on cellular structures highly consistent with influence of an electrical current, but not diagnostic since deposits of calcium salts on dermal fibers were not observed. A biopsy taken one month after alleged electrical torture showed a conical scar, 1-2 mm broad, with increased number of fibroblasts and tightly packed, thin collagen fibers, arranged parallel to the surface, consistent with, but not diagnostic of, electrical injury.

Method

After receiving informed consent from the patient, and before biopsy, the lesion must be photographed according to accepted forensic methods. Under local anesthesia, a 3-4 mm punch biopsy is obtained, and placed in buffered formalin or similar fixative. Skin biopsy should be performed as soon as possible after injury. Since electrical trauma is usually confined to the epidermis and superficial dermis, the lesions may quickly disappear. Biopsies can be taken from more than one lesion, but the potential distress to the patient must be considered.

Biopsy material should be examined by a pathologist experienced in dermatopathology.

Diagnostic findings for electrical injury

  1. Vesicular nuclei in epidermis, sweat glands and vessel walls (only one differential diagnosis: injuries via basic solutions)
  2. Deposits of calcium salts distinctly located on collagen and elastic fibers (the differential diagnosis, calcinosis cutis, is a rare disorder only found in 75 of 220,000 consecutive human skin biopsies, and the calcium deposits are usually massive without distinct location on collagen and elastic fibers.

Typical, but not diagnostic, findings for electrical injury

  1. Lesions appearing in conical segments, often 1-2 mm large
  2. Deposits of iron or copper on epidermis (from the electrode)
  3. Homogenous cytoplasm in epidermis, sweat glands and vessel walls
  4. Deposits of calcium salts on cellular structures in segmental lesions
  5. No abnormal histologic observations

In some cases, the use of diagnostic tests may aid in corroborating allegations of torture. Before obtaining such tests, however, clinicians should carefully consider the potential value of such tests and their inherent limitations in light of the level of … Continue reading →

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Module 6: Psychological Evidence of Torture and Ill-Treatment

Objectives

  • To appreciate the central role of psychological evaluation in medical evaluations of torture and ill-treatment
  • To understand how to conduct a psychological evaluation, document psychological findings, and formulate clinical impressions and conclusions regarding torture and ill-treatment
  • To review transference, counter-transference, re-traumatisation issues
  • Using the Psychological Evaluations # 1 and #2, students will be asked to develop interpretations of the psychological findings and conclusions and recommendations using Istanbul Protocol standards
  • To understand the value and limitations of diagnostic classifications (ICD-10 and DSM) in the evaluation of psychological evidence of torture and ill-treatment
  • To understand the value and limitations of psychometric instruments (questionnaires, scales, etc) during the psychological evaluation
  • To be familiar with psychological evaluations of torture and ill-treatment in children

Content

  • The central role of the psychological evaluation
  • Conducting the psychological evaluation
  • Psychological findings and diagnostic considerations
  • Components of the psychological/psychiatric evaluation
    • Identifying Data
    • History of Torture and Ill-treatment
    • Current Psychological Complaints
    • Post-torture History
    • Pre-torture History
    • Medical History
    • Past Psychiatric History
    • Neuro-psychological Assessment
    • Mental Status Examination
    • Assessment of Social Function
    • Psychological Testing and the Use of Checklists and Questionnaires
    • Clinical Impression
    • Recommendations
    • Treatment Considerations
  • Children and Torture
    • Developmental Considerations
    • Clinical Considerations
    • Role of the Family
  • International statistical classification of diseases and related health problems, Annex

Discussion Topics

  • Students should work in groups or individually on one or both of the Psychological Evaluations (#1 and #2, see Appendix I at the end of this Module). Each group should write up their interpretation of findings and conclusions and recommendations.
  • Additional Discussion Topics:
    • Discuss the reasons why some survivors of torture have difficulties recalling and recounting their experiences
    • Discuss possible reasons for inconsistencies in the evaluation and strategies to explain inconsistencies in medico-legal reports
    • Discuss how to assess the possibility of simulation of psychological symptoms
    • Discuss who can/should conduct the psychological evaluations in your country (consider: qualifications, authority, official vs. non-official, etc)
    • Discuss current, country-specific challenges in conducting psychological evaluations of torture and ill-treatment and their validity, or lack thereof, in medico-legal contexts

Teaching Formats

  • Group Activity:
    • Students should work in groups or individually on one or both of the Psychological Evaluations (#1 and #2, see Appendix I at the end of this Module). Each group should write up their interpretation of findings and conclusions and recommendations based on Istanbul Protocol standards.
    • A facilitator should be identified to moderate the discussion and rapporteur should be identified to record the group’s findings and report them when the class reconvenes.
    • After 20-30 minutes of group discussion, the entire class should reconvene
    • Rapporteurs should briefly report on their group’s findings
    • Open class discussion
  • Alternative Option:
    • Divide the class into several groups and assign each group with one or more (or all) of the Discussion Topics
    • Follow the usual sequence for conducting group activities as outlined above
  • Individual Research/Assignment:
    • Individual students should assigned to read one or both of the Psychological Evaluations and write up their interpretation of findings and conclusions and recommendations based on Istanbul Protocol
  • Journal Entry: (Instructor to assign; Write a few paragraphs — no more than a page)
    • Respond to one or more of the Discussion Topics
    • In your opinion, what are the most significant challenges in conducting a psychological evaluation of torture and ill treatment? Explain.

Primary Resources

  • The Istanbul Protocol, Chapter VI
  • Psychological Evaluation of Torture Allegations: An International Training Manual
  • The Medical Documentation of Torture
  • Medical Investigation and Documentation of Torture: A Handbook for Health Professionals
  • Trainers’ Guidelines for Health Professionals: Training of Users

Objectives To appreciate the central role of psychological evaluation in medical evaluations of torture and ill-treatment To understand how to conduct a psychological evaluation, document psychological findings, and formulate clinical impressions and conclusions regarding torture and ill-treatment To review transference, … Continue reading →

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