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Istanbul Protocol Model Medical Curriculum

Educational Resources for Health Professional Students

Objectivity

Conducting an objective and impartial evaluation should not preclude the evaluator from being empathic. It is essential for clinicians to maintain the professional boundaries and at the same time to acknowledge the pain and distress that they observe. The clinician should communicate their understanding of the individual’s pain and suffering and adopt a supportive, non-judgmental approach. Clinicians need to be sensitive and empathic in their questioning while remaining objective in their clinical assessment.

Conducting an objective and impartial evaluation should not preclude the evaluator from being empathic. It is essential for clinicians to maintain the professional boundaries and at the same time to acknowledge the pain and distress that they observe. The clinician … Continue reading →

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Torture in the World Today

Amnesty International documented cases of torture and other cruel, inhuman or degrading treatment in 81 countries in 2007.[1] Some studies indicate that between 5 and 35% of the world’s refugees have been estimated to have experienced torture.[2] In 2007, there were 15.9 million refugees around the world and an estimated 26 million people displaced internally by conflict.[3] This suggests that the number of torture survivors in the world today may range from 2 to 15 million. These estimates do not include those affected by war or other human rights violations.

Among foreign-born patients presenting to an urban primary care center in the United States, approximately 1 in 9 met the definition established by the UN Convention Against Torture. As survivors of torture, these patients may have significant psychological and physical sequelae. This statistic underscores the necessity for primary care physicians to screen for a torture history among foreign-born patients and to effectively address their problems.[4]

[1] Amnesty International Annual Report 2008: The State of the World’s Human Rights. Available at: http://thereport.amnesty.org/eng/facts-and-figures [1]

[2] Baker R: Psychosocial consequences for tortured refugees seeking asylum and refugee status in Europe, chap 5, In Basoglu M (Ed): Torture and Its Consequences: Current Treatment Approaches. New York, NY, Cambridge University Press, 1992.

[3] Refugees International. Helpful Facts and Figures. Available at: http://www.refugeesinternational.org/get-involved/helpful-facts-%2526-figures [2]

[4] Crosby SS, Marie Norredam M, Paasche-Orlow MK, Piwowarczyk L, Heeren T, and Michael A Grodin MA. Prevalence of Torture Survivors Among Foreign-Born Patients Presenting to an Urban Ambulatory Care Practic. J Gen Intern Med. 2006 July; 21(7): 764–768.

Quelle

  • [1] http://thereport.amnesty.org/eng/facts-and-figures
  • [2] http://www.refugeesinternational.org/get-involved/helpful-facts-%2526-figures

Amnesty International documented cases of torture and other cruel, inhuman or degrading treatment in 81 countries in 2007.[1] Some studies indicate that between 5 and 35% of the world’s refugees have been estimated to have experienced torture.[2] In 2007, there … Continue reading →

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Issues surrounding examinations of individuals in the presence of security forces

Health professionals, whether working in places of detention, called to visit a police station or other place of detention, or working in national health services, may well be presented with detainees to examine in the presence of security forces. The reasons for such examination may include a statutory initial medical examination upon arrival in a place of detention, complaint of illness or ill-treatment by a detainee, or routine referral for medical treatment. When faced with a detainee, the health professional must apply their usual ethical principles in any assessment and treatment. The detainee must give informed consent to any examination, procedure or treatment, and this should include an explanation of who will have access to any findings, and how these findings may be used. Informed consent requires that the consenting individual:

  • Is mentally competent
  • Receives full disclosure of information, i.e. risks vs. benefits
  • Understands the information provided
  • Gives his/her consent voluntarily
  • Provides authorisation for his/her consent

Two further points of particular importance in the examination of detainees must be highlighted: the maintenance of medical confidentiality and the use of restraints (such as handcuffs) on detainees. Medical ethics dictates that consultations and the information gained therein should be confidential between the doctor and the patient. In the case of prisoners, the security forces (police, military or prison guards) will often maintain that they must remain present during any consultation, the most common reason being that it is for the protection of the health professionals. In some circumstances, the security personnel might insist that the detainee remain in restraints (handcuffs, ankle-cuffs) and even with a hood or blindfold during the consultation. Thus there is an immediate conflict between security and medical concerns.

As stated above, health professionals have a duty to observe their usual ethical practise in their treatment of detainees. In brief, there can be no blanket rule that dictates that all detainees are dangerous and merit, in all circumstances, the presence of security personnel and/or restraints. If escape is an issue, health professionals can conduct consultations with the security personnel outside the door, or as a less acceptable alternative, with the door open and the personnel out of range of hearing. Further, security concerns can be addressed by conducting the consultation in a room that has only one entrance, and either no windows or barred windows.

The routine use of restraints during medical consultation or treatment is also contrary to medical ethics and international standards on treatment of prisoners. Health professionals must not accept such practises. Restraints not only interfere with the proper diagnosis, management and treatment of patients, but they also run contrary to the inherent dignity of all human beings. The only possible acceptable justification for use of restraints is as a last resort when there is substantiated reason to believe that this particular detainee presents an immediate and current violent threat to himself or others. Health professionals can and should question the use of restraints if they have reason to doubt such a risk exists. In the exceptional circumstances that restraints are used, they should be as minimal as possible.

The use of hoods or blindfolds during any contact between a detainee and health professionals is absolutely unacceptable under any circumstances. The use of hoods or blindfolds has in itself been found to be a form of ill-treatment. In the health setting hoods or blindfolds not only impair any meaningful contact with the patient, they also prevent the identification of any health professionals and may thus add to a perception of impunity in any cases of ill-treatment.

Health professionals, whether working in places of detention, called to visit a police station or other place of detention, or working in national health services, may well be presented with detainees to examine in the presence of security forces. The … Continue reading →

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Psychosocial History (post-arrest)

It is also important to obtain information concerning the individual’s post-detention/torture psychosocial history, including any difficulties the individual may have experienced such as continued harassment/persecution by authorities, fear for his/her own safety as well as the safety of family/friends following release from detention, inability to return to work or school. Obtain summary information concerning the events of the individual fleeing his/her country of origin and arrival in subsequent locations.

It is also important to obtain information concerning the individual’s post-detention/torture psychosocial history, including any difficulties the individual may have experienced such as continued harassment/persecution by authorities, fear for his/her own safety as well as the safety of family/friends following … Continue reading →

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Asphyxiation

The most common way of inducing asphyxia to near-death is submarino as it is nicknamed in Latin American countries. The head is immersed in water for minutes at a time to the point of drowning, then brought out and immersed again. In some countries the victim is suspended by the ankles and lowered repeatedly into a tank. A variant of submarino is for a plastic bag or similar impervious material filled with liquid to be tied over the head. In all these techniques the water is often contaminated with sewage or chemicals, adding to the immediate distress and increasing the likelihood of permanent ill-effects.

“Waterboarding” is another form of asphyxiation torture that dates back to the Middle Ages and recently practised by the United States. Victims are strapped to a board or made to lie in a supine position with their heads lower than the rest of their bodies, their faces covered with cloth, and water is poured over their mouths to create the sensation of drowning.

Dry submarino is practised with a plastic bag or similar impervious material placed over the head and tied tightly around the neck. Again, there is often contaminated material or an irritant such as chilli powder inside the bag. In Sri Lanka a small amount of petrol is often put in the bag so that there is chemical poisoning as well as asphyxiation.

The immediate effects of these techniques vary according to whether there has been any contamination. If so, there is likely to be severe upper respiratory and perhaps broncho-pulmonary inflammation. Conjunctivitis or otitis media may follow, particularly after submarino. Irritants such as petrol or chilli may cause a dermatitis which is indistinguishable from acne. Any long-term effects of these techniques are not easy to assess but many victims attribute their asthma or bronchitis to having been asphyxiated many years previously. If there was no history of pre-existing disability, it may be reasonable to consider this as a possibility.

The most common way of inducing asphyxia to near-death is submarino as it is nicknamed in Latin American countries. The head is immersed in water for minutes at a time to the point of drowning, then brought out and immersed … Continue reading →

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Module 7: Case Example #01

Objectives

  • To conduct a complete medical evaluation of an alleged torture victim using Istanbul Protocol standards, including assessments of physical and psychological evidence of torture
  • To develop essential interview skills including: effective communication, earning trust, balancing empathy and objectivity, applying appropriated questioning techniques, obtaining informed consent, ensuring procedural safeguards, providing an appropriate and comfortable setting, respecting gender considerations, taking steps to avoid re-traumatisation
  • To understand the relevant transference and counter-transference issues that may arise in the course of conducting medical evaluations of alleged torture victims
  • To identify possible reasons for difficulties recalling and recounting the story and/or inconsistencies in the story of the alleged victim
  • To provide a well-reasoned interpretation of findings and conclusions regarding torture and ill-treatment.
  • To appreciate the possible difficulties that may arise during an interview with an alleged torture victim
  • To identify and address individual interviewing strengths and weaknesses in conducting an interview

Content

  • See Introduction and Preliminary Considerations and Materials below
  • Review of Case Summary #01 by students
  • Interview of individual role-player (alleged torture victim) by students or instructors (NOTE: role-players use Case Narrative #01 to act their parts)
  • Instructor supervision/demonstration of interview(s) using Guidelines for Instructors
    Case #01 (see Guidelines for Instructors file)
  • Debriefing between interviewers and role-players
  • Class discussion
  • Assignment: Ask students (individuals or groups) to write up a medical report of
    evaluation findings to be used in Module #9

Discussion Topics

  • Interviewing skills: How did the interviewers feel they performed? What observations/comments can the instructor and/other students share?
  • Interview content: Was the interview complete? Was there any relevant components left out?
  • Role-players should share their reactions to the interview, followed by the interviewers
  • Discuss strategies to effectively address transference and counter-transference issues that arise in the course of interviewing survivors of torture
  • Discuss your most significant concerns in conducting a psychological evaluation. Discuss how you can address them

Teaching Formats

  • Group Activity:
    • See Introduction and Preliminary Considerations and Materials below
    • See Discussion Topics above
  • Individual Research/Assignment:
    • Discuss your most significant concerns in conducting a psychological evaluation. Discuss how you can address them.
  • Journal Entry: (Instructor to assign; Write a few paragraphs — no more than a page)
    • Consider how transference and counter-transference reactions may affect routine medical encounters between patients and clinicians
    • What are your most significant concerns in conducting a psychological evaluation? Discuss how you can address them

Primary Resources

  • The Istanbul Protocol
  • Case Examples #01 (Case Summary, Narrative and Guidelines for Instructors)

Objectives To conduct a complete medical evaluation of an alleged torture victim using Istanbul Protocol standards, including assessments of physical and psychological evidence of torture To develop essential interview skills including: effective communication, earning trust, balancing empathy and objectivity, applying … Continue reading →

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Safeguards for special categories of detainees

All detained people have the right to equal treatment without discrimination on the grounds of race, colour, sex, sexual orientation, language, religion, political or other opinion, national or social origin, property, birth or other status. Particular allowances should, however, be made for the rights and needs of special categories of detainees including women, juveniles, elderly people, foreigners, ethnic minorities, people with different sexual orientation, people who are sick, people with mental health problems or learning disabilities, and other groups or individuals who may be particularly vulnerable during detention. Some groups may be targeted for discriminatory abuse by the staff of the institution where they are detained. They may also be vulnerable to abuse from other detainees.

Women in detention

The Human Rights Committee has expressed concern at the practise of allowing male prison officers access to women’s detention centres, which has led to serious allegations of sexual abuse of women and the invasion of their privacy.[1] It has also stated that female staff should be present during the interrogation of female detainees and prisoners and should be solely responsible for conducting body searches.[2]

The Standard Minimum Rules for the Treatment of Prisoners state that women in custody should be supervised by female members of staff.[3] They should also either be held in separate institutions, or segregated within an institution, under the authority of female staff. No male staff should enter the part of the institution set apart for women unaccompanied by a female member of staff.[4] In institutions where women are held in custody, facilities for pre-natal and post-natal care and treatment must be provided.[5] Whenever possible, arrangements should be made for children to be born in a hospital outside the institution.[6] The UN Special Rapporteur on Torture has recommended that states should provide gender-sensitive training for judicial and law enforcement officers and other public officials.[7]

Juvenile detainees

Some specific obligations with respect to the use of pre-trial detention in cases involving children are found in the Convention on the Rights of the Child. The Convention applies to children up to the age of 18, who would normally be regarded as juveniles within most criminal justice systems. Article 37 emphasises that the detention of children – pre-trial or any other form – should be a measure of last resort and used for the shortest appropriate period of time. It requires due account to be taken of the needs of children who are deprived of their liberty and that they should be kept separately from adults unless it is considered in their best interest not to do so. Article 39 obliges states, inter alia, to promote physical and psychological recovery and social reintegration of a child victim of torture or any other form of cruel, inhuman or degrading treatment or punishment as well as any form of neglect, exploitation, or abuse.

People with mental health problems

The Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care state that: ‘All persons with a mental illness, or who are being treated as such persons, shall be treated with humanity and respect for the inherent dignity of the human person.’[8] ‘All persons with a mental illness, or who are being treated as such persons, have the right to protection from economic, sexual and other forms of exploitation, physical or other abuse and degrading treatment.’[9]

The Standard Minimum Rules for the Treatment of Prisoners also state that people with mental health problems shall not be detained in prisons and ‘shall be observed and treated in specialized institutions under medical management.’[10]

[1] Observations of the Human Rights Committee: USA, UN Doc. CCPR/C/79/Add.50, 7 April 1995, para.20.

[2] Human Rights Committee, General Comment 16, (Twenty-third session, 1988), Compilation of General Comments and General Recommendations Adopted by Human Rights Treaty Bodies, U.N. Doc. HRI\GEN\1\Rev.1 at 21 (1994), para. 8.

[3] Standard Minimum Rules 8(a) and 53.

[4] Ibid.

[5] Rule 23.

[6] Ibid.

[7] Report of the UN Special Rapporteur on Torture, UN Doc. E/CN.4/1995/34, p. 8.

[8] Principle 2.

[9] Principle 3.

[10] Standard Minimum Rules para. 82.

All detained people have the right to equal treatment without discrimination on the grounds of race, colour, sex, sexual orientation, language, religion, political or other opinion, national or social origin, property, birth or other status. Particular allowances should, however, be … Continue reading →

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Country-Specific Legal Standards and Torture Practices

Torture practises vary, to some extent, in different regions of the world, as do national legal standards, and the extent of human rights monitoring and documentation of such practises. A systematic, country-specific review of legal standards and torture practises is beyond the scope of this Curriculum. The editors of the Model Curriculum advise instructors and students to research and include relevant country-specific materials for effective national adaptation of the modules contained in this curriculum.

The Prevention through Documentation Project has included 10 target countries (Georgia, Mexico, Morocco, Sri Lanka Uganda, Ecuador, Egypt, Kenya, the Philippines, and Serbia). Country assessment reports by the IRCT are availabe (see: http://www.irct.org/Target-countries-2709.aspx [6]) and may serve as a model for national adaptation efforts. A series of national adaptation resources have been developed to relate generic, international materials to local settings (see: http://www.irct.org/Purpose—principles-2715.aspx [7] or contact the IRCT for additional information).

The following additional resources may be helpful in researching relevant country conditions:

Human Rights Reports

Treatment Centers for Survivors of Torture

Quelle

  • [1] http://cpt.coe.int/en
  • [2] http://www1.umn.edu/humanrts/research
  • [3] http://www.state.gov/g/drl/rls/hrrpt
  • [4] http://www2.ohchr.org/english/issues/torture/rapporteur
  • [5] http://www.ohchr.org/EN/Pages/WelcomePage.aspx
  • [6] http://www.irct.org/Target-countries-2709.aspx
  • [7] http://www.irct.org/Purpose---principles-2715.aspx
  • [8] http://www.amnesty.org
  • [9] http://www.hrw.org
  • [10] http://www.un.org
  • [11] http://www.irct.org/Find-IRCT-members-33.aspx
  • [12] http://www.medecinsdumonde.org
  • [13] http://physiciansforhumanrights.org
  • [14] http://www.ifrc.org
  • [15] http://www.irct.org
  • [16] http://www.amnesty.org/en/health-and-human-rights/research/links

Torture practises vary, to some extent, in different regions of the world, as do national legal standards, and the extent of human rights monitoring and documentation of such practises. A systematic, country-specific review of legal standards and torture practises is … Continue reading →

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Safety and Security

Clinicians should carefully consider the context in which they are working, take necessary precautions and provide safeguards accordingly. If interviewing people who are still imprisoned or in similar situations in which reprisals are possible, all precautions should be taken to ensure that they do not place the detainee in danger (or in additional difficulty). Promises must not be made, for example, to provide security for the witness or for relatives who might be at risk, unless the interviewer is certain that they can be fulfilled. Witnesses might believe that international organisations or others investigating allegations of torture have more power to protect them than is the case. It is part of the informed consent process that individuals are aware of all the issues before they agree for a clinician to make a formal report. If the risk of harm from reprisals is a virtual certainty, conducting a medical evaluation may be considered unethical even if informed consent is obtained. This may be the case in the context of documenting human rights violations in places of ongoing conflict.

Whether or not certain questions can be asked safely will vary considerably and depends on the degree to which confidentiality and security can be ensured. When necessary, questions about forbidden activities should be avoided.

If the forensic medical examination supports allegations of torture, the detainee should not be returned to the place of detention, but rather should appear before the prosecutor or judge to determine the detainee’s legal disposition (see Procedural Safeguards below).

An interviewer will make notes of the interview, and may use other recording devices. The reasons for this should be explained to the interviewee who should be reassured as to how the notes and other records will be used and asked for consent. The way in which any records of such interviews are stored can be important in protecting the security of the interviewer and the interviewee. In many countries where torture is prevalent, the police have been known to raid clinics and search or confiscate medical records. In order to protect patients, therefore, in such conditions records should have no obvious identifying information on any document inside (such as initials or date of birth), and the files themselves being numbered with a register kept in a secure place elsewhere. Patients can be given cards with the identifying number so that treatment can be continued even if the register is not available. In some circumstances it may be necessary to hold records at a different location or even in a third country to ensure their security.

If information about an individual needs to be transmitted to another body, fax transmission is generally safer than e-mail as a copy of the latter may be stored on the sending computer or held on the server of the internet service provider. In some countries the authorities routinely screen all outgoing messages.

Clinicians should carefully consider the context in which they are working, take necessary precautions and provide safeguards accordingly. If interviewing people who are still imprisoned or in similar situations in which reprisals are possible, all precautions should be taken to … Continue reading →

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Abusive medical treatment

Health professionals should also be wary of any attempts (from officials) to ask them to administer treatment or medication that are not aimed at benefiting the physical or mental health of the patient, but only at assisting an interrogation or the management of a patient or detainee.

The individual need not be in prison, or in detention at all, to be tortured. Health professionals must be aware that they might be considered responsible for ill-treatment in settings where patients do not have freedom of movement, for example, those detained under mental health legislation or in facilities for the elderly. Inappropriate use of medical treatment, such as overuse of sedatives, may also be ill-treatment.

For information on the role of medical personnel in torture by the United States in its “War on Terror,” see: http://www.uctv.tv/search-details.asp?showID=15575 [1], a presentation by: Vincent Iacopino MD, PhD, Physicians for Human Rights, in the Global Health and Human Rights series, offered by the UCSF Mini Medical School for the Public, October 23, 2008.

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  • [1] http://www.uctv.tv/search-details.asp?showID=15575

Health professionals should also be wary of any attempts (from officials) to ask them to administer treatment or medication that are not aimed at benefiting the physical or mental health of the patient, but only at assisting an interrogation or … Continue reading →

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