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Module 5 Answers

  1. Answer: B

    Although acute lesions may be characteristic of the alleged injuries, most lesions heal within about six weeks of torture, leaving no scars or, at the most, non-specific scars.

  2. Answer: C

    A complete physical examination is recommended unless the allegations of torture are limited and there is no history of loss of consciousness or neurological or psychological symptoms that may affect recall of torture allegations. Under such circumstances, a directed examination may be appropriate in which only pertinent positive and negative evidence is pursued on examination.

  3. Answer: F

    All of the forms of historical information listed may be useful in correlating regional practices of torture with individual allegations of abuse.

  4. Answer: C

    Inquiries should be structured to elicit an open-ended, chronological account of events experienced during detention.

  5. Answer: E

    In addition to location, size, shape and color, each of the factors listed above should be included in clinical descriptions of skin lesions.

  6. Answer: B

    Lacerations are caused by a tangential force such as a blow or a fall and produce tears of the skin. The wound edges tend to be irregular, and often any may be bruised and/or abraded. Tissue bridges may be present. Incisions are caused by sharp objects like a knife, bayonet, or broken glass that produce a more or less deep, sharp and well-demarcated skin wound.

  7. Answer: C or D

    The photograph shows a large 4 cm x 6 cm contusion with underlying edema and/or hematoma formation. There are a series of parallel linear abrasions that correspond to the ridges of a police baton (see photo below). These physical findings should be considered “highly consistent” with or “virtually diagnostic” of the alleged injury since it is very unlikely they were caused by any other mode of injury or pathophysiological process. “Proof” of torture implies 100% certainty and should be avoided unless it can be supported by the evidence. In this case the injury may have been inflicted in the context of “resisting arrest.”
    [Courtesy of Amnesty International, The Netherlands.]

  8. Answer: A, B, D

    Contusions cause blood to leak from small vessels. If the skin and subcutaneous tissues are thin, the bruise becomes apparent relatively quickly and may take the shape of the weapon used. The extent and severity of a contusion are related to the amount of force applied, but more importantly vascular structures affected. Elderly people and children who have loosely supported vascular structure will bruise more easily than young adults. Many medical conditions are associated with easy bruising. As the extravasated red cells are destroyed, the aging bruise goes through variable colour changes. Speculative judgments should be avoided in the evaluation of the nature and age of blunt traumatic lesions.

  9. Answer: B, C, D

    Full thickness wounds heal in one of two ways. When the wound is small and the edges are opposed, it heals from the top down (by primary intention). This tends to leave a small, tidy scar. If this process cannot occur, especially if the wound gapes, it heals from below (by secondary intention). This is a slow process and prone to infection, and will leave a wide scar. Scars related to self-inflicted injuries are generally superficial and within easy reach of the dominant hand. Contusions and abrasions may cause hyperpigmented scars, especially in darker skins, due to post-inflammatory hyperpigmentation. Also scars of distinctive shape and if in multiples suggest intentional injuries rather than those caused accidentally.

  10. Answer: B

    The photograph shows an oval scar above the left hip that is approximately 7 cm x 4 cm. It is a macular lesion with a depigmented, atrophic center, lacking normal skin accessories (hair). The periphery shows a hyperpigmented zone about 1 cm. wide. This scar is most consistent with a 2nd degree burn from a heated instrument.

  11. Answer: A

    This scar is the result of an abrasion injury as the individual was dragged across a rough surface.

  12. Answer: C

    This man sustained blunt trauma to the right supraorbital region which resulted in a typical laceration scar. The appearance of the scar is the result of the healing of irregular wound edges and tissue bridges.

  13. Answer: B

    The photograph shows 2 linear incisions resulting from slashes with a knife. The biconvex appearance of the scars suggest that they healed by secondary intention. These scars are most consistent with incisions because of the sharp, well-demarcated appearance of the scars.

  14. Answer: C

    The multiple linear, scars are most consistent with lacerations from whipping with an electrical wire.

  15. Answer: D

    The photograph shows evidence of multiple cigarette burns 7 days following the injury.

  16. Answer: A, B, C

    Whenever possible, the examination of women alleging rape should be performed by an expert in documenting sexual assault. Otherwise, the examining physician should speak to an expert or consult a standard text on clinical forensic medicine. A thorough physical examination should be performed, including meticulous documentation of all physical findings. It is rare to find any physical evidence when examining female genitalia more than one week after an assault. Even during examination of the female genitalia immediately after rape, there is identifiable damage in less than 50 per cent of the cases. It is unwise to draw conclusions about a refusal to consent to genital examination. If the alleged victim refuses consent, the doctor should record any relevant observations on the alleged victim’s demeanour, such as embarrassment or fear, or cultural considerations.

  17. Answer: F

    All of the statements listed are true.

  18. Answer: A

    Rectal tears with or without bleeding may be noted. Disruption of the rugal pattern may manifest as smooth fan-shaped scarring. When these scars are seen out of midline (i.e. not at 12 or 6 o’clock), they can be an indication of penetrating trauma.

  19. Answer: A

    Poor quality photographs are better than none, but they should be followed up with professional photographs as soon as possible.

  20. Answer: E

    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.