Module 8 Answers

Police or other law enforcement officials should never be present in the examination room. This procedural safeguard may be precluded only when, in the opinion of the examining doctor, there is compelling evidence that the detainee poses a serious safety risk to health personnel. Under such circumstances, security personnel of the health facility, not the police or other law enforcement officials, should be available upon the medical examiner’s request. In such cases, security personnel should still remain out of earshot (i.e. be only within visual contact) of the patient. The presence of police officers, soldiers, prison officers or other law enforcement officials in the examination room, for whatever reason, should be noted in the physician’s official medical report. The presence of police officers, soldiers, prison officials or other law enforcement officials during the examination may be grounds for disregarding a negative medical report. The identity and titles of others who are present in the examination room during the medical evaluations should be indicated in the report.

Under no circumstances should a copy of the medical report be transferred to law enforcement officials or security personnel.

The routine use of restraints during medical consultation or treatment is 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.

It is important to obtain a complete medical history, including prior medical, surgical and/or psychiatric problems. Clinicians should document any history of injuries before the period of detention and any possible after-effects. Knowledge of prior injuries may help to differentiate physical findings related to torture from those that are not.

Mr. Adam’s psychosocial history contains information relevant to his psychological symptoms, or lack thereof, following the alleged torture and ill treatment. Mr. Adam’s political beliefs and activities have likely mitigated more severe psychological symptoms. His predominant reaction of anger is, in part, likely due to the killing of one of his brothers by security forces.

Mr. Adam’s history is significant for multiple lapses in consciousness. He was not blindfolded during the alleged torture, only during transport to the place where he was detained. Also, he does not demonstrate evidence of organic brain impairment or significant psychological sequelae.

Mr. Adam indicated that his multiple episodes of loss of consciousness were associated with asphyxia and electric shocks to his penis. Diagnostic imaging of the brain and EEG studies are not indicated in the absence of significant head trauma, seizure activity or a focal neurological deficit. Given minimal psychological symptoms and normal cognitive functioning, neuropsychological testing would not be indicated. A complete neurological examination would be adequate under the circumstances.

Sexual assault, including rape, is common among male detainees. Given the intense shame that is usually associated with sexual assault, additional information may not be spontaneously reported. It is important, therefore, to ask Mr. Adam something like: “Many men who are detained by police and security forces are assaulted sexually, including rape. Did anything like this happen to you?”

Mr. Adam’s difficulty having erections is most likely psychosomatic in origin since he indicated that he has noted normal erections upon waking from sleep.

Although Mr. Adam’s alleges being suspended from his hands tied behind his back, his acute symptoms of arm pain when lifting heavy objects and right arm numbness subsequently resolved. In the absence of any current complaint and/or numbness or weakness on physical examination, an EMG is not indicated.

Electric shock often does not result in acute lesions. When present, electric burns usually consist of a red brown circular lesion, 1 – 3 mm in diameter, usually without inflammation, and may result in a hyperpigmented scar. The absence of such changes should not be construed as an inconsistency.

Survivors of torture who ascribe positive meaning to their suffering (e.g. World War II veterans and political activists) often have fewer and less severe psychological symptoms. Fear of police reprisals would likely increase Mr. Adam’s psychological symptoms. Although support from family member also may mitigate psychological symptoms, Mr. Adam’s parents expressed strong disapproval of his political activity and consider his action to be “foolish and dangerous.” This has resulted in considerable discord between them. He and his father have not spoken to one another in the past several weeks. Nonetheless, his parents’ concern may represent a longstanding source of support.

Cigarette burns typically result in 5 to 10 mm, circular, macular scars with a depigmented centre and a hyperpigmented, relatively indistinct periphery. The lack of a depigmented centre in Mr. Adam’s case may be related to the relative degree of heat applied. The characteristics of the lesions and location on one arm only, are highly consistent with his allegations of cigarette burns.

Mr. Adam was examined months after he was released from detention. The possibility of self-inflicted injuries cannot be fully excluded.

Mr. Adam’s physical examination findings of hyperpigmented, circumferential scars above both wrists are highly consistent with his allegations of “rope burns” from suspension torture.

All of the explanations listed indicate why these physical findings are not likely to be the result of self-inflicted injuries.

Striae distensae (stretch marks) are most common on the abdomen (especially after pregnancy), the lower back, the upper thighs, and around the axillae. They are hypopigmented lines in which the skin might be folded. They must not be confused with scars from whipping. In striae, the skin is intact. Axillary striae may not be noticed by individuals until after suspension torture.

Mr. Adam’s psychological findings may not be as extensive or severe as some might expect, but this can be adequately explained by symptom mitigation from his political beliefs and activities and possibly by support from family and friends. Effective coping mechanism also may help to explain his resilience, but this was not thoroughly assessed in Case Example #02. Mr. Adam’s allegations of abuse appear to be at least “consistent with” his psychological evaluation findings.

Psychological instruments may serve as a useful adjunct to the qualitative, psychological evaluation and may be particularly helpful if an individual has trouble expressing in words his or her experiences and symptoms. This is not the case for Mr. Adam, however. In addition, caution must be exercised in the interpretation of responses and scores of psychological instruments because established norms do not exist for many populations.

All of the considerations listed would support the credibility of Mr. Adam’s allegations of torture and ill treatment and, if relevant, may be included in the clinician’s written reports and oral testimony. Note that inconsistencies that are attributable to an individual’s torture experience may, in fact, support an individual’s allegations of abuse, rather than undermine it.