Conclusions

At the end of the report, the health professional must give his or her opinion of the totality of his or her findings, both physical and mental. He or she can say how strongly the findings support or do not support the allegations. The report may have corroborative value when it is added to the other evidence in the case.

All the available information should then be brought together in order to prepare the final report, including:

• Copies of any previous court decisions about the individual
• Correspondence from other health professionals to whom the patient has been referred
• Background information about the situation in the country to which the allegations of torture relate (e.g. from the UNHCR (United Nations High Commissioner for Refugees) or Amnesty International)
• The account of the event(s) as described by the individual
• Notes on the individual’s description of his or her physical and mental health
• Records of the psychological and physical findings from the interview(s)
• The results of any clinical investigations
• Recommendations for further treatment

This will then allow the health professional to give an opinion of the likelihood that the alleged victim had been tortured in the way that he or she described, to the standard of proof required by the appropriate forum. Ultimately, the court decides whether the individual is credible, but health professionals must not ignore the issue. Credibility is not an all-or-nothing concept – there is a continuum between the absolute truth and the complete fabrication of events, with at least three points in-between:

1. A mixture of falsehood and truth, e.g. a fabricated history of a recent detention added to a genuine one in the past
2. Conscious or subconscious exaggeration – saying that the ill-treatment was more frequent and more severe than actually happened
3. Genuine errors arising from mistakes and misunderstandings. The health professional should then make a final statement summarising the opinion.

The components of written reports are elaborated throughout this Curriculum. The following guidelines are based on the Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (the “Istanbul Protocol”), Appendix IV. These guidelines are not intended as a fixed protocol. Rather, they should be applied with due consideration to the purpose of an individual evaluation and a reasonable assessment of available resources. Please note that assessments of physical and psychological evidence of torture and ill-treatment may be conducted by one or more clinicians depending on their qualifications.

Guidelines for Medical Evaluations of Torture and Ill Treatment

(see Istanbul Protocol [1] Annex IV)

Case Information

Date of Evaluation:……………………… Exam. Requested By (Name/Position):…………
Case ID/Report #: ……………………… Duration of Evaluation: ……Hours ……Minutes
Subject’s Given Name:..………………… Birth Date:………… Birth Place………………
Subject’s Family Name:..………………… Gender: female / male
Reason for Exam…………………… Subject’s ID#:……………………………………
Clinician’s Name:……………………….. Interpreter Yes/No: Name:…..……………………
Informed Consent: Yes/No; If “No,” Provide Reason:…..……………………………
Subject Accompanied By (Name/Position):…………………………………..…………………
Person(s) Present During Examination (Name/Position):……………………..…………………
Subject Restrained During Exam: Yes/No; If “Yes,” How/Why?……………………………………….
Medical Report Transferred to (Name/Position/ID#):…………………………………………….
Transfer Date: …………………….. Transfer Time: …………………….
Medical Evaluation/Investigation Conducted without Restriction (For Subjects in Custody): Yes/No
Provide Details of Any Restrictions:…………………………………..……………………

Clinician’s Qualifications (For Judicial Testimonies)

1. Medical Education and Clinical Training
2. Psychological/Psychiatric Training
3. Experience in Documenting Evidence of Torture and Ill-treatment
4. Regional Human Rights Expertise Relevant to the Investigation
5. Relevant Publications, Presentations and Training Courses
6. Provide Curriculum Vitae

Statement Regarding Veracity of Testimony (For Judicial Testimonies)

For example: “I personally know the facts recited below, except as to those stated on information and belief, which I believe to be true. I would be prepared to testify to the above statements based on my personal knowledge and belief.”

Background Information

1. General Information: (age, occupation, education, family composition, etc.)
2. Past Medical History
3. Review of Prior Medical Evaluations of Torture and Ill-treatment:
4. Psychosocial History Pre-Arrest

Allegations of Torture and Ill-treatment

1. Summary of Detention(s) and Abuse
2. Circumstances of Arrest and Detention
3. Initial and Subsequent Places of Detention: (chronology, transportation, and detention conditions)
4. Narrative Account of Ill-treatment of Torture: (in each place of detention)
5. Review of Torture Methods

Physical Symptoms and Disabilities

1. Describe the development of acute and chronic symptoms and disabilities and the subsequent healing processes.
2. Acute Symptoms and Disabilities
3. Chronic Symptoms and Disabilities

Physical Examination

1. General Appearance
2. Skin
3. Face/Head
4. Eyes/Ears/Nose/Throat
5. Oral Cavity/Teeth
6. Chest/Abdomen (including vital signs)
7. Genitourinary System
8. Musculoskeletal System
9. Nervous System (Central and Peripheral)

Psychological History/Examination

1. Methods of Assessment
2. Current Psychological Complaints
3. Post-Torture History
4. Pre-Torture History
5. Past Psychological/Psychiatric History
6. Substance Use and Abuse History
7. Mental Status Examination
8. Assessment of Social Functioning
9. [Psychological Testing]
10. [Neuropsychological]

Photographs

Diagnostic Test Results (see Appendix I for indications and limitations)

Consultations

Interpretation of Finding

1. Physical Evidence:
   1. Correlate the degree of consistency between the history of acute and chronic physical symptoms and disabilities with allegations of abuse.
   2. Correlate the degree of consistency between physical examination findings and allegations of abuse. (Note: the absence of physical findings does not exclude the possibility that that torture or ill-treatment was inflicted.)
   3. Correlate the degree of consistency between examination findings of the individual with knowledge of torture methods and their common after-effects used in a particular region.
2. Psychological Evidence:
   1. Correlate the degree of consistency between the psychological findings and the alleged report of torture.
   2. Provide an assessment of whether the psychological findings are expected or typical reactions to extreme stress within the cultural and social context of the individual.
   3. Indicate the status of the individual in the fluctuating course of trauma-related mental disorders over time; i.e. what is the time frame in relation to the torture events and where in the course of recovery is the individual.
   4. Identify any coexisting stressors impinging on the individual (e.g. ongoing persecution, forced migration, exile, loss of family and social role, etc.) and the impact these may have on the individual.
   5. Mention physical conditions that may contribute to the clinical picture, especially with regard to possible evidence of head injury sustained during torture and/or detention.

Conclusions and Recommendations

1. Statement of opinion on the consistency between all sources of evidence cited above (physical and psychological findings, historical information, photographic findings, diagnostic test results, knowledge of regional practices of torture, consultation reports, etc.) and allegations of torture and ill-treatment.
2. Reiterate the symptoms and/or disabilities that the individual continues to suffer as a result of the alleged abuse.
3. Provide any recommendations for further evaluation and/or care for the individual.

Statement of Truthfulness (For Judicial Testimonies)

For example, “I declare under penalty of perjury, pursuant to the laws of (XX country), that the foregoing is true and correct and that this affidavit was executed on X/X/X at (City), (State or Province).”

Statement of Restrictions on the Medical Evaluation/Investigation (For Subjects in Custody)

For example, “The undersigned clinician(s) personally certify that they were allowed to work freely and independently, and permitted to speak with and examine (the subject) in private, without any restriction or reservation, and without any form of coercion being used by the detaining authorities;” or alternatively: “The undersigned clinician(s) had to carry out his/her/their evaluation/investigation with the following restrictions:…”

Clinician’s Signature, Date, Place

Relevant Appendices

e.g. Clinician’s Curriculum Vitae, Anatomical Drawings for Identification of Torture and Ill-treatment, Photographs, Consultations, and Diagnostic Test Results, among others.

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In the process of correlating the degree of consistency between physical and psychological findings and allegations of abuse, it is helpful to use the following terms (adapted from IP, §125):

• Not consistent: The finding could not have been caused by the trauma described. (If this term is used in a medico-legal report, the writer should explain why the individual’s account is considered to be credible, if that is the case, despite this inconsistency.
• Consistent with: The finding could have been caused by the trauma described, but it is non-specific and there are common alternative possible causes.
• Highly consistent: The finding could have been caused by the trauma described and there are few other possible causes. (Depending on the level of proof required by the court, such findings may be sufficient to corroborate the individual’s testimony.)
• Typical of: This phrase is used for lesions that are ‘highly consistent’ with the attribution and additionally the appearance is one that is usually found with this type of trauma (for example, cigarette burns).
• Diagnostic of: This finding could not have been caused in any way other than that described. (This is strongly supportive of the individual’s account, but does not, by itself, confirm that torture has occurred because the status of the perpetrator and the purpose of the assault are also relevant.)