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Other monitoring mechanisms

A number of other mechanisms have been developed by the UN Commission on Human Rights (since 2006, the UN Human Rights Council) to look at specific types of human rights violations wherever in the world they occur. These country-specific and thematic mechanisms include special rapporteurs, representatives and independent experts or working groups. They are created by resolution in response to situations that are considered to be of sufficient concern to require an in-depth study. The procedures report publicly to the Commission on Human Rights each year and some also report to the UN General Assembly.

The main thematic mechanisms of relevance for this manual are: the Special Rapporteur on Torture, the Special Rapporteur on Violence Against Women, the Special Rapporteur on the Independence of Judges and Lawyers, the Working Group on Enforced or Involuntary Disappearances, and the Working Group on Arbitrary Detention. A number of other thematic mechanisms also exist. The work of these bodies is not mutually exclusive and they may make either joint or separate interventions in connection with the same allegation.

A number of other mechanisms have been developed by the UN Commission on Human Rights (since 2006, the UN Human Rights Council) to look at specific types of human rights violations wherever in the world they occur. These country-specific and … Continue reading →

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Difficulties Recalling and Recounting

Torture survivors may have difficulties in recalling and recounting the specific details of the torture experience and other parts of the history for several important reasons. Clinicians should be familiar with such factors as they commonly manifest as inconsistencies in the interview. Difficulty recalling and recounting may be related to:

  • Factors directly related to the torture experience
    • Factors during torture itself, such as blindfolding, drugging, lapses of consciousness, etc.
    • Disorientation in time and place during torture due to the nature of torture or extreme stress experienced during torture.
    • Neuro-psychiatric memory impairment resulting from head injuries, suffocation, near drowning, starvation, hunger strikes or vitamin deficiencies.
    • Experiencing repeated and similar events may also lead to difficulties in recalling clearly the details of specific events.
  • Factors related to the psychological impact of torture
    • PTSD-related memory disturbances recalling the traumatic event or intrusive memories, nightmares and the inability to remember important details of the event.
    • Denial and avoidance, which can be protective coping mechanisms, in these particular circumstances.
    • High emotional arousal and impaired memory secondary to trauma-related mental illnesses, such as depression and post-traumatic stress disorder.
    • Other psychological symptoms such as concentration difficulties, fragmentation or repression of traumatic memories, confusion, dissociation, amnesia.
    • Feelings of guilt or shame.
  • Cultural factors
    • Cultural differences in the perception of time.
    • Culturally prescribed sanctions that allow traumatic experiences to be revealed only in highly confidential settings.
  • Factors related to interview conditions or barriers of communication
    • Fear of placing oneself or others at risk.
    • Lack of trust in the examining clinician and/or interpreter.
    • Lack of feeling safe during the interview.
    • Environmental barriers such as lack of privacy, comfort of interview setting, inadequate time for the interview.
    • Physical barriers such as pain or other discomforts, fatigue, sensory deficits.
    • Socio-cultural barriers such as the gender of the interviewer, language and cultural differences.
    • Barriers due to transference/counter-transference reactions during the interview.
    • Inadequately conducted and/or poorly structured interviews.

Torture survivors may have difficulties in recalling and recounting the specific details of the torture experience and other parts of the history for several important reasons. Clinicians should be familiar with such factors as they commonly manifest as inconsistencies in … Continue reading →

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Safeguards Against Torture for Those Deprived of Their Liberty

It is important for clinicians who conduct medical evaluations of torture and ill-treatment to be familiar with legal safeguards against torture for those deprived of their liberty. Everyone has the right to liberty and security of person — including the right to be free from arbitrary arrest or detention.[1] When the state deprives a person of liberty, it assumes a duty of care to maintain that person’s safety and to safeguard his or her welfare. Detainees are not to be subjected to any hardship or constraint other than that resulting from the deprivation of liberty.[2] These rights are guaranteed by Article 7 and 10(1) of the International Covenant on Civil and Political Rights (ICCPR) which, respectively, prohibit torture and ill-treatment and safeguard the rights of people deprived of their liberty. The prohibition on torture and ill-treatment apply to all people all the time. Certain rights in the treaties, such as the right not to be subject to arbitrary detention, may under certain circumstances be restricted in a public emergency, but safeguards necessary for the prohibition of torture, such as limiting periods in which people can be held in incommunicado detention, must continue to apply.[3]

Individuals may be at risk of torture or ill-treatment before they are subject to legal formalities such as arrest and charge. Indeed the European Committee for the Prevention of Torture (CPT) has stressed that it is during the period immediately following deprivation of liberty that the risk of torture and ill-treatment is at its greatest.[4] The following international standards, therefore, apply from the moment that someone is deprived of his or her liberty.

[1] Article 9 (1) International Covenant on Civil and Political Rights; Article 5 European Convention on Human Rights; Article 6 African Charter of Human and People’s Rights; Article 7 American Convention on Human Rights.

[2] Human Rights Committee, General Comment 21, Article 10 (Forty-fourth session, 1992), Compilation of General Comments and General Recommendations Adopted by Human Rights Treaty Bodies, U.N. Doc. HRIGEN1Rev.1 at 33 (1994), para. 3.

[3] Human Rights Committee General Comment No. 29, States of Emergency (art. 4), adopted at the 1950th meeting, on 24 July 2001, para. 16. See also Aksoy v Turkey, ECtHR, Judgment 18 December 1996; Brannigan and MacBride v UK, ECtHR, Judgment 26 May 1993; Brogan v UK, ECtHR Judgment 29 November 1988; ‘Habeas Corpus in Emergency Situations’, Advisory Opinion OC-8/87 of 30 January 1987, Annual Report of the Inter-American Court, 1987, OAS/Ser.L/V/III.17 doc.13, 1987; and ‘Judicial Guarantees in States of Emergency’, Advisory Opinion OC-9/87 of 6 October 1987, Annual Report of the Inter-American Court, 1988, OAS/Ser.L/V/III.19 doc.13, 1988.

[4] European Committee for the Prevention of Torture and Inhuman and Degrading Treatment or Punishment, the CPT Standards, Substantive Sections of the CPT’s General Reports, Council of Europe, October 2001, CPT/Inf/E(2002), p.12, para. 41.

It is important for clinicians who conduct medical evaluations of torture and ill-treatment to be familiar with legal safeguards against torture for those deprived of their liberty. Everyone has the right to liberty and security of person — including the … Continue reading →

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Musculoskeletal System

Complaints of musculoskeletal aches and pains are very common in survivors of torture. They may be the result of repeated beatings, of suspension, or of other positional torture. They may also be somatic. They are non-specific, but should be documented. In accordance with the characteristics of torture, complaints are characterized as pain in the respective region of the body, limitation of joint movement, swelling, parasthesiae, numbness, loss of sensation to touch, and tendon reflex loss.

Physical examination of the skeleton should include testing for mobility of joints, the spine and the extremities. Pain with motion, contractures, strength, evidence of compartment syndrome, fractures with or without deformity, and dislocations should all be noted after documenting visible signs such as contusions, abrasions, and lacerations as described above. Trauma to muscle should be checked for, such as muscle rupture and muscle tearing. Specific clinical signs of ligament tear include swelling, bruising, muscle spasm, and painful stress test, often with joint laxity. There may be a palpable gap in the ligament. If it is completely torn, then considerable swelling and bruising occurs. Tendon ruptures, avulsions from the insertion of the bone, and dislocation of a tendon from its groove may all be observed.

Back pain is also common in survivors of torture, and there may be some local tenderness in the lumbar spine. However, these findings are non-specific and common in the general population. Fractures of the vertebral pedicles (the parts of the vertebra going away from the main body) may result from direct blunt force and, in some instances, radiography of the vertebrae may indicate recent or healed fractures.

Fractures

Fractures are caused by a loss of bone integrity due to the effect of a blunt mechanical force on various vector planes. Fractures can be caused by a direct blow, in which case the fracture is at the site of the impact, or by twisting or crushing, in which case the fracture tends to be at the weakest part of the bone. In the acute phase, local swelling, bony deformity, tenderness and loss of function will be typical findings on clinical examination. In the chronic phase, various degrees of bony deformity, pain with activity and loss of function may be found. A direct fracture occurs at the site of impact or at the site where the force was applied. In an indirect fracture, the location, contours, and other characteristics of a fracture reflect the nature and direction of the applied force. The most frequent fractures seen in survivors of torture are of the nasal bones, the ribs, the radius, ulna and small bones of the hand, the transverse process of vertebrae, and those of the coccyx. The hyoid bone and laryngeal cartilage may be fractured in partial strangulation or from blows to the neck.

If a person alleges that a bone was fractured during torture and a callus is palpable, that should normally be sufficient to document. X-rays are unlikely to add anything. Generally, even with an X-ray, it is only possible to say that a bone was fractured within a wide time-frame, but very rarely that the fracture was caused by torture. Mal-united fractures are highly supportive of a history of torture with no immediate medical treatment.

Routine radiographs are recommended at the initial examination, if facilities are available. Injuries to tendons, ligaments, and muscles are best evaluated with MRI, but arthrography (arthroscopy) can also be performed. In the acute stage, MRI can detect hemorrhage and possible muscle tears. Muscles usually heal completely without scarring, so later imaging studies will be negative. MRI or scintigraphy may detect bone injury such as a subperiosteal haematoma, which may not be detected on routine radiographs or CT. Radiographic aging of relatively recent fractures should be performed by an experienced trauma radiologist.

Complaints of musculoskeletal aches and pains are very common in survivors of torture. They may be the result of repeated beatings, of suspension, or of other positional torture. They may also be somatic. They are non-specific, but should be documented. … Continue reading →

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Module 3 Presentation: Interview Considerations


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Gathering of evidence

The medical evidence will be used in combination with the other types of evidence mentioned above. Detailed guidelines on gathering medical evidence, including the interviewing of alleged victims, physical and psychological examinations, and writing medical reports, are addressed in the following Modules.

Health professionals engaged in the documentation and investigation of torture ought also, however, to be aware of certain non-medical aspects of evidence gathering. In ideal circumstances, there will be a number of people responsible for collection of evidence, and other members of the team, particularly the lawyers or NGO professionals, will coordinate the collection and ensure that all requisite details have been gathered. However, in some circumstances not all members of the team will have access to the alleged victim, and it is therefore crucial that each member is aware of the necessary details essential for the substantiation of alleged abuse. In other circumstances, health professionals may participate in human rights investigations and monitoring. The level of proof and detail may vary depending on the purpose of documentation: for example, a criminal trial requires higher standards of proof than a civil hearing or administrative procedures determining potential risk in case of deportation. If the health professional is the only person with access to the alleged victim or other source of information, it is vital that he or she attempts to collect, or ensures that others collect, key information, beyond the purely medical evidence.

The medical evidence will be used in combination with the other types of evidence mentioned above. Detailed guidelines on gathering medical evidence, including the interviewing of alleged victims, physical and psychological examinations, and writing medical reports, are addressed in the … Continue reading →

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Module 4 Presentation: Torture Methods and their Medical Consequences


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Psychological Evidence of Torture

According the to Istanbul Protocol, the psychological impacts can vary depending on a variety of factors: “…the psychological consequences of a mock execution are not the same as those due to a sexual assault, and solitary confinement and isolation are not likely to produce the same effects as physical acts of torture. Likewise, one cannot assume that the effects of detention and torture on an adult will be the same as those on a child.” Despite this variation, certain psychological reactions have been documented in torture survivors with some regularity, and these evaluations remain key by “…provid[ing] useful evidence for medico-legal examinations, political asylum applications, establishing conditions under which false confessions may have been obtained, understanding regional practises of torture, identifying the therapeutic needs of victims and as testimony in human rights investigations.”

Although there may be considerable variability in psychological effects, torture and ill-treatment often result in profound, long-term psychological trauma. According to the Istanbul Protocol, the most common psychological problems are posttraumatic stress disorder (PTSD) and major depression, but may include the following:

  • Re-experiencing the trauma
  • Avoidance and emotional numbing
  • Hyperarousal symptoms
  • Symptoms of depression
  • Damaged self-concept and foreshortened future
  • Dissociation, depersonalisation, and atypical behaviour
  • Somatic complaints
  • Sexual dysfunction
  • Psychosis
  • Substance abuse
  • Neuropsychological impairment

As with physical injuries, the absence of a definite mental health syndrome or condition, such as PTSD or depression, does not rule out torture and/or ill-treatment. Whether an individual presents with mental health problems depends on multiple factors, including but not limited to age, gender, mental preparedness, personality traits, degree of psychological trauma, and cultural/religious values.

Such psychological symptoms and disabilities can last many years or even a lifetime. It is important to realize that the severity of psychological reactions depends on the unique cultural, social, and political meanings that torture and ill-treatment have for each individual, and significant ill effects do not require extreme physical harm. Seemingly benign forms of ill-treatment can and do have marked, long-term psychological effects.

The psychological examination should elicit background information about the victim’s life both preceding and following the alleged torture or ill-treatment. Components of the psychiatric evaluation should include: a) history of torture and ill-treatment, b) current psychological complaints, c) post-torture history, d) pre-torture history, e) medical history, f) psychiatric history, g) substance use and abuse history, h) mental status examination, i) assessment of social function, j) psychological testing and the use of checklists and questionnaires, and k) clinical impression. Such information enables examiners to assess the presence of significant psychological symptoms and its relationship to the alleged trauma and other possible causes.

According the to Istanbul Protocol, the psychological impacts can vary depending on a variety of factors: “…the psychological consequences of a mock execution are not the same as those due to a sexual assault, and solitary confinement and isolation are … Continue reading →

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Summary of Detention(s) and Abuse

Before obtaining a detailed account of events, elicit summary information, including dates, places, duration of detention, frequency and duration of torture sessions. A summary will help to make effective use of time. In some cases where survivors have been tortured on multiple occasions, they may be able to recall what happened to them, but often can not recall exactly where and when each event occurred. In such circumstances, it may be advisable to elicit the historical account by methods of abuse rather than as a series of events during specific arrests.

Similarly, in taking a history it may often be useful to have “what happened where” documented as much as possible. “Holding places” are often operated by different security/police/armed forces, and what events happened in different places may be useful to get a full picture of the torture system. Obtaining a map of where the torture occurred may be useful in piecing together different histories from different people. This will often prove very useful for the overall evaluation.

Before obtaining a detailed account of events, elicit summary information, including dates, places, duration of detention, frequency and duration of torture sessions. A summary will help to make effective use of time. In some cases where survivors have been tortured … Continue reading →

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Restraint, Shackling and Positional Torture

Some degree of restraint is clearly necessary and legitimate at the time of arrest or during transfer in order to prevent a detainee from escaping. However, once detention has been secured, there can be no legitimate need for artificial restraint. The use of shackles or leg irons is specifically forbidden by Rule 33 of the UN Standard Minimum Rules for the Treatment of Prisoners. In spite of this ruling, extreme and prolonged measures are very often taken. Sometimes an attempt is made to justify its use as preventing escape but usually they are applied to cause humiliation or as a punishment. The restraint may be continued for days or even weeks, far longer than needed for legitimate purposes.

Handcuffs, wrist or ankle ties leave no mark if they are applied properly, and in some countries officers take care to prevent damage. In India, for instance, police often use the detainee’s turban cloth to bind the wrists or ankles. Conversely, restraints may cause abrasions or bruising even after a short time if they are of rough or harsh material or are applied too tightly. Thin ligatures tightly applied may cause deep wounds after a few hours. This type of handcuff, which automatically continues to tighten if the prisoner struggles, is particularly dangerous and can cause characteristic lesions.

The use of leg irons is widespread in police stations and prisons. Pakistani prisons are particularly notorious for its use, often for long periods of time. They are used as punishment, as a means of extorting bribes and intimidating or humiliating prisoners. Often the rings round the ankles are roughly finished and cause severe abrasions and scarring which may be highly consistent with allegations of abuse.

There are many forms of positional torture, all of which tie or restrain the victim in contorted, hyperextended or other unnatural positions, which cause severe pain and may produce injuries to ligaments, tendons, nerves and blood vessels. Characteristically, these forms of torture leave few, if any, external marks or radiological findings, despite subsequent frequently severe chronic disability.

Positional torture is directed towards tendons, joints and muscles. The ‘five-point tie’ is a technique of trussing up a captive used in several African countries. A single fine rope is tied round the wrists, ankles and neck or mouth, holding the trunk tightly in extreme extension. An attempt to relieve the pain by moving one limb tightens it more around the others. If this type of restraint is continued for any length of time there is almost certain to be permanent scarring and perhaps peripheral nerve or vascular lesions.

In China, many forms of shackling are used as punishment and are given nicknames to disguise the appallingly painful methods used. For instance, Su Qin bei jian (literally, ‘Su Qin carries a sword on his back’) describes the shackling of one arm pulled over the shoulder to the other which is twisted behind the back. Another is liankao, describing various methods of shackling the hands and feet behind the back.

Cramped or distorted postures or prolonged standing are used routinely in many countries. An example is Israel, where ‘moderate physical pressure’ is permitted by law. Several techniques have been devised by the General Security Service (Shin Bet) and routinely used to put detainees under undue stress. In shabeh the victim is shackled for hours to a low chair whose front legs have been shortened so that the detainee must constantly struggle to avoid sliding off. Shabeh is usually combined with methods of abuse, i.e. placing an often filthy sack over the victim’s head, exposing him or her to loud music and sometimes to extreme temperatures and sleep deprivation.

In gambaz the detainee is forced to crouch on his toes in the ‘frog’ position for long periods. In kas’at tawila the subject is made to kneel with his back up against a table and his cuffed arms resting on the table behind him while the interrogator’s legs push against his shoulders. A small chamber nick-named ‘the refrigerator’ is used to keep the victim immobile for hours or days.

The UN Committee against Torture has determined that restraining detainees in very painful positions is by itself an act of both torture and cruel, inhuman or degrading treatment.[1] It recently determined that the use of “short shackling” by US (United States) personnel constitutes either torture or cruel, inhuman or degrading treatment and has recommended that the method be prohibited.[2] In a review of US practises, the UN Special Rapporteur on Torture has condemned the use of stress positions on detainees by the United States as violating the Convention Against Torture.[3]

[1] Hashemian F, Crosby S, Iacopino V, Keller A, Nguyen L, Ozkalipici O, et, al. Broken Laws, Broken Lives: Medical Evidence of Torture by US Personnel and It’s Impact. Physicians for Human Rights. June, 2008. pp. 100. (Hereafter: Broken Laws, Broken Lives)

[2] Broken Laws, Broken Lives pp. 100.

[3] Broken Laws, Broken Lives pp. 100

Some degree of restraint is clearly necessary and legitimate at the time of arrest or during transfer in order to prevent a detainee from escaping. However, once detention has been secured, there can be no legitimate need for artificial restraint. … Continue reading →

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