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Perianal Examination

After anal rape or insertion of objects into the anus of either gender, pain and bleeding can occur for days or weeks. This often leads to constipation, which can be exacerbated by the poor diet in many places of detention. Gastrointestinal and urinary symptoms may also occur. Generally, visual inspection of the anogenital region is sufficient to find scarring and other lesions of the skin. The focus of the examination will depend on the history. In the acute phase, any examination beyond visual inspection may require local or general anaesthesia and should be performed by a specialist. For example, If an individual has persistent bleeding after an object was pushed through the anus, there may be scarring of the rectal mucosa and this can be looked for by proctoscopy. In the chronic phase, several symptoms may persist, and they should be investigated. There may be anal scars of unusual size or position, and these should be documented. Anal fissures may persist for many years, but it is normally impossible to differentiate between those caused by torture and those caused by other mechanisms. On examination of the anus, the following findings should be looked for and documented:

  • Fissures tend to be non-specific findings as they can occur in a number of “normal” situations (constipation, poor hygiene). However, when seen in an acute situation (i.e. within 72 hours) fissures are more specific findings and can be considered evidence of penetration;
  • 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;
  • Skin tags, which can be the result of healing trauma;
  • Purulent discharge from the anus. Cultures should be taken for gonorrhoea and chlamydia in all cases of alleged rectal penetration, regardless of whether a discharge is noted.

Following rape, the possibility of sexually transmitted diseases should be considered and local protocols followed. If there is any possibility of the perpetrator being prosecuted, air dried internal and external anal swabs can be taken up to five days after the rape, even if the survivor has defecated, and stored for DNA testing.

After anal rape or insertion of objects into the anus of either gender, pain and bleeding can occur for days or weeks. This often leads to constipation, which can be exacerbated by the poor diet in many places of detention. … Continue reading →

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Prohibition of Torture in International Law

Torture cannot be justified under any circumstances. The UN has condemned torture as a denial of the purposes of its Charter and as a violation of the human rights and fundamental freedoms proclaimed in the Universal Declaration of Human Rights. Torture is also prohibited by most domestic legal systems in the world. Even where there is no specific crime of torture in domestic law, there are usually other laws under which the perpetrators can be held to account. Nevertheless, acts of torture and ill-treatment remain widespread across the world.

The international community has developed standards to protect people against torture that apply to all legal systems in the world. The standards take into account the diversity of legal systems that exist and set out minimum guarantees that every system should provide. Judges and prosecutors have a responsibility to ensure that these standards are adhered to, within the framework of their own legal systems. Even if a country has not ratified a particular treaty prohibiting torture, the country is in any event bound on the basis of general international law, because the prohibition of torture is so fundamental.[1]

The prohibition of torture in international law is notable in that it is absolute, applying at all times and in all circumstances. Article 5 of the 1948 Universal Declaration of Human Rights states: ‘No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment.’ The right to be free from torture and other ill-treatment is taken up in major international and regional human rights treaties, including the International Covenant on Civil and Political Rights (1966), the European Convention on Human Rights (1950), the American Convention on Human Rights (1978) and the African Charter on Human and People’s Rights (1981). In 1984 the UN adopted the Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, highlighting the particular attention given to this absolute prohibition, and providing additional rules to assist in prevention and investigation.

The prohibition of torture is the concern not only of those countries which have ratified particular treaties, but is also a rule of general or customary international law, which binds all states even in the absence of treaty ratification. In fact, the prohibition of torture is generally regarded as having the special status of a ‘peremptory norm’ of international law, and states cannot choose to disregard or derogate from it.

In addition to international law, many national laws will also include a prohibition of torture. However, the lack of a clear prohibition in domestic law will not release the state from its international legal obligations to refrain from and prevent torture under all circumstances, and to investigate allegations, punish perpetrators, and provide reparations to victims.

The prohibition against torture and other ill-treatment extends even to times of armed conflict, whether the conflict is international (between countries) or internal (within a single country). In times of conflict all parties have to refrain from subjecting anyone in their hands to torture and other ill-treatment, whether they are combatants taking part in the fighting, whether they no longer take part in the fighting (e.g. due to being detained, or being wounded or sick) or whether they are civilians. International humanitarian law, of which the Geneva Conventions form a part, contains laws protecting people in times of armed conflict. The prohibition against torture in humanitarian law is expressly found in a number of provisions of the four 1949 Geneva Conventions and their Additional Protocols of 1977. An act of torture committed in the context of an armed conflict is a war crime.

Torture is also considered to be a crime against humanity when the acts are perpetrated as part of a widespread or systematic attack against a civilian population, whether or not they are committed in the course of an armed conflict.

Under international law, the use of torture can be regarded as both the responsibility of the state itself and the individual criminal responsibility of persons involved. Those who carry out the act of torture can be tried in domestic and international courts.

In summary, the strong and unequivocal prohibition of torture means that torture can never be justified, in any situation, including public emergencies and even war. No case of torture, whatever the circumstances, can be ignored.

A number of UN bodies have been created by particular conventions to monitor compliance with these standards and provide guidance on how they should be interpreted. These bodies generally issue general comments and recommendations, review reports by states parties and issue concluding observations on the compliance of a state with the relevant convention. Some also consider complaints from individuals who claim to have suffered violations. In this way they can provide authoritative interpretations of the treaty provisions and the obligations that these place on states parties.

[1] Article 38 of the Statute of the International Court of Justice lists the means for determining the rules of international law as: international conventions establishing rules, international custom as evidence of a general practice accepted as law, the general principles of law recognised by civilised nations and judicial decisions and the teaching of eminent publicists. General international law (customary international law) consists of norms that emanate from various combinations of these sources.

Torture cannot be justified under any circumstances. The UN has condemned torture as a denial of the purposes of its Charter and as a violation of the human rights and fundamental freedoms proclaimed in the Universal Declaration of Human Rights. … Continue reading →

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Role of judges and prosecutors

Judges and prosecutors have a responsibility to ensure that they do not themselves, unintentionally or otherwise, collude with acts of torture while carrying out their official functions. In some legal systems, prosecutors may be directly involved in conducting interrogations in which coercive methods of extracting confessions and information are used. In some situations, prosecutors may rely on information or confessions, when conducting cases, without ensuring that the information was not obtained by coercive means.

Sometimes judges and prosecutors fail to ensure that the laws and procedures designed to protect people in detention, and prevent acts of torture and other forms of ill-treatment, are upheld. They may also fail to require that a person making a statement or confession does so in their presence; fail to explore for signs of physical or mental distress on a detainee who is brought before them; return a detainee to the custody of law enforcement officials where there is reason to believe that the detainee will suffer ill-treatment; fail to react to signs which indicate that a person may have been ill-treated even in the absence of a formal complaint; fail to sufficiently take complaints of ill-treatment seriously; fail to investigate such allegations with a view to bringing proceedings against the perpetrators; and fail to exercise their powers to carry out thorough inspections of places of detention.

Conversely, judges and prosecutors may exercise their powers to prevent and investigate acts of torture. They may demand that a suspect be brought before them at the earliest opportunity and check that he or she is being properly treated. Where they have discretion, they may interpret the balance of proof, with respect to allegations of torture and the admissibility of evidence obtained through it, in ways that discourage law enforcement officers, and those in charge of places of detention, from carrying out, or permitting others to carry out, torture and other forms of ill-treatment. They may also stay alert to all possibilities that their own courts or tribunals do not conform to the highest possible standards with respect to preventing and investigating torture.

While international law provides a basic minimum, there are also examples from different countries that can be drawn on when developing standards of good practise. The case studies contained in this manual, which only represent a brief snap-shot of such cases drawn from around the world, are intended to illustrate how judges and prosecutors have sought to combat torture within their own national jurisdictions.

Judges and prosecutors have a responsibility to ensure that they do not themselves, unintentionally or otherwise, collude with acts of torture while carrying out their official functions. In some legal systems, prosecutors may be directly involved in conducting interrogations in … Continue reading →

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Dual Obligations

Many health professionals have dual obligations (also referred to as ‘dual loyalties’), in that they owe a primary duty to the patient to promote his or her best interests and often a separate duty to employers. There is also a general duty to society to ensure that violations of human rights are prevented, and that the interests of . The dilemmas arising from dual obligations are particularly acute, however, for health professionals working with the police, military, and other security services or in the prison system. In these situations, either through the fact of their employment or ideological reasons, the obligations to their employer (the State) as well as the interests of their employer and their non-medical colleagues may all be in conflict with the best interests of their patients. A military doctor, for example, may belong to the very same government forces to which suspected perpetrators belong, thus interposing the loyalty to their comrades, military unit and military objectives, due to a separate obligation to the individual patient. A military or prison doctor may be under pressure to ignore allegations, or not conduct proper examinations and/or to falsify any record of their findings.

However, health professionals hold a particular duty to act impartially and to document and report any suspected ill-treatment through the appropriate channels. Health professionals must only document that which they have personally verified themselves, and they must document this truthfully, fully and accurately. Health professionals must be able to make clinical decisions independently from employers, governments, and other bodies in order to act in the best medical interests of their patients. They cannot be obliged by contractual or other considerations to compromise their professional independence.

There are various situations in which dual obligations and other ethical and legal issues may arise:

  • They could be asked to perform a medical examination prior to interrogation in order to verify that the individual will be able to withstand physical torture or other ill-treatment.
  • They could be asked to revive or treat an individual during an abusive interrogation to enable further interrogation.
  • They may be asked to provide medical knowledge or individual medical information concerning physical health or to identify psychological weaknesses or fears, that can be exploited in order to facilitate interrogation, or to develop new methods.
  • Health professionals could be asked to be complicit in the falsifying of medical reports in order to cover up any indications of abuse.

Health professionals undertaking the above tasks may be guilty of playing an active or passive role in the abuse of an individual. In all these cases the health professional must abide by the rules of medical ethics and retain their primary loyalty to the patient, refusing to participate in or condone torture or other ill-treatment, and doing all they can to end the abuse, including the full and accurate documentation of any possible psychological or physical sequelae.

It should be kept in mind that in addition to the principles of medical ethics, health professionals working for the state are also bound by the rules of international law and which could, in certain cases, lead to individual criminal responsibility of the health professional for participation in torture. Obeying the orders of a superior would not provide a defence to a charge of participation in torture.

Forensic doctors may have a different relationship with individuals they examine. In their usual function, forensic doctors have a duty to the courts, to which they provide independent medical expert opinion, even though they may be paid by one or other party. Before beginning any examination, forensic doctors must explain their role to the individual and make clear that medical confidentiality is not a usual part of their role, as it would be in
a therapeutic context, as their primary duty is to objectively document evidence that can be presented to a court. However, forensic doctors should not examine individuals without making clear the nature of their role and gaining specific consent. If consent is refused, this must be noted and respected. Depending on the jurisdiction, following such refusal by the subject, a court order may be required before any examination or taking of samples can
proceed. The forensic doctor should seek to include in their findings and report, only that medical information that is relevant to the case, and should leave out that medical information which can remain confidential to the patient (e.g. if HIV status is not relevant to the case, then it should not be raised in the findings). They must not falsify their reports but provide impartial evidence, including making clear in their reports any evidence of ill treatment.

There is consensus in international and national declarations of ethical precepts that other imperatives, including the law, cannot oblige health professionals to act contrary to medical ethics and to their conscience. In such cases, health professionals must decline to comply with the law or a regulation rather than compromise basic ethical precepts. Whatever the circumstances of their employment, all health professionals owe a fundamental duty to care for the people they are asked to examine or treat. They cannot be obliged by contractual or other considerations to compromise their professional independence. They must make an unbiased assessment of the patient’s health interests and act accordingly.

Many health professionals have dual obligations (also referred to as ‘dual loyalties’), in that they owe a primary duty to the patient to promote his or her best interests and often a separate duty to employers. There is also a … Continue reading →

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Privacy

Examinations must be conducted in private under the control of the clinician. Privacy during the interviews is not only necessary for ethical reasons, but also when talking about sensitive issues that may be embarrassing or shameful for the person being evaluated. The clinician should establish and maintain privacy during the entire interview (IP, §83, 124). Police or other law enforcement officials should never be present in the examination room. 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 clinician’s report. Their presence during the examination may be grounds for disregarding a negative medical report (IP, §124, 125). If any other persons are present in the interview room during the interview, the identity, titles, affiliations of those persons should be indicated in the report (IP, §125).

Examinations must be conducted in private under the control of the clinician. Privacy during the interviews is not only necessary for ethical reasons, but also when talking about sensitive issues that may be embarrassing or shameful for the person being … Continue reading →

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International criminal courts and tribunals

National criminal courts are primarily responsible for the investigation and prosecution of crimes of torture and other criminal forms of ill-treatment. A number of ad hoc international criminal tribunals have been established in recent years – including the International Criminal Tribunal for the former Yugoslavia (ICTY) and the International Criminal Tribunal for Rwanda (ICTR). Crimes of torture as crimes against humanity and war crimes are included in the Statute of ICTY,[1] ICTR[2] and the Rome Statute of the International Criminal Court (ICC).[3] The Statute of the ICC was agreed in 1998 and received the 60 ratifications necessary for it to come into effect in 2002. The ICC will, in future, be able to prosecute some crimes of torture when national courts are unable or unwilling to do so.

[24] Article 5, ICTY.

[25] Article 3, ICTR.

[26] Articles 7 and 8, ICC.

National criminal courts are primarily responsible for the investigation and prosecution of crimes of torture and other criminal forms of ill-treatment. A number of ad hoc international criminal tribunals have been established in recent years – including the International Criminal … Continue reading →

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Module 4: Torture Methods and their Medical Consequences

Objectives

  • To provide in-depth information on specific torture methods, how they are applied and possible acute and chronic physical findings associated with them
  • To develop an understanding of the extent to which physical findings corroborate specific allegations of torture and ill-treatment
  • To be able to describe and identify physical findings, likely causes of injury and opinion regarding the possibility of torture/ill-treatment
  • To understand common psychosocial consequences of torture and ill-treatment
  • To be familiar with factors which may affect the variability of psychological evidence of torture and ill-treatment

Content

  • The subjective element of suffering
  • Torture methods
    • Beating
    • Falanga
    • Ear trauma
    • Eye trauma
    • Restraint, shackling and positional torture
    • Suspension
    • Crushing and stretch Injuries
    • Burning
    • Electrical injuries
    • Aspyxiation
    • Violent shaking
    • Sexual assault
    • Sexual humiliation
    • Prolonged isolation and sensory deprivation
    • Sleep deprivation
    • Temperature manipulation
    • Sensory bombardment
    • Threats of harm
  • Psychological consequences of torture
    • The Paradox of Psychological Consequences of Torture
    • The Psychological Consequences of Torture
    • Social, Political and Cultural Context
    • Risk factors for Trauma and Torture-Related Disorders
    • Psychological Symptoms

Discussion Topics

  • Students should work in groups or individually on answering questions contained in Self-Assessment 4
  • Additional Discussion Topics:
    • Discuss the overall value of physical evidence of torture and limitations thereof
    • Consider relationships between physical and psychological evidence of torture. Provide 92 examples of interrelated findings.
    • What patterns of physical injury support the allegation of torture?
    • Discuss possible interpretations of the absence of physical evidence of torture and ill treatment

Teaching Formats

  • Group Activity:
    • Divide the class into several groups and have each group work on answering questions contained in Self-Assessment 4
    • A facilitator should be identified to moderate the discussion and rapporteur should be identified to record the group’s findings and report them when the class reconvenes.
    • After 20-30 minutes of group discussion, the entire class should reconvene
    • Rapporteurs should briefly report on their group’s findings
    • Open class discussion
  • Alternative Option:
    • Divide the class into several groups and assign each group with one or more (or all) of the Discussion Topics
    • Follow the usual sequence for conducting group activities as outlined above
  • Individual Research/Assignment:
    • Individual students should answer all questions contained in Self-Assessment 4
    • Journal Entry: (Instructor to assign Write a few paragraphs — no more than a page)
    • Respond to one or more of the Discussion Topics

Primary Resources

  • The Istanbul Protocol, Chapters V and VI
  • The Medical Documentation of Torture
  • Medical Investigation and Documentation of Torture: A Handbook for Health Professionals
  • Examining Asylum Seekers
  • Medical Physical Examination of Alleged Torture Victims: A Practical Guide to the Istanbul Protocol for Medical Doctors
  • Dermatologic Findings after Alleged Torture (PowerPoint file). Lis Danielsen and Ole Vedel Rasmussen, IRCT 2004-2005.
  • Torture Methods (PowerPoint file). Ole Vedel Rasmussen, IRCT 2004-2005.
  • Işkence Atlaı: Işkencenin Tibbi Olarak Belgelendirilmesinde Muayene ve Tanısal Inceleme Sonuclarının Kullanılması
  • Trainers’ Guidelines for Health Professionals: Training of Users

Objectives To provide in-depth information on specific torture methods, how they are applied and possible acute and chronic physical findings associated with them To develop an understanding of the extent to which physical findings corroborate specific allegations of torture and … Continue reading →

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Self-Assessment and Quiz

  1. Which of the following is/are included in the UN Convention Against Torture (CAT) definition of torture?
    1. The intentional infliction of severe mental or physical pain or suffering
    2. Perpetrated by or with the consent or acquiescence of the state authorities
    3. Pain and suffering arising from lawful sanctions
    4. For a specific purpose, such as gaining information, punishment or intimidation or for any other reason
    5. All of the above
  2. What distinguishes cruel, inhuman and degrading treatment or punishment (CID or ill-treatment) from torture?
    1. The use of psychological methods of abuse only, but not physical methods
    2. The degree of severity of mental or physical pain or suffering inflicted
    3. Perpetrated by or with the consent or acquiescence of state authorities
    4. Ill-treatment does not have to be inflicted for a specific purpose
    5. All of the above
  3. Which of the following is a reasonable estimate of the number of countries that practice in the world today?
    1. Nearly all of the countries in the world
    2. Nearly half the countries in the world
    3. About one fourth of the countries in the world
    4. None of the above
  4. International Law prohibiting torture is nearly as old as the practice of torture itself
    1. True
    2. False
  5. Which of the following accurately describes the purpose of torture?
    1. To establish and maintain social control
    2. To suppress and punish political opponents and criminals
    3. To force individuals to “confess” to crimes
    4. To instill a sense of terror within a population
    5. All of the Above
  6. According to the UN Convention Against Torture, which of the following conditions are exceptions for the prohibition against torture?
    1. If an official “state of emergency” is declared
    2. When domestic law allows for exceptions
    3. If the infliction of severe physical and/or mental pain was not the intent of the alleged perpetrators
    4. None of the above
  7. The provision of non-refoulment in the Convention Against Torture refers to:
    1. Not allowing suspected torturers to emigrate to other countries
    2. Not returning individuals to countries where they may be tortured
    3. Not allowing individuals asylum on the basis of torture claims
    4. Not returning suspected torturers to the country where the alleged crimes were committed
  8. States have legal obligations to protect individuals from torture and ill-treatment by non-state actors?
    1. True
    2. False
  9. Perpetrators of torture and ill treatment are commonly officials involved in the criminal investigation process, and those responsible for the security of the state.
    1. True
    2. False
  10. States do not have a legal obligation to investigate acts of torture or ill-treatment unless there has been a formal complaint about it.
    1. True
    2. False
  11. Which of the following is not a condition of prison visits by the International Committee of the Red Cross (ICRC)?
    1. Access to all detainees
    2. Access at any time
    3. To interview detainees in private
    4. To make ICRC investigation findings public
  12. International law prohibiting torture and ill treatment does not apply to states that have not signed or ratified relevant declarations, covenants or conventions which prohibit torture and ill treatment.
    1. True
    2. False
  13. According to the Convention Against Torture, victims of torture have a right to redress and adequate compensation.
    1. True
    2. False
  14. Which of the following will likely decrease the risk of torture and/or ill treatment among persons deprived of their liberty?
    1. Access to legal counsel
    2. Access to a medical doctor
    3. Regular monitoring of detention facilities by UN and regional human rights bodies
    4. Judicial remand within 24 hours of detention
    5. All of the above
  15. The December 2002 Optional Protocol to the UN Convention Against Torture creates a mechanism for regular inspection, by independent international and national bodies, of all places where people are deprived of liberty, within countries that agree to be bound by this Protocol.
    1. True
    2. False
  16. According to international standards:
    1. Detainees should be afforded prompt and regular access to doctors
    2. Detainees should be offered a medical examination as soon as possible after being detained
    3. Care and treatment shall be provided free of charge
    4. Detainees have the right to request a second medical opinion by a doctor of their choice
    5. All of the above
  17. The UN Standard Minimum Rules for the Treatment of Prisoners state that detainees or prisoners needing special treatment must be transferred to specialised institutions or civil hospitals for that treatment.
    1. True
    2. False
  18. Measures to prevent torture and ill treatment include:
    1. Effective monitoring of places of detention
    2. Prohibiting confessions obtained through torture and ill treatment
    3. Unrestricted access to one’s own lawyer and doctor
    4. Ensuring the right to legal challenge of detention before a judge
    5. All of the above
  19. Measures for accountability of torture and ill treatment include:
    1. Effective investigations of allegations of torture and ill treatment
    2. Allowing torture to be prosecuted as an “abuse of police duty”
    3. Ensuring that alleged perpetrators are subject to criminal proceedings
    4. Ensuring adequate victim and witness protection
    5. All of the above
  20. Because all detained people have the right to equal treatment without discrimination, differential treatment for special categories of detainees is not permitted.
    1. True
    2. False

Which of the following is/are included in the UN Convention Against Torture (CAT) definition of torture? The intentional infliction of severe mental or physical pain or suffering Perpetrated by or with the consent or acquiescence of the state authorities Pain … Continue reading →

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Module 2 Presentation: Istanbul Protocol Standards for Medical Documentation of Torture and Medical Ethics


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Download Module 2: Istanbul Protocol Standards for Medical Documentation of Torture and Medical Ethics (PowerPoint Presentation) (ppt)

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Quality of information

The primary goal of documenting allegations of human rights violations is to create an accurate, reliable and precise record of events. The uses to which this record may be put are varied, but all rely on the quality of the record which has been established. Factors which contribute to the quality of information are:

  • The source of the information. Was the information obtained directly from the victim? The further away from the alleged victim or incident the information comes, the less reliable it is likely to be.
  • The level of detail. Is the allegation very detailed? Are there unexplained gaps in the account? The more detail obtained, the better, because it helps others to understand what happened, and it also helps to prevent allegations of fabrication. Psychological and/or organic explanations for gaps should be kept in mind.
  • The absence or presence of contradictions. Minor inconsistencies are common and should not affect the overall quality of the information, but major inconsistencies or contradictions should prompt seeking further clarification of the information.
  • The absence or presence of elements which support (corroborate) or disprove the allegation. Are there witness statements, medical certificates or any other supporting information? The more supporting documentation that is provided, the more likely it is that the allegation will be found credible, but its absence is not evidence that the ill-treatment did not occur.
  • The extent to which the information demonstrates a pattern. Is the allegation one of a number alleging similar facts? Where there is evidence of a practise, there may be a greater presumption that the information is true.
  • The age of the information. Is the information very recent? Does it relate to facts which occurred several years previously? The fresher the information, the easier it is to investigate or verify the facts alleged.

The primary goal of documenting allegations of human rights violations is to create an accurate, reliable and precise record of events. The uses to which this record may be put are varied, but all rely on the quality of the … Continue reading →

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