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Sexual Assault
Sexual torture begins with forced nudity, which in many countries is a constant factor in torture situations. An individual is never as vulnerable as when naked and helpless. Nudity enhances the psychological terror of every aspect of torture, as there is always the potential of abuse, rape or sodomy. Furthermore, verbal sexual threats, abuse and mocking are also part of sexual torture, as they enhance the humiliation and its degrading aspects. The groping of women is traumatic in all cases and is considered to be torture.
Sexual assault is clearly not simply a physical assault on the individual, but in many instances it is the psychological insult that is most injurious. Often, sexual assaults will be accompanied by direct or implied threats. In the case of women, the threat may be one of becoming pregnant. For men, those inflicting the torture may also threaten (incorrectly but usually deliberately) that the victim will become impotent or sterile. For men or women there may be the threat of contracting HIV or other sexually transmitted infections (STIs) and often the threat or fear that sexual humiliation, assault or rape will lead to ostracism from the community and being prevented from ever marrying or starting a family. Sexual assaults can be categorised as:
- Assaults to the genitals
- Electric shocks to the genitals and anus
- Forced sexual acts on themselves or on/with others
- Object inserted into the vagina (in women)
- Object inserted in the urethral meatus (in men)
- Object inserted through the anus
- Penis forced into the mouth
- Penis forced through the anus
- Penis forced into the vagina (in women).
The term ‘rape’ refers to the last of these, but in many jurisdictions it can mean one or more of the others. Thus if the term is used, the act should also be specified.
There are some differences between sexual torture of men and sexual torture of women, but several issues apply to both. Rape is always associated with the risk of developing sexually transmitted diseases, particularly human immunodeficiency virus (HIV).[1] Currently, the only effective prophylaxis against HIV must be taken within hours of the incident, and may not be available in countries where torture occurs routinely. In most cases, there will be a lewd sexual component, and in other cases torture is targeted at the genitals. Electricity and blows are generally targeted on the genitals in men, with or without additional anal torture. The resulting physical trauma is enhanced by verbal abuse. There are often threats of loss of masculinity to men and consequent loss of respect in society. Prisoners may be placed naked in cells with family members, friends or total strangers, breaking cultural taboos. This can be made worse by the absence of privacy when using toilet facilities. Additionally, prisoners may be forced to abuse each other sexually, which can be particularly difficult to cope with emotionally. The fear of potential rape among women, given profound cultural stigma associated with rape, can add to the trauma. Not to be neglected are the trauma of potential pregnancy, which males, obviously, do not experience, the fear of losing virginity and the fear of not being able to have children (even if the rape can be hidden from a potential husband and the rest of society).
Children may also be victims of rape and sexual assault. Even older children may be unaware of what happened to them, and may not be able to give a coherent account of their experience. Using drawings and, if available, dolls may help them explain where they do not have the necessary language or understanding. It is even more important that the examination is performed by someone who is experienced in this field.
If in cases of sexual abuse the alleged victim does not wish the event to be known due to sociocultural pressures or personal reasons, the physician who carries out the medical examination, investigative agencies and the courts have an obligation to cooperate in maintaining the victim’s privacy. Establishing a rapport with torture survivors who have recently been sexually assaulted requires special psychological education and appropriate psychological support. Any treatment that would increase the psychological trauma of a torture survivor should be avoided. Before starting the examination, permission must be obtained from the individual for any kind of examination, and this should be confirmed by the alleged victim before the more intimate parts of the examination. The individual should be informed about the importance of the examination and its possible findings in a clear and comprehensible manner.
Review of symptoms
A thorough history of the alleged assault should be recorded. There are, however, some specific questions that are relevant only to an allegation of sexual abuse. These seek to elicit current symptoms resulting from a recent assault, for example bleeding, vaginal or anal discharge and location of pain, bruises or sores. In cases of sexual assault in the past, questions should be directed to ongoing symptoms that resulted from the assault, such as urinary frequency, incontinence or dysuria, irregularity of menstruation, subsequent history of pregnancy, abortion or vaginal haemorrhage, problems with sexual activity, including intercourse and anal pain, bleeding, constipation or incontinence.
Ideally, there should be adequate physical and technical facilities for appropriate examination of survivors of sexual violation by a team of experienced psychiatrists, psychologists, gynaecologists and nurses, who are trained in the treatment of survivors of sexual torture. An additional purpose of the consultation after sexual assault is to offer support, advice and, if appropriate, reassurance. This should cover issues such as sexually transmitted diseases, HIV, pregnancy, if the alleged victim is a woman, and permanent physical damage, because torturers often tell victims that they will never normally function sexually again, which can become a self-fulfilling prophecy.
[1]I. Lunde and J. Ortmann, “Sexual torture and the treatment of its consequences”, Torture and Its Consequences, Current Treatment Approaches, M. Başoglu, ed. (Cambridge, Cambridge University Press, 1992), pp. 310-331.
Sexual torture begins with forced nudity, which in many countries is a constant factor in torture situations. An individual is never as vulnerable as when naked and helpless. Nudity enhances the psychological terror of every aspect of torture, as there … Continue reading
Toolkit: Istanbul Protocol Model Medical Curriculum
Subject: Module 4: Torture Methods and their Medical Consequences
Issue: Torture
Use: Training
Subject: Module 4: Torture Methods and their Medical Consequences
Issue: Torture
Use: Training
Security
The security of the individual who may complain of or show signs of ill-treatment is closely related to the issues of consent and confidentiality described above. In examining or treating these individuals, the health professional must keep in mind the security of both the patient and him or herself. Often, the patient may have the impression that the health professional can provide an element of physical protection, and even prevent further arrest or ill-treatment. This sense of protection may be even more commonplace when health professionals visit the individual while they are still detained (particularly if it is a visit by an international team) since it is assumed that the fact of having access to the place of detention invests them with greater powers.
The security of the individual extends to how any information collected is used or to whom it is divulged. Clearly the release of any information is governed by the issues of consent and of confidentiality since identifiable information may itself lead to recriminations for the individual, or their family, or indeed the health personnel. Health professionals thus have a duty to ensure that individuals are aware of the limits of their ability to protect them, and must ensure that no information is released or passed on that may put interviewees at risk. All documentation must be stored safely.
The security of the individual who may complain of or show signs of ill-treatment is closely related to the issues of consent and confidentiality described above. In examining or treating these individuals, the health professional must keep in mind the … Continue reading
Common Situations for Torture Allegations
Torture and other forms of ill-treatment may take place in virtually any location. People are particularly at risk when they are deprived of their liberty, held in pre-trial detention, before the person has access to a lawyer or court. People being held in incommunicado detention — without access to anyone in the outside world — are particularly vulnerable.
In some countries, torture is commonplace. Certain times and situations could, however, be considered as high-risk circumstances. These include conflict zones, and situations of political unrest or general violce.
Allegations of torture can come from a variety of sources and at different time. The primary source of information is clearly from the individuals themselves, and this could happen while invustody, immediately after release, or at a later date. The families of survivors are another extremely important source of information as the survivors of torture themselves may be unable, or unwilling, to speak out. In any of the descriptions below, the role of families should also be kept in mind. Information can also come from other sources, such as the media and the work of non-governmental organizations.
Health professionals may find themselves being called upon to assist with an investigation in addition to providing medical treatment. Documentation may range from clear, comprehensive notes that may be summarized later, to a full medico-legal report. Sometimes useful evidence can be gained from analyzing clinical data on survivors of torture and presenting them in a way that does not permit individuals to be identified.
Detainees are probably the segment of the population most likely to suffer torture and other ill-treatment since this kind of abuse is usually inflicted while an indivudial is in some form of custody. The greatest risk of torture and other forms of ill-treatment to individuals is in the first phase of arrest and detention, before they have access to a lawyer or court. Furthermore, incommunicado detention, which prohibits access to anyone such as their lawyer or family, is probably the single highest risk factor for torture since there is not external monitoring of the detention and interrogation process.
It should also be remembered that while torture per se is less common once a person is on remand or sentenced and in prison, deliberately poor conditions of detention, certain treatment or punishments inflicted by staff, or a failure to protect individuals from other prisoners, may also amount to forms of ill-treatment or, in some cases, torture.
Torture and other forms of ill-treatment may take place in virtually any location. People are particularly at risk when they are deprived of their liberty, held in pre-trial detention, before the person has access to a lawyer or court. People … Continue reading
Toolkit: Istanbul Protocol Model Medical Curriculum
Subject: Module 1: International Legal Standards (Overview)
Issue: Torture
Use: Training
Subject: Module 1: International Legal Standards (Overview)
Issue: Torture
Use: Training
Risk of Re-traumatisation
Physical and psychological examinations by their very nature may re-traumatise an individual by provoking and/or exacerbating psychological distress and symptoms by eliciting painful memories. The interview must be structured so as to minimise the risk of re-traumatisation. According to the Istanbul Protocol:
Several basic rules must be respected (see chapter III, sect. C.2 (g). Information is certainly important, but the person being interviewed is even more so, and listening is more important than asking questions.
— (IP, §134)
The clinician needs to balance two important requirements which should be complementary, but may sometimes conflict: the need to obtain a useful account, and the importance of respecting the needs of the person being interviewed. The primary goal of documenting allegations of torture is to create an accurate, reliable, precise and detailed record of events by taking into account the personal situation and the psychological condition of the individual.
Interviewers should show sensitivity in their questioning and watch out for signs of tiredness or distress. A subjective assessment has to be made by the clinician about whether and to what extent pressing for details is necessary for the effectiveness of the report in court, especially if the interviewee demonstrates obvious signs of distress.
Physical and psychological examinations by their very nature may re-traumatise an individual by provoking and/or exacerbating psychological distress and symptoms by eliciting painful memories. The interview must be structured so as to minimise the risk of re-traumatisation. According to the … Continue reading
Toolkit: Istanbul Protocol Model Medical Curriculum
Subject: Module 3: Interview Considerations
Issue: Torture
Use: Training
Subject: Module 3: Interview Considerations
Issue: Torture
Use: Training
Gender Considerations
Ideally, an investigation team should contain specialists of both genders, permitting the person who says that they have been tortured to choose the gender of the investigator and, where necessary, the interpreter. This is particularly important when a woman has been detained in a situation where rape is known to happen, even if she has not, so far, complained of it. Even if no sexual assault takes place, most torture has sexual aspects. The re-traumatisation can often be worse if she feels she has to describe what happened to a person who is physically similar to her torturers, who will inevitably have been mostly or entirely men. In some cultures, it would be impossible for a male investigator to question a female victim, and this must be respected. However, in most cultures, if there is only a male physician available, many women would prefer to talk to him rather than a female of another profession in order to gain the medical information and advice that she wants. In such a case, it is essential that the interpreter, if used, be female. Some interviewees may also prefer that the interpreter be from outside their immediate locality, both because of the danger of being reminded of their torture and because of the perceived threat to their confidentiality. If no interpreter is necessary, then a female member of the investigating team should be present as a chaperone throughout at least the physical examination and, if the patient wishes, throughout the entire interview.
When the individual is male and has been sexually abused, the situation is more complex because he too will have been sexually abused mostly or entirely by men. Some men would, therefore, prefer to describe their experiences to women because their fear of other men is so great, while others would not want to discuss such personal matters in front of a woman.
Ideally, an investigation team should contain specialists of both genders, permitting the person who says that they have been tortured to choose the gender of the investigator and, where necessary, the interpreter. This is particularly important when a woman has … Continue reading
Toolkit: Istanbul Protocol Model Medical Curriculum
Subject: Module 3: Interview Considerations
Issue: Torture
Use: Training
Subject: Module 3: Interview Considerations
Issue: Torture
Use: Training
Closing
To conclude the medical evaluation, the clinician should review the next steps in the process of medical documentation, for example, that the clinician will forward a copy of his or her report to the individual’s attorney, or that the clinician is recommending additional tests or consultations. The clinician should consider acknowledging the emotional difficulty of the interview and thank the interviewee for his or her time and effort. During the psychological examination, the clinician may have reassured the individual that their symptoms are nomal reactions to extreme experiences. This is particularly helpful when the individual feels that their symptoms are a sign of “going crazy.” The clinician may consider reviewing this point with the individual at the end of the interview.
To conclude the medical evaluation, the clinician should review the next steps in the process of medical documentation, for example, that the clinician will forward a copy of his or her report to the individual’s attorney, or that the clinician … Continue reading
Toolkit: Istanbul Protocol Model Medical Curriculum
Subject: Module 3: Interview Considerations
Issue: Torture
Use: Training
Subject: Module 3: Interview Considerations
Issue: Torture
Use: Training
Sexual Humiliation
Sexual humiliation usually involves forcing individuals to perform humiliating acts, often in an attempt to exploit cultural and religious stereotypes regarding sexual behavior and induce feelings of shame, guilt and worthlessness.
Sexual humiliation can result in lasting psychological symptoms in the form of posttraumatic stress disorder and major depression, and that individuals often relive the humiliation long after their release through flashbacks and nightmares. Sexually humiliating treatment can also affect an individual’s sense of identity and autonomy. Individuals often experience feelings of intense shame, guilt, grief, fear, and social isolation. Victims who have been forced into humiliating acts can feel “responsible for participating in their own degradation” resulting in intense and long lasting shame.
The UN Special Rapporteur on Torture has found that both depriving detainees of clothing and stripping them naked are psychologically harmful methods used by the United States that constitute torture and ill-treatment.[1] The European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment has found that even mere threats of sexual humiliation “could be considered to amount to psychological torture.”[2]
[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. 108. (Hereafter: Broken Laws, Broken Lives).
[2] Broken Laws, Broken Lives pp. 108.
Sexual humiliation usually involves forcing individuals to perform humiliating acts, often in an attempt to exploit cultural and religious stereotypes regarding sexual behavior and induce feelings of shame, guilt and worthlessness. Sexual humiliation can result in lasting psychological symptoms in … Continue reading
Toolkit: Istanbul Protocol Model Medical Curriculum
Subject: Module 4: Torture Methods and their Medical Consequences
Issue: Torture
Use: Training
Subject: Module 4: Torture Methods and their Medical Consequences
Issue: Torture
Use: Training
Where Does Torture and Ill-treatment Occur?
Torture can occur anywhere but usually occurs during the initial phase of arrest and detention, thus often in the hands of police, gendarmerie, military or other security agencies and may be in official places of detention such as police stations, or in unofficial (or ‘secret’) locations. The fact that torture may not just be confined to places of detention is recognized in the Statute of the International Criminal Court, which states that it may occur when a person is “in the custody or control” or a party. Torture and other forms of cruel, inhuman and degrading treatment or punishment can also occur in the hands of opposition forces and informal militias. There is a duty on the state to protect people from these groups and to investigate and punish as necessary.
Torture is not just limited to what happens in the interrogation room, but may also relate to specific elements of the conditions of detention which are constructed to deliberately aggravate mental and physical suffering. Often the generally harsh conditions of detention (including inadequate or insufficient food, hygiene, personal cleanliness, access to toilets, and access to medical care) are aimed at exerting further pressure on individuals and contribute to and form part of ill-treatment that may in some cases constitute torture.
Torture can occur anywhere but usually occurs during the initial phase of arrest and detention, thus often in the hands of police, gendarmerie, military or other security agencies and may be in official places of detention such as police stations, … Continue reading
Toolkit: Istanbul Protocol Model Medical Curriculum
Subject: Module 1: International Legal Standards (Overview)
Issue: Torture
Use: Training
Subject: Module 1: International Legal Standards (Overview)
Issue: Torture
Use: Training
Involvement of other health professionals in torture
Health professionals may at times have concerns that other health professionals might be participating directly or indirectly in the torture or other ill-treatment of individuals. The appropriate course of action in such cases can depend on the particular circumstances, for instance, whether the concerned health professional is working within the same institution as those he or she suspects; whether he or she is a local practitioner or part of an international visiting team; and the assessment of level of risk that may be involved in various courses of action. In some cases, a private discussion with trusted colleagues may be enough to clarify and bring about positive change. In other cases, there may be a need to turn (sometimes discreetly) to outside bodies, national or international (such as medical associations or human rights bodies), in order to seek advice.
Health professionals may at times have concerns that other health professionals might be participating directly or indirectly in the torture or other ill-treatment of individuals. The appropriate course of action in such cases can depend on the particular circumstances, for … Continue reading
