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OFFICE OF THE UNITED NATIONS HIGH COMMISSIONER FOR HUMAN RIGHTS Geneva PROFESSIONAL TRAINING SERIES No. 8/Rev.1 UNITED NATIONS New York and Geneva, 2004 Istanbul Protocol Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment UNITED NATIONS PUBLICATION Sales No. E.04.XIV.3 ISBN 92-1-116726-4 ISSN 1020-1688 NOTE The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the United Nations concerning the legal status of any country, territory, city or area, or of its authorities, or concerning the delimitation of its frontiers or boundaries. * * * Material contained in this publication may be freely quoted or reprinted, pro- vided credit is given and a copy of the publication containing the reprinted material is sent to the Office of the High Commissioner for Human Rights, United Nations, 1211 Geneva 10, Switzerland. ISBN 92-1-154156-5 HR/P/PT/8/Rev.1 vi Chapter Paragraphs Page 55. Protection of witnesses ................................................................. 112 23 56. Proceedings................................................................................... 113 23 57. Notice of inquiry........................................................................... 114 23 58. Receipt of evidence ...................................................................... 115 23 59. Rights of parties............................................................................ 116 24 10. Evaluation of evidence ................................................................. 117 24 11. Report of the commission............................................................. 118-119 24 IV. GENERAL CONSIDERATIONS FOR INTERVIEWS.................................................... 120-160 25 A. Purpose of inquiry, examination and documentation ............................ 121-122 25 B. Procedural safeguards with respect to detainees ................................... 123-126 25 C. Official visits to detention centres ......................................................... 127-134 26 D. Techniques of questioning ..................................................................... 135 27 E. Documenting the background................................................................ 136-141 27 1. Psychosocial history and pre-arrest ................................................ 136 27 2. Summary of detention and abuse.................................................... 137 27 3. Circumstances of detention ............................................................ 138 28 4. Place and conditions of detention................................................... 139 28 5. Methods of torture and ill-treatment............................................... 140-141 28 F. Assessment of the background .............................................................. 142-143 28 G. Review of torture methods .................................................................... 144-145 29 H. Risk of re-traumatization of the interviewee ......................................... 146-149 29 I. Use of interpreters ................................................................................. 150-153 30 J. Gender issues......................................................................................... 154-155 30 K. Indications for referral ........................................................................... 156 31 L. Interpretation of findings and conclusions ............................................ 157-160 31 IV. PHYSICAL EVIDENCE OF TORTURE..................................................................... 161-233 33 A Interview structure................................................................................. 163-167 33 B. Medical history ...................................................................................... 168-172 34 1. Acute symptoms ............................................................................. 170 34 2. Chronic symptoms.......................................................................... 171 34 3. Summary of an interview ............................................................... 172 34 C. The physical examination...................................................................... 173-186 34 1. Skin................................................................................................. 176 35 2. Face................................................................................................. 177-182 35 3. Chest and abdomen......................................................................... 183 36 4. Musculoskeletal system.................................................................. 184 36 5. Genito-urinary system .................................................................... 185 36 6. Central and peripheral nervous systems ......................................... 186 36 D. Examination and evaluation following specific forms of torture .......... 187-232 36 1. Beatings and other forms of blunt trauma ...................................... 189-202 37 2. Beatings to the feet ......................................................................... 203-205 38 3. Suspension ...................................................................................... 206-209 39 4. Other positional torture................................................................... 210-211 40 5. Electric shock torture...................................................................... 212 40 6. Dental torture.................................................................................. 213 41 7. Asphyxiation................................................................................... 214 41 8. Sexual torture including rape.......................................................... 215-232 41 E. Specialized diagnostic tests ................................................................... 233 44 VI. PSYCHOLOGICAL EVIDENCE OF TORTURE .......................................................... 234-315 45 A. General considerations .......................................................................... 234-239 45 1. The central role of the psychological evaluation............................ 234-237 45 2. The context of the psychological evaluation .................................. 238-239 46 vii Paragraphs Page B. Psychological consequences of torture.................................................. 240-259 46 1. Cautionary remarks......................................................................... 240 46 2. Common psychological responses.................................................. 241-249 46 3. Diagnostic classifications ............................................................... 250-259 47 C. The psychological/psychiatric evaluation ............................................. 260-315 49 1. Ethical and clinical considerations ................................................. 260-262 49 2. The interview process..................................................................... 263-274 50 3. Components of the psychological/psychiatric evaluation .............. 275-291 52 4. Neuropsychological assessment ..................................................... 292-309 54 5. Children and torture........................................................................ 310-315 57 ANNEXES III. Principles on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment ............................................................... 59 III. Diagnostic tests.................................................................................................................... 61 III. Anatomical drawings for the documentation of torture and ill-treatment ........................... 65 IV. Guidelines for the medical evaluation of torture and ill-treatment ..................................... 73 viii CONTRIBUTING AUTHORS AND OTHER PARTICIPANTS Project coordinators Dr. Vincent Iacopino, Physicians for Human Rights USA, Boston, United States Dr. Önder Özkalipçi, Human Rights Foundation of Turkey, Istanbul, Turkey Ms. Caroline Schlar, Action for Torture Survivors (HRFT), Geneva Editorial committee Dr. Kathleen Allden, Indochinese Psychiatric Clinic, Boston, and Department of Psychiatry, Dartmouth Medical School, Lebanon, New Hampshire, United States Dr. Türkcan Baykal, Human Rights Foundation of Turkey, Izmir, Turkey Dr. Vincent Iacopino, Physicians for Human Rights USA, Boston, United States Dr. Robert Kirschner, Physicians for Human Rights USA, Chicago, United States Dr. Önder Özkalipçi, Human Rights Foundation of Turkey, Istanbul, Turkey Dr. Michael Peel, The Medical Foundation for the Care of Victims of Torture, London Dr. Hernan Reyes, Center for the Study of Society and Medicine, Columbia Univer- sity, New York Mr. James Welsh, Amnesty International, London Rapporteurs Dr. Kathleen Allden, Indochinese Psychiatric Clinic, Boston, and Department of Psychiatry, Dartmouth Medical School, Lebanon, New Hampshire, United States Ms. Barbara Frey, Institute for Global Studies, University of Minnesota, Minneapolis, United States Dr. Robert Kirschner, Physicians for Human Rights USA, Chicago, United States Dr. Şebnem Korur Fincanci, Society of Forensic Medicine Specialists, Istanbul, Turkey Dr. Hernan Reyes, Center for the Study of Society and Medicine, Columbia University, New York Ms. Ann Sommerville, British Medical Association, London Dr. Numfondo Walaza, The Trauma Centre for Survivors of Violence and Torture, Cape Town, South Africa Contributing authors Dr. Suat Alptekin, Forensic Medicine Department, Istanbul, Turkey Dr. Zuhal Amato, Ethics Department, Doküz Eylul Medical Faculty, Izmir, Turkey Dr. Alp Ayan, Human Rights Foundation of Turkey, Izmir, Turkey Dr. Semih Aytaçlar, Sonomed, Istanbul, Turkey Dr. Metin Bakkalci, Human Rights Foundation of Turkey, Ankara, Dr. Ümit Biçer, Society of Forensic Medicine Specialists, Istanbul, Turkey Dr. Yeşim Can, Human Rights Foundation of Turkey, Istanbul, Turkey Dr. John Chisholm, British Medical Association, London Dr. Lis Danielsen, International Rehabilitation Council for Torture Victims, Copenhagen Dr. Hanan Diab, Physicians for Human Rights Palestine, Gaza 1 INTRODUCTION Torture is defined in this manual in the words of the United Nations Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, 1984: [T]orture means any act by which severe pain or suffering, whether physical or men- tal, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession, punishing him for an act he or a third person, has com- mitted or is suspected of having committed, or intimidating or coercing him or a third per- son, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity. It does not include pain or suffering arising only from, inherent in or incidental to lawful sanctions.1 Torture is a profound concern of the world community. Its purpose is to destroy deliberately not only the physical and emotional well-being of individuals but also, in some instances, the dignity and will of entire communities. It concerns all members of the human family because it impugns the very meaning of our existence and our hopes for a brighter future.2 Although international human rights and humanitarian law consistently prohibit torture under any circumstance (see chapter I), torture and ill-treatment are practised in more than half of the world’s countries.3, 4 The striking disparity between the absolute prohibition of torture and its prevalence in the world today demonstrates the need for States to identify and implement effective measures to protect individuals from torture and ill-treatment. This manual was developed to enable States to address one of the most fundamental concerns in protecting individuals from torture—effective docu- mentation. Such documentation brings evidence of torture and ill-treatment to light so that perpetrators may be held accountable for their actions and the interests of justice may be served. The documentation methods contained in this manual are also appli- cable to other contexts, including human rights investigations and monitoring, political asylum evaluations, the defence of individuals who “confess” to crimes during torture and needs assessments for the care of torture victims, among others. In the case of health professionals who are coerced into neglect, misrepresentation or falsification of evidence of torture, this manual also provides an international point of reference for health professionals and adjudicators alike. During the past two decades, much has been learned about torture and its conse- quences, but no international guidelines for documentation were available prior to the development of this manual. The Istanbul Protocol: Manual on the Effective Investi- gation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treat- ment or Punishment is intended to serve as international guidelines for the assessment of persons who allege torture and ill-treatment, for investigating cases of alleged tor- ture and for reporting findings to the judiciary or any other investigative body. This manual includes principles for the effective investigation and documentation of torture, 1 Since 1982, the recommendations concerning United Nations assistance to victims of torture made by the Board of Trustees of the United Nations Voluntary Fund for Victims of Torture to the Secretary- General of the United Nations, are based on article 1 of the Declaration on the Protection of All Persons from Being Subjected to Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, which provides that “Torture constitutes an aggravated and deliberate form of cruel, inhuman or degrading treatment or punishment” and that “It does not include pain or suffering arising only from, inherent in or incidental to, lawful sanctions to the extent consistent with the Standard Minimum Rules for the Treatment of Prisoners”, as well as on all other relevant international instruments. 2 V. Iacopino, “Treatment of survivors of political torture: commentary”, The Journal of Ambulatory Care Management, vol. 21 (2) (1998), pp. 5-13. 3 Amnesty International, Amnesty International Report 1999 (London, AIP, 1999). 4 M. Basoglu, “Prevention of torture and care of survivors: an integrated approach”, The Journal of the American Medical Association (JAMA), vol. 270 (1993), pp. 606-611. ^ , 2 and other cruel, inhuman or degrading treatment or punishment (see annex I). These principles outline minimum standards for States in order to ensure the effective docu- mentation of torture.5 The guidelines contained in this manual are not presented as a fixed protocol. Rather, they represent minimum standards based on the principles and should be used taking into account available resources. The manual and principles are the result of three years of analysis, research and drafting, undertaken by more than 75 experts in law, health and human rights, representing 40 organizations or institutions from 15 countries. The conceptualization and preparation of this manual was a col- laborative effort between forensic scientists, physicians, psychologists, human-rights monitors and lawyers working in Chile, Costa Rica, Denmark, France, Germany, India, Israel, the Netherlands, South Africa, Sri Lanka, Switzerland, Turkey, the United King- dom, the United States of America, and the occupied Palestinian territories. 5 The Principles on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment are annexed to General Assembly resolution 55/89 of 4 December 2000 and to Commission on Human Rights resolution 2000/43 of 20 April 2000, both adopted without a vote. 3 1. The right to be free from torture is firmly estab- lished under international law. The Universal Declaration of Human Rights, the International Covenant on Civil and Political Rights and the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punish- ment all expressly prohibit torture. Similarly, several regional instruments establish the right to be free from torture. The American Convention on Human Rights, the African Charter on Human and Peoples’ Rights and the European Convention for the Protection of Human Rights and Fundamental Freedoms all contain express prohibi- tions of torture. A. International humanitarian law 2. The international treaties governing armed con- flicts establish international humanitarian law or the law of war. The prohibition of torture under international humanitarian law is only a small, but important, part of the wider protection these treaties provide for all victims of war. The four Geneva Conventions of 1949 have been ratified by 188 States. They establish rules for the conduct of international armed conflict and, especially, for the treatment of persons who do not, or who no longer, take part in hostilities, including the wounded, the captured and civilians. All four conventions prohibit the infliction of torture and other forms of ill-treatment. Two Protocols of 1977, additional to the Geneva Conventions, expand the protection and scope of these conventions. Protocol I (ratified to date by 153 States) covers international con- flicts. Protocol II (ratified to date by 145 States) covers non-international conflicts. 3. More important to the purpose here, however, is what is known as “Common Article 3”, found in all four conventions. Common Article 3 applies to armed con- flicts “not of an international character”, no further defi- nition being given. It is taken to define core obligations that must be respected in all armed conflicts and not just in international wars between countries. This is generally taken to mean that no matter what the nature of a war or conflict, certain basic rules cannot be abrogated. The pro- hibition of torture is one of these and represents an element common to international humanitarian law and human rights law. 4. Common Article 3 states: . . . the following acts are and shall remain prohibited at any time and in any place whatsoever. . . violence to life and person, in particular mur- der of all kinds, mutilation, cruel treatment and torture; . . . outrages upon personal dignity, in particular humiliating and degrading treatment.. . CHAPTER I RELEVANT INTERNATIONAL LEGAL STANDARDS 5. As the Special Rapporteur on the question of tor- ture, Nigel Rodley, has stated: The prohibition of torture or other ill-treatment could hardly be for- mulated in more absolute terms. In the words of the official commen- tary on the text by the International Committee of the Red Cross (ICRC), no possible loophole is left; there can be no excuse, no attenu- ating circumstances.6 6. A further link between international humanitarian law and human rights law is found in the preamble to Protocol II, which itself regulates non-international armed conflicts (such as fully-fledged civil wars), and which states that: “… international instruments relating to human rights offer a basic protection to the human per- son.”7 B. The United Nations 7. The United Nations has sought for many years to develop universally applicable standards to ensure adequate protection for all persons against torture or cruel, inhuman or degrading treatment. The conventions, declarations and resolutions adopted by the Member States of the United Nations clearly state that there may be no exception to the prohibition of torture and establish other obligations to ensure protection against such abuses. Among the most important of these instruments are the Universal Declaration of Human Rights,8 the Interna- tional Covenant on Civil and Political Rights,9 the Stand- ard Minimum Rules for the Treatment of Prisoners,10 the Declaration on the Protection of All Persons from Being Subjected to Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (Declaration on the Protection against Torture),11 the Code of Conduct on 6 N. Rodley, The Treatment of Prisoners under International Law, 2nd ed. (Oxford, Clarendon Press, 1999), p. 58. 7 Second preambular paragraph of Protocol II (1977), additional to the Geneva Conventions of 1949. 8 General Assembly resolution 217 A (III) of 10 December 1948, art. 5; see Official Records of the General Assembly, Third Session (A/810), p. 71. 9 Entered into force on 23 March 1976; see General Assembly resolution 2200 A (XXI), of 16 December 1966, annex, art. 7; Official Records of the General Assembly, Twenty-first Session, Supplement No. 16 (A/6316), p. 52, and United Nations, Treaty Series, vol. 999, p.171. 10 Adopted on 30 August 1955 by the First United Nations Congress on the Prevention of Crime and the Treatment of Offenders. 11 General Assembly resolution 3452 (XXX) of 9 December 1975, annex, arts. 2 and 4; see Official Records of the General Assembly, Thirtieth Session, Supplement No. 34 (A/10034), p. 91. 6 gated promptly and impartially by competent authorities so as to make the remedy effective”. Where a State has ratified the first Optional Protocol to the International Covenant on Civil and Political Rights, an individual may submit a communication to the Committee complaining that his rights under the Covenant have been violated. If found admissible, the Committee issues a decision on the merits, which is made public in its annual report. (c) Commission on Human Rights 18. The Commission on Human Rights is the pri- mary human rights body of the United Nations. It is com- posed of 53 Member States elected by the Economic and Social Council for three-year terms. The Commission meets annually for six weeks in Geneva to act on human rights issues. The Commission may initiate studies and fact-finding missions, draft conventions and declarations for approval by higher United Nations bodies and discuss specific human rights violations in public or private ses- sions. On 6 June 1967, the Economic and Social Council, in resolution 1235, authorized the Commission to exam- ine allegations of gross violations of human rights and to “make a thorough study of situations which reveal a consistent pattern of violations of human rights”.22 Under this mandate, the Commission has, among other pro- cedures, adopted resolutions expressing concern about human rights violations and has appointed special rappor- teurs to address human rights violations falling under a particular theme. The Commission has also adopted reso- lutions regarding torture and other cruel, inhuman or degrading treatment or punishment. In its resolution 1998/38, the Commission stressed that “all allegations of torture or cruel, inhuman or degrading treatment or pun- ishment should be promptly and impartially examined by the competent national authority”. (d) Special Rapporteur on the question of torture 19. In 1985, the Commission decided, in resolution 1985/33, to appoint a Special Rapporteur on the question of torture. The Special Rapporteur is charged with seek- ing and receiving credible and reliable information on questions relevant to torture and to respond to that infor- mation without delay. The Commission has continued to renew the Special Rapporteur’s mandate in subsequent resolutions. 20. The Special Rapporteur’s authority to monitor extends to all Member States of the United Nations and to all States with observer status, regardless of the State’s ratification of the Convention against Torture. The Spe- cial Rapporteur establishes contact with Governments, asks them for information on legislative and administra- tive measures taken to prevent torture, requests them to remedy any consequences and asks them to respond to information alleging the actual occurrence of torture. The Special Rapporteur also receives requests for urgent action, which he or she brings to the attention of the Gov- ernments concerned in order to ensure protection of an individual’s right to physical and mental integrity. In addi- tion, the Special Rapporteur holds consultations with gov- 22 Ibid., E/4393. ernment representatives who wish to meet with him or her and, in accordance with the position’s mandate, makes in situ visits to some parts of the world. The Special Rappor- teur submits reports to the Commission on Human Rights and to the General Assembly. These reports describe actions that the Special Rapporteur has taken under his or her mandate and persistently draw attention to the impor- tance of prompt investigation of torture allegations. In the Report of the Special Rapporteur on the question of tor- ture of 12 January 1995, the Special Rapporteur, Nigel Rodley, made a series of recommendations. In para- graph 926 (g) of the report, he stated: When a detainee or relative or lawyer lodges a torture complaint, an inquiry should always take place.. . Independent national authorities, such as a national commission or ombudsman with investigatory and/ or prosecutorial powers, should be established to receive and to inves- tigate complaints. Complaints about torture should be dealt with im- mediately and should be investigated by an independent authority with no relation to that which is investigating or prosecuting the case against the alleged victim.23 21. The Special Rapporteur emphasized this recom- mendation in his report of 9 January 1996.24 Discussing his concern about torture practices, the Special Rappor- teur pointed out in paragraph 136 that “both under general international law and under the Convention against Tor- ture and Other Cruel, Inhuman or Degrading Treatment or Punishment, States are obliged to investigate allegations of torture”. (e) Special Rapporteur on violence against women 22. The Special Rapporteur on violence against women was established in 1994 by resolution 1994/45 of the Commission on Human Rights and that mandate was renewed by resolution 1997/44. The Special Rapporteur has established procedures to seek clarification and infor- mation from Governments, in a humanitarian spirit, on specific cases of alleged violence in order to identify and investigate specific situations and allegations of violence against women in any country. These communications may concern one or more individuals identified by name or information of a more general nature relating to a pre- vailing situation condoning or perpetrating violence against women. The definition of gender-based violence against women used by the Special Rapporteur is taken from the Declaration on the Elimination of Violence against Women, adopted by the General Assembly in resolution 48/104 of 20 December 1993. Urgent appeals may be sent by the Special Rapporteur in cases of gender- based violence against women that involve or may involve an imminent threat or fear of threat to the right to life or physical integrity of a person. The Special Rappor- teur urges the competent national authorities not only to provide comprehensive information on the case but also to carry out an independent and impartial investigation concerning the case transmitted and to take immediate action to ensure that no further violation of the human rights of women occur. 23 Ibid., E/CN.4/1995/34. 24 Ibid., E/CN.4/1996/35. 7 23. The Special Rapporteur reports annually to the Commission on Human Rights on communications sent to Governments and on replies received by him or her. On the basis of information received from Governments and other reliable sources, the Special Rapporteur makes rec- ommendations to the Governments concerned with a view to finding durable solutions to the elimination of violence against women in any country. The Special Rap- porteur may send follow-up communications to Govern- ments when no replies have been received or when insuf- ficient information has been provided. Should a particular situation of violence against women in any given country persist and information received by the Special Rappor- teur indicate that no measures are or have been taken by a Government to ensure the protection of the human rights of women, the Special Rapporteur may consider the pos- sibility of seeking permission from the Government con- cerned to visit that country in order to carry out an on-site fact-finding mission. (f) United Nations Voluntary Fund for Victims of Torture 24. The physical and psychological after-effects of torture can be devastating and last for years, affecting not only the victims but also members of their families. Assistance in recovering from the trauma suffered can be obtained from organizations that specialize in assisting victims of torture. In December 1981, the General Assem- bly established the United Nations Voluntary Fund for Victims of Torture to receive voluntary contributions for distribution to non-governmental organizations (NGOs) that provide psychological, medical, social, economic, legal and other forms of humanitarian assistance to vic- tims of torture and members of their families. Depending on the voluntary contributions available, the Fund may finance about 200 NGO projects assisting about 80,000 victims of torture and members of their families in about 80 countries worldwide. The Fund financed the drafting and translation of the present manual and recommended its publication in the Professional Training Series of the Office of the United Nations High Commissioner for Human Rights, following a recommendation of its Board of Trustees, which subsidizes a limited number of projects to train health professionals and others on how to provide specialized assistance to victims of torture. C. Regional organizations 25. Regional bodies have also contributed to the development of standards for the prevention of torture. These bodies include the Inter-American Commission on Human Rights, the Inter-American Court of Human Rights, the European Court of Human Rights, the Euro- pean Committee for the Prevention of Torture and the African Commission on Human Rights. 1. The Inter-American Commission on Human Rights and the Inter-American Court of Human Rights 26. On 22 November 1969, the Organization of American States adopted the American Convention on Human Rights, which entered into force on 18 July 1978.25 Article 5 of the Convention states: 1. Every person has the right to have his physical, mental, and moral integrity respected. 2. No one shall be subjected to torture or to cruel, inhuman, or degrading punishment or treatment. All persons deprived of their lib- erty shall be treated with respect for the inherent dignity of the human person. 27. Article 33 of the Convention provides for the establishment of the Inter-American Commission on Human Rights and the Inter-American Court of Human Rights. As stated in its regulations, the Commission’s principal function is to promote the observance and defence of human rights and to serve as an advisory body to the Organization of American States in this area.26 In fulfilling this function, the Commission has looked to the Inter-American Convention to Prevent and Punish Tor- ture to guide its interpretation of what is meant by torture under article 5.27 The Inter-American Convention to Pre- vent and Punish Torture was adopted by the Organization of American States on 9 December 1985 and entered into force on 28 February 1987.28 Article 2 of the Convention defines torture as: .. .stany act intentionally performed whereby physical or mental pain or suffering is inflicted on a person for purposes of criminal investiga- tion, as a means of intimidation, as personal punishment, as a preven- tive measure, as a penalty, or for any other purpose. Torture shall also be understood to be the use of methods upon a person intended to oblit- erate the personality of the victim or to diminish his physical or mental capacities, even if they do not cause physical pain or mental anguish. 28. Under article 1, the States parties to the Conven- tion undertake to prevent and punish torture in accordance with the terms of the Convention. States parties to the Convention are required to conduct an immediate and proper investigation into any allegation that torture has occurred within their jurisdiction. 29. Article 8 provides that “States Parties shall guar- antee that any person making an accusation of having been subjected to torture within their jurisdiction shall have the right to an impartial examination of his case”. Likewise, if there is an accusation or well-grounded rea- son to believe that an act of torture has been committed within their jurisdiction, the States parties must guarantee that their respective authorities will proceed properly and immediately to conduct an investigation into the case and initiate, whenever appropriate, the corresponding criminal process. 30. In one of its 1998 country reports, the Commis- sion noted that an obstacle to the effective prosecution of torturers is the lack of independence in an investigation of claims of torture, as the investigation is required to be undertaken by federal bodies likely to be acquainted with 25 Organization of American States, Treaty Series, No. 36, and United Nations, Treaty Series, vol. 1144, p. 123, reprinted in “Basic documents pertaining to human rights in the inter-American system” (OEA/Ser. L.V/II.82, document 6, rev. 1), p. 25 (1992). 26 “Regulations of the Inter-American Commission on Human Rights” (OEA/Ser.L.V/II.92), document 31, rev. 3 of 3 May 1996, art. (1). 27 See case 10.832, report No. 35/96, Inter-American Commission on Human Rights Annual Report 1997, para. 75. 28 Organization of American States, Treaty Series, No. 67. 8 parties accused of committing torture.29 The Commission cited article 8 to underscore the importance of an “impar- tial examination” of each case.30 31. The Inter-American Court of Human Rights has addressed the necessity of investigating claims of viola- tions of the American Convention on Human Rights. In its decision in the Velásquez Rodríguez case, judgement of 29 July 1988, the Court stated that: The State is obligated to investigate every situation involving a viola- tion of the rights protected by the Convention. If the State apparatus acts in such a way that the violation goes unpunished and the victim’s full enjoyment of such rights is not restored as soon as possible, the State has failed to comply with its duty to ensure the free and full exer- cise of those rights to the persons within its jurisdiction. 32. Article 5 of the Convention provides for the right to be free from torture. Although the case dealt specifi- cally with the issue of disappearance, one of the rights referred to by the Court as guaranteed by the American Convention on Human Rights is the right not to be sub- jected to torture or other forms of ill-treatment. 2. The European Court of Human Rights 33. On 4 November 1950, the Council of Europe adopted the European Convention for the Protection of Human Rights and Fundamental Freedoms, which entered into force on 3 September 1953.31 Article 3 of the European Convention states that “No one shall be sub- jected to torture or to inhuman or degrading treatment or punishment”. The European Convention established con- trol mechanisms consisting of the European Court and the European Commission of Human Rights. Since the reform that entered into force on 1 November 1998, a new permanent Court has replaced the former Court and Com- mission. The right of individual applications is now man- datory, and all victims have direct access to the Court. The Court has had the occasion to consider the necessity of investigating allegations of torture as a way of ensuring the rights guaranteed by article 3. 34. The first judgement on this issue was the decision in the Aksoy v. Turkey case (100/1995/606/694), delivered on 18 December 1996.32 In that case, the Court consid- ered that: [w]here an individual is taken into police custody in good health but is found to be injured at the time of release, it is incumbent on the State to provide a plausible explanation as to the causing of the injury, failing which a clear issue arises under Article 3 of the Convention.33 35. The Court went on to hold that the injuries inflicted on the applicant resulted from torture and that article 3 had been violated.34 Furthermore, the Court interpreted article 13 of the Convention, which provides 29 Inter-American Commission on Human Rights, Report on the Situation of Human Rights in Mexico, 1998, para. 323. 30 Ibid., para. 324. 31 United Nations, Treaty Series, vol. 213, p. 222. 32 See Additional Protocols Nos. 3, 5 and 8, which entered into force on 21 September 1970, 20 December 1971 and 1 January 1990, European Treaty Series Nos. 45, 46 and 118, respectively. 33 See European Court of Human Rights, Reports of Judgments and Decisions 1996–VI, para. 61. 34 Ibid., para. 64. for the right to an effective remedy before a national authority, as imposing an obligation to investigate claims of torture thoroughly. Considering the “fundamental importance of the prohibition of torture” and the vulner- ability of torture victims, the Court held that “Article 13 imposes, without prejudice to any other remedy available under the domestic system, an obligation on States to carry out a thorough and effective investigation of inci- dents of torture”.35 36. According to the Court’s interpretation, the notion of an “effective remedy” in article 13 entails a thor- ough investigation of every “arguable claim” of torture. The Court noted that although the Convention has no express provision, such as article 12 of the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, “such a requirement is implicit in the notion of an ‘effective remedy’ under Article 13”.36 The Court then found that the State had violated article 13 by failing to investigate the applicant’s allegation of tor- ture.37 37. In a judgement of 28 October 1998 in the case of Assenov and Others v. Bulgaria (90/1997/874/1086), the Court went even further in recognizing an obligation for the State to investigate allegations of torture not only under article 13 but also under article 3. In this case, a young Romany arrested by the police showed medical evidence of beatings, but it was impossible to assess, on the basis of available evidence, whether these injuries were caused by his father or by the police. The Court rec- ognized that “the degree of bruising found by the doctor who examined Mr. Assenov . . .indicates that the latter’s injuries, whether caused by his father or by the police, were sufficiently serious to amount to ill-treatment within the scope of Article 3”.38 Contrary to the Commission that held that there was no violation of article 3, the Court did not stop there. It went on and considered that the facts raised “a reasonable suspicion that these injuries may have been caused by the police”.39 Hence the Court held that: [I]n these circumstances, where an individual raises an arguable claim that he has been seriously ill-treated by the police or other such agents of the State unlawfully and in breach of Article 3, that provision, read in conjunction with the State’s general duty under Article 1 of the Convention “to secure to everyone within their jurisdiction the rights and freedoms defined in [the] Convention”, requires by implication that there should be an effective official investigation. This investi-gation.. . should be capable of leading to the identification and punishment of those responsible. If this were not the case, the general legal prohibition of torture and inhuman and degrading treatment and punishment, despite its fundamental importance.. ., would be ineffective in practice and it would be possible in some cases for agents of the State to abuse the rights of those within their control with virtual impunity.40 38. For the first time, the Court concluded that a vio- lation of article 3 had occurred, not from ill-treatment per se but from a failure to carry out effective official investigation on the allegation of ill-treatment. In addi- 35 Ibid., para. 98. 36 Ibid. 37 Ibid., para. 100. 38 Ibid., Reports of Judgments and Decisions 1998–VIII, para. 95. 39 Ibid., para. 101. 40 Ibid., para. 102. 11 48. All professions work within ethical codes, which provide a statement of the shared values and acknowl- edged duties of professionals and set moral standards with which they are expected to comply. Ethical standards are established primarily in two ways: by international instru- ments drawn up by bodies like the United Nations and by codes of principles drafted by the professions themselves, through their representative associations, nationally or internationally. The fundamental tenets are invariably the same and focus on obligations owed by the professional to individual clients or patients, to society at large and to colleagues in order to maintain the honour of the profes- sion. These obligations reflect and complement the rights to which all people are entitled under international instru- ments. A. Ethics of the legal profession 49. As the ultimate arbiters of justice, judges play a special role in the protection of the rights of citizens. International standards create an ethical duty on the part of judges to ensure that the rights of individuals are pro- tected. Principle 6 of the United Nations Basic Principles on the Independence of the Judiciary states that “The prin- ciple of the independence of the judiciary entitles and requires the judiciary to ensure that judicial proceedings are conducted fairly and that the rights of the parties are respected”.45 Similarly, prosecutors have an ethical duty to investigate and prosecute a crime of torture committed by public officials. Article 15 of the United Nations Guidelines on the Role of Prosecutors states: “Prosecu- tors shall give due attention to the prosecution of crimes committed by public officials, particularly corruption, abuse of power, grave violations of human rights and other crimes recognized by international law and, where authorized by law or consistent with local practice, the investigation of such offences.”46 50. International standards also establish a duty for lawyers, in carrying out their professional functions, to promote and protect human rights and fundamental 45 Adopted by the Seventh United Nations Congress on the Prevention of Crime and the Treatment of Offenders, held at Milan, Italy, from 26 August to 6 September 1985 and endorsed by General Assembly resolutions 40/32 of 29 November 1985 and 40/146 of 13 December 1985. 46 Adopted by the Eighth United Nations Congress on the Prevention of Crime and the Treatment of Offenders, held in Havana from 27 August to 7 September 1990. freedoms. Principle 14 of the United Nations Basic Prin- ciples on the Role of Lawyers provides: “Lawyers, in pro- tecting the rights of their clients and in promoting the cause of justice, shall seek to uphold human rights and fundamental freedoms recognized by national and inter- national law and shall at all times act freely and diligently in accordance with the law and recognized standards and ethics of the legal profession.”47 B. Health-care ethics 51. There are very clear links between concepts of human rights and the well-established principle of health- care ethics. The ethical obligations of health professionals are articulated at three levels and are reflected in United Nations documents in the same way as they are for the legal profession. They are also embodied in statements issued by international organizations representing health professionals, such as the World Medical Association, the World Psychiatric Association and the International Council of Nurses.48 National medical associations and nursing organizations also issue codes of ethics, which their members are expected to follow. The central tenet of all health-care ethics, however articulated, is the funda- mental duty always to act in the best interests of the patient, regardless of other constraints, pressures or con- tractual obligations. In some countries, medical ethical principles, such as that of doctor-patient confidentiality, are incorporated into national law. Even where ethical principles are not established in law in this way, all health professionals are morally bound by the standards set by their professional bodies. They are judged to be guilty of misconduct if they deviate from professional standards without reasonable justification. 1. United Nations statements relevant to health professionals 52. Health professionals, like all other persons work- ing in prison systems, must observe the Standard Mini- mum Rules for the Treatment of Prisoners, which require that medical, including psychiatric, services must be 47 See footnote 46 above. 48 There are also a number of regional groupings, such as the Commonwealth Medical Association and the International Conference of Islamic Medical Associations that issue important statements on medical ethics and human rights for their members. CHAPTER II RELEVANT ETHICAL CODES 12 available to all prisoners without discrimination and that all sick prisoners or those requesting treatment be seen daily.49 These requirements reinforce the ethical obliga- tions of physicians, discussed below, to treat and act in the best interests of patients for whom they have a duty to care. In addition, the United Nations has specifically addressed the ethical obligations of doctors and other health professionals in the Principles of Medical Ethics relevant to the Role of Health Personnel, particularly Phy- sicians, in the Protection of Prisoners and Detainees against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment.50 These make clear that health professionals have a moral duty to protect the physical and mental health of detainees. They are specifically pro- hibited from using medical knowledge and skills in any manner that contravenes international statements of indi- vidual rights.51 In particular, it is a gross contravention of health-care ethics to participate, actively or passively, in torture or condone it in any way. 53. “Participation in torture” includes evaluating an individual’s capacity to withstand ill-treatment; being present at, supervising or inflicting maltreatment; resusci- tating individuals for the purposes of further maltreatment or providing medical treatment immediately before, dur- ing or after torture on the instructions of those likely to be responsible for it; providing professional knowledge or individuals’ personal health information to torturers; and intentionally neglecting evidence and falsifying reports, such as autopsy reports and death certificates.52 The United Nations Principles also incorporate one of the fun- damental rules of health-care ethics by emphasizing that the only ethical relationship between prisoners and health professionals is one designed to evaluate, protect and improve prisoners’ health. Thus, assessment of detainees’ health in order to facilitate punishment or torture is clearly unethical. 2. Statements from international professional bodies 54. Many statements from international professional bodies focus on principles relevant to the protection of human rights and represent a clear international medical consensus on these issues. Declarations of the World Medical Association define internationally agreed aspects of the ethical duties to which all doctors are held. The World Medical Association’s Declaration of Tokyo53 reit- erates the prohibition of any form of medical participation or medical presence in torture or ill-treatment. This is reinforced by the United Nations Principles that specifi- cally refer to the Declaration of Tokyo. Doctors are 49 Standard Minimum Rules for the Treatment of Prisoners and Procedures for the Effective Implementation of the Standard Minimum Rules, adopted by the United Nations in 1955. 50 Adopted by the General Assembly in 1982. 51 Particularly the Universal Declaration of Human Rights, the International Covenants on Human Rights and the Declaration on the Protection of All Persons from Being Subjected to Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. 52 Health professionals must, however, bear in mind the duty of confidentiality owed to patients and the obligation to obtain informed consent for disclosure of information, particularly when individuals may be put at risk by such disclosure (see chapter II, sect. C.3). 53 Adopted by the World Medical Association in 1975. clearly prohibited from providing information or any medical instrument or substance that would facilitate ill- treatment. The same rule is specifically applied to psychiatry in the World Psychiatric Association’s Declaration of Hawaii,54 which prohibits the misuse of psychiatric skills to violate the human rights of any indi- vidual or group. The International Conference on Islamic Medicine made a similar point in its Declaration of Kuwait,55 which bans doctors from allowing their special knowledge to be used “to harm, destroy or inflict damage on the body, mind or spirit, whatever the military or political reason”. Similar provisions are made for nurses in the directive on the Nurse’s Role in the Care of Detainees and Prisoners.56 55. Health professionals also have a duty to support colleagues who speak out against human rights violations. Failure to do so risks not only an infringement of patient rights and a contravention of the declarations listed above but also brings the health professions into disrepute. Tar- nishing the honour of the profession is considered to be serious professional misconduct. The World Medical Association’s resolution on human rights57 calls on all national medical associations to review the human rights situation in their own countries and ensure that doctors do not conceal evidence of abuse even where they fear reprisal. It requires national bodies to provide clear guidance, especially for doctors working in the prison system, to protest alleged violations of human rights and provide effective machinery for investigating doctors’ unethical activities in the human rights sphere. It also requires that they support individual doctors who call attention to human rights abuses. The World Medical Association’s subsequent Declaration of Hamburg58 reaffirms the responsibility of individuals and organized medical groups worldwide to encourage doctors to resist torture or any pressure to act contrary to ethical princi- ples. It calls upon individual doctors to speak out against maltreatment and urges national and international medical organizations to support doctors who resist such pressure. 3. National codes of medical ethics 56. The third level at which ethical principles are articulated is through national codes. These reflect the same core values as mentioned above, since medical eth- ics are the expression of values common to all doctors. In virtually all cultures and codes, the same basic presump- tions occur about duties to avoid harm, help the sick, protect the vulnerable and not discriminate between patients on any basis other than the urgency of their medical needs. Identical values are present in the codes for the nursing profession. A problematic aspect of ethical principles is that they do not, however, provide definitive rules for every dilemma but require some interpretation. When weighing ethical dilemmas, it is vital that health professionals bear in mind the fundamental moral 54 Adopted in 1977. 55 Adopted in 1981 (1401 in the Islamic calendar). 56 Adopted by the International Council of Nurses in 1975. 57 Adopted in 1990. 58 Adopted in 1997. 13 obligations expressed in their shared professional values but also that they implement them in a manner that reflects the basic duty to avoid harm to their patients. C. Principles common to all codes of health-care ethics 57. The principle of professional independence requires health professionals always to concentrate on the core purpose of medicine, which is to alleviate suffering and distress and avoid harm, despite other pressures. Sev- eral other ethical principles are so fundamental that they are invariably found in all codes and ethical statements. The most basic are the injunctions to provide compassion- ate care, do no harm and to respect patients’ rights. These are central requirements for all health professionals. 1. The duty to provide compassionate care 58. The duty to provide care is expressed in a variety of ways in national and international codes and declara- tions. One aspect of this duty is the medical duty to respond to those in medical need. This is reflected in the World Medical Association’s International Code of Medical Ethics,59 which recognizes the moral obligation of doctors to provide emergency care as a humanitarian duty. The duty to respond to need and suffering is echoed in traditional statements in virtually all cultures. 59. Underpinning much of modern medical ethics are the principles established in the earliest statements of professional values that require doctors to provide care even at some risk to themselves. For example, the Caraka Samhita, a Hindu code dating from the first century AD, instructs doctors to “endeavour for the relief of patients with all thy heart and soul. Thou shall not desert or injure thy patient for the sake of thy life or thy living”. Similar instructions were given in early Islamic codes and the modern Declaration of Kuwait requires doctors to focus on the needy, be they “near or far, virtuous or sinner, friend or enemy”. 60. Western medical values have been dominated by the influence of the Hippocratic oath and similar pledges, such as the Prayer of Maimonides. The Hippocratic oath represents a solemn promise of solidarity with other doc- tors and a commitment to benefit and care for patients while avoiding harming them. It also contains a promise to maintain confidentiality. These four concepts are reflected in various forms in all modern professional codes of health-care ethics. The World Medical Associa- tion’s Declaration of Geneva60 is a modern restatement of the Hippocratic values. It is a promise by which doctors undertake to make the health of their patients their pri- mary consideration and vow to devote themselves to the service of humanity with conscience and dignity. 61. Aspects of the duty to care are reflected in many of the World Medical Association’s declarations, which make clear that doctors must always do what is best for 59 Adopted in 1949. 60 Adopted in 1948. the patient, including detainees and alleged criminals. This duty is often expressed through the notion of profes- sional independence, requiring doctors to adhere to best medical practices despite any pressure that might be applied. The World Medical Association’s International Code of Medical Ethics emphasizes doctors’ duty to pro- vide care “in full technical and moral independence, with compassion and respect for human dignity”. It also stresses the duty to act only in the patient’s interest and says that doctors owe their patients complete loyalty. The World Medical Association’s Tokyo Declaration and Dec- laration on Physician Independence and Professional Freedom61 make unambiguously clear that doctors must insist on being free to act in patients’ interests, regardless of other considerations, including the instructions of employers, prison authorities or security forces. The latter declaration requires doctors to ensure that they “have the professional independence to represent and defend the health needs of patients against all who would deny or restrict needed care for those who are sick or injured”. Similar principles are prescribed for nurses in the Interna- tional Council of Nurses Code of Ethics. 62. Another way in which duty to provide care is expressed by the World Medical Association is through its recognition of patient rights. Its Declaration of Lisbon on the Rights of the Patient62 recognizes that every person is entitled, without discrimination, to appropriate health care and reiterates that doctors must always act in a patient’s best interest. Patients must be guaranteed autonomy and justice, according to the Declaration, and both doctors and providers of medical care must uphold patient’s rights. “Whenever legislation, government action or any other administration or institution denies patients these rights, physicians should pursue appropri- ate means to assure or to restore them.” Individuals are entitled to appropriate health care, regardless of factors such as their ethnic origin, political beliefs, nationality, gender, religion or individual merit. People accused or convicted of crimes have an equal moral entitlement to appropriate medical and nursing care. The World Medical Association’s Declaration of Lisbon emphasizes that the only acceptable criterion for discriminating between patients is the relative urgency of their medical need. 2. Informed consent 63. While the declarations reflecting a duty of care all emphasize an obligation to act in the best interests of the individual being examined or treated, this presupposes that health professionals know what is in the patient’s best interest. An absolutely fundamental precept of modern medical ethics is that patients themselves are the best judge of their own interests. This requires health profes- sionals to give normal precedence to a competent adult patient’s wishes rather than to the views of any person in authority about what would be best for that individual. Where the patient is unconscious or otherwise incapable of giving valid consent, health professionals must make a judgement about how that person’s best interests can be 61 Adopted by the World Medical Association in 1986. 62 Adopted by the World Medical Association in 1981; amended by its General Assembly at its forty-seventh session in September 1995. 17 74. States are required under international law to investigate reported incidents of torture promptly and impartially. Where evidence warrants it, a State in whose territory a person alleged to have committed or partici- pated in torture is present, must either extradite the alleged perpetrator to another State that has competent jurisdiction or submit the case to its own competent authorities for the purpose of prosecution under national or local criminal laws. The fundamental principles of any viable investigation into incidents of torture are compe- tence, impartiality, independence, promptness and thor- oughness. These elements can be adapted to any legal sys- tem and should guide all investigations of alleged torture. 75. Where investigative procedures are inadequate because of a lack of resources or expertise, the appearance of bias, the apparent existence of a pattern of abuse or other substantial reasons, States shall pursue investiga- tions through an independent commission of inquiry or similar procedure. Members of that commission must be chosen for their recognized impartiality, competence and independence as individuals. In particular, they must be independent of any institution, agency or person that may be the subject of the inquiry. 76. Section A describes the broad purpose of an investigation into torture. Section B sets forth basic prin- ciples on the effective investigation and documentation of torture and other cruel, inhuman or degrading treatment or punishment. Section C sets forth suggested procedures for conducting an investigation into alleged torture, first con- sidering the decision regarding the appropriate investiga- tive authority, then offering guidelines regarding collec- tion of oral testimony from the reported victim and other witnesses and collection of physical evidence. Section D provides guidelines for establishing a special independent commission of inquiry. These guidelines are based on the experiences of several countries that have established independent commissions to investigate alleged human rights abuses, including extrajudicial killings, torture and disappearances. A. Purposes of an investigation into torture 77. The broad purpose of the investigation is to establish the facts relating to alleged incidents of torture, with a view to identifying those responsible for the inci- dents and facilitating their prosecution, or for use in the context of other procedures designed to obtain redress for victims. The issues addressed here may also be relevant for other types of investigations of torture. To fulfil this purpose, those carrying out the investigation must, at a minimum, seek to obtain statements from the victims of alleged torture; to recover and preserve evidence, includ- ing medical evidence, related to the alleged torture to aid in any potential prosecution of those responsible; to iden- tify possible witnesses and obtain statements from them concerning the alleged torture; and to determine how, when and where the alleged incidents of torture occurred as well as any pattern or practice that may have brought about the torture. B. Principles on the Effective Investigation and Documentation of Torture and Other Cruel, Inhu- man or Degrading Treatment or Punishment 78. The following principles represent a consensus among individuals and organizations having expertise in the investigation of torture. The purposes of effective investigation and documentation of torture and other cruel, inhuman or degrading treatment or punishment (hereinafter referred to as torture or other ill-treatment) include the following: (a) Clarification of the facts and establishment and acknowledgement of individual and State responsibility for victims and their families; (b) Identification of measures needed to prevent recurrence; (c) Facilitation of prosecution or, as appropriate, disci- plinary sanctions for those indicated by the investigation as being responsible and demonstration of the need for full reparation and redress from the State, including fair and adequate financial compensation and provision of the means for medical care and rehabilitation. 79. States must ensure that complaints and reports of torture or ill-treatment are promptly and effectively inves- tigated. Even in the absence of an express complaint, an investigation should be undertaken if there are other indi- cations that torture or ill-treatment might have occurred. The investigators, who shall be independent of the sus- pected perpetrators and the agency they serve, must be competent and impartial. They must have access to or be empowered to commission investigations by impartial medical or other experts. The methods used to carry out these investigations must meet the highest professional standards, and the findings must be made public. CHAPTER III LEGAL INVESTIGATION OF TORTURE 18 80. The investigative authority shall have the power and obligation to obtain all the information necessary to the inquiry.68 The persons conducting the investigation must have at their disposal all the necessary budgetary and technical resources for effective investigation. They must also have the authority to oblige all those acting in an official capacity allegedly involved in torture or ill- treatment to appear and testify. The same applies to any witness. To this end, the investigative authority is entitled to issue summonses to witnesses, including any officials allegedly involved, and to demand the production of evi- dence. Alleged victims of torture or ill-treatment, wit- nesses, those conducting the investigation and their fami- lies must be protected from violence, threats of violence or any other form of intimidation that may arise pursuant to the investigation. Those potentially implicated in tor- ture or ill-treatment should be removed from any position of control or power, whether direct or indirect, over complainants, witnesses or their families, as well as those conducting the investigation. 81. Alleged victims of torture or ill-treatment and their legal representatives must be informed of, and have access to, any hearing as well as to all information rel- evant to the investigation and must be entitled to present other evidence. 82. In cases in which the established investigative procedures are inadequate because of insufficient exper- tise or suspected bias, or because of the apparent exist- ence of a pattern of abuse, or for other substantial reasons, States must ensure that investigations are undertaken through an independent commission of inquiry or similar procedure. Members of such a commission should be cho- sen for their recognized impartiality, competence and independence as individuals. In particular, they must be independent of any suspected perpetrators and the institu- tions or agencies they may serve. The commission must have the authority to obtain all information necessary to the inquiry and shall conduct the inquiry as provided for under these principles.69 A written report, made within a reasonable time, must include the scope of the inquiry, procedures and methods used to evaluate evidence as well as conclusions and recommendations based on findings of fact and on applicable law. On completion, this report must be made public. It must also describe in detail spe- cific events that were found to have occurred, the evi- dence upon which such findings were based and list the names of witnesses who testified with the exception of those whose identities have been withheld for their own protection. The State must, within a reasonable period of time, reply to the report of the investigation and, as appro- priate, indicate steps to be taken in response. 83. Medical experts involved in the investigation of torture or ill-treatment should behave at all times in con- formity with the highest ethical standards and, in particu- lar, must obtain informed consent before any examination is undertaken. The examination must conform to estab- lished standards of medical practice. In particular, exami- nations must be conducted in private under the control of 68 Under certain circumstances professional ethics may require information to be kept confidential. These requirements should be respected. 69 See footnote 68. the medical expert and outside the presence of security agents and other government officials. The medical expert should promptly prepare an accurate written report. This report should include at least the following: (a) The circumstances of the interview. The name of the subject and name and affiliation of those present at the examination; the exact time and date, location, nature and address of the institution (including, where appropriate, the room) where the examination is being conducted (e.g. detention centre, clinic, house, etc.); any appropriate cir- cumstances at the time of the examination (e.g. nature of any restraints on arrival or during the examination, pres- ence of security forces during the examination, demean- our of those accompanying the prisoner, threatening state- ments to the examiner, etc.); and any other relevant factor; (b) The background. A detailed record of the subject’s story as given during the interview, including alleged methods of torture or ill-treatment, the time when torture or ill-treatment was alleged to have occurred and all com- plaints of physical and psychological symptoms; (c) A physical and psychological examination. A record of all physical and psychological findings upon clinical examination including appropriate diagnostic tests and, where possible, colour photographs of all inju- ries; (d) An opinion. An interpretation as to the probable relationship of physical and psychological findings to possible torture or ill-treatment. A recommendation for any necessary medical and psychological treatment or further examination should also be given; (e) A record of authorship. The report should clearly identify those carrying out the examination and should be signed. 84. The report should be confidential and communi- cated to the subject or his or her nominated representative. The views of the subject and his or her representative about the examination process should be solicited and recorded in the report. The report should be provided in writing, where appropriate, to the authority responsible for investigating the allegation of torture or ill-treatment. It is the responsibility of the State to ensure that the report is delivered securely to these persons. The report should not be made available to any other person, except with the consent of the subject or when authorized by a court empowered to enforce the transfer. For general consid- erations for written reports following allegations of tor- ture, see chapter IV. Chapters V and VI describe in detail the physical and psychological assessments, respectively. C. Procedures of a torture investigation 1. Determination of the appropriate investigative body 85. In cases where involvement in torture by public officials is suspected, including possible orders for the use of torture by ministers, ministerial aides, officers acting with the knowledge of ministers, senior officers in State ministries, senior military leaders or tolerance of torture by such individuals, an objective and impartial investiga- tion may not be possible unless a special commission of inquiry is established. A commission of inquiry may also 19 be necessary where the expertise or the impartiality of the investigators is called into question. 86. Factors that support a belief that the State was involved in the torture or that special circumstances exist that should trigger the creation of a special impartial investigation mechanism include: (a) Where the victim was last seen unharmed in police custody or detention; (b) Where the modus operandi is recognizably attrib- utable to State-sponsored torture; (c) Where persons in the State or associated with the State have attempted to obstruct or delay the investigation of the torture; (d) Where public interest would be served by an inde- pendent inquiry; (e) Where investigation by regular investigative agen- cies is in question because of lack of expertise or lack of impartiality or for other reasons, including the importance of the matter, the apparent existence of a pattern of abuse, complaints from the person or the above inadequacies or other substantial reasons. 87. Several considerations should be taken into account when a State decides to establish an independent commission of inquiry. First, persons subject to an inquiry should be guaranteed the minimum procedural safeguards protected by international law at all stages of the investi- gation. Second, investigators should have the support of adequate technical and administrative personnel, as well as access to objective, impartial legal advice to ensure that the investigation will produce admissible evidence for criminal proceedings. Third, investigators should receive the full scope of the State’s resources and powers. Finally, investigators should have the power to seek help from the international community of experts in law and medicine. 2. Interviewing the alleged victim and other witnesses 88. Because of the nature of torture cases and the trauma individuals suffer as a result, often including a devastating sense of powerlessness, it is particularly important to show sensitivity to the alleged torture victim and other witnesses. The State must protect alleged vic- tims of torture, witnesses and their families from vio- lence, threats of violence or any other form of intimida- tion that may arise pursuant to the investigation. Investigators must inform witnesses about the conse- quences of their involvement in the investigation and about any subsequent developments in the case that may affect them. (a) Informed consent and other protection for the alleged victim 89. From the outset, the alleged victim should be informed, wherever possible, of the nature of the proceed- ings, why his or her evidence is being sought, if and how evidence offered by the alleged victim may be used. Investigators should explain to the person which portions of the investigation will be public information and which portions will be confidential. The person has the right to refuse to cooperate with all or part of the investigation. Every effort should be made to accommodate his or her schedule and wishes. The alleged torture victim should be regularly informed of the progress of the investigation. The alleged victim should also be notified of all key hear- ings in the investigation and prosecution of the case. The investigators should inform the alleged victim of the arrest of the suspected perpetrator. Alleged victims of tor- ture should be given contact information for advocacy and treatment groups that might be of assistance to them. Investigators should work with advocacy groups within their jurisdiction to ensure that there is a mutual exchange of information and training concerning torture. (b) Selection of the investigator 90. The authorities investigating the case must iden- tify a person primarily responsible for questioning the alleged victim. While the alleged victim may need to dis- cuss his or her case with both legal and medical profes- sionals, the investigating team should make every effort to minimize unnecessary repetitions of the person’s story. In selecting a person as the primary investigator with responsibility for the alleged torture victim, special con- sideration should be given to the victim’s preference for a person of the same gender, the same cultural background or the ability to communicate in his or her native lan- guage. The primary investigator should have prior train- ing or experience in documenting torture and in working with victims of trauma, including torture. In situations where an investigator with prior training or experience is not available, the primary investigator should make every effort to become informed about torture and its physical and psychological consequences before interviewing the individual. Information about torture is available from sources including this manual, several professional and training publications, training courses and professional conferences. The investigator should also have access to international expert advice and assistance throughout the investigation. (c) Context of the investigation 91. Investigators should carefully consider the con- text in which they are working, take necessary precau- tions and provide safeguards accordingly. If interviewing people who are still imprisoned or in similar situations in which reprisals are possible, the interviewer should use care not to put them in danger. In situations where talking to an investigator may endanger someone, a “group inter- view” may be preferable to an individual interview. In other cases, the interviewer must choose a place for the private interview where the witness feels comfortable to talk freely. 92. Evaluations occur in a variety of political con- texts. This results in important differences in the manner in which evaluations should be conducted. The legal standards under which the investigation is conducted are also affected by the context. For example, an investiga- tion culminating in the trial of an alleged perpetrator will require the highest level of proof, whereas a report sup- porting an application for political asylum in a third coun- try need provide only a relatively low level of proof of tor- ture. The investigator must adapt the following guidelines according to the particular situation and purpose of the 22 carrying out a thorough investigation of the place where torture allegedly occurred. Investigators must have unre- stricted access to the alleged scene of torture. Their access must include, but not be limited to, open or closed areas, including buildings, vehicles, offices, prison cells or other premises where torture is alleged to have taken place. 103. Any building or area under investigation must be closed off so as not to lose any possible evidence. Only investigators and their staff should be allowed entry into the area once it has been designated as under investiga- tion. Examination of the scene for any material evidence should take place. All evidence must be properly col- lected, handled, packaged, labelled and placed in safe- keeping to prevent contamination, tampering or loss of evidence. If the torture has allegedly taken place recently enough for such evidence to be relevant, any samples found of body fluids (such as blood or semen), hair, fibres and threads should be collected, labelled and properly preserved. Any implements that could be used to inflict torture, whether they be destined for that purpose or used circumstantially, should be taken and preserved. If recent enough to be relevant, any fingerprints located must be lifted and preserved. A labelled sketch of the premises or place where torture has allegedly taken place must be made to scale, showing all relevant details, such as the location of the floors in a building, rooms, entrances, win- dows, furniture and surrounding terrain. Colour photo- graphs must also be taken to record the same. A record of the identity of all persons at the alleged torture scene must be made, including complete names, addresses and tele- phone numbers or other contact information. If torture is recent enough for it to be relevant, an inventory of the clothing of the person alleging torture should be taken and tested at a laboratory, if available, for bodily fluids and other physical evidence. Information must be obtained from anyone present on the premises or in the area under investigation to determine whether they were witness to the incidents of alleged torture. Any relevant papers, records or documents should be saved for evidential use and handwriting analysis. 4. Medical evidence 104. The investigator should arrange for a medical examination of the alleged victim. The timeliness of such medical examination is particularly important. A medical examination should be undertaken regardless of the length of time since the torture, but if it is alleged to have happened within the past six weeks, such an examination should be arranged urgently before acute signs fade. The examination should include an assessment of the need for treatment of injuries and illnesses, psychological help, advice and follow-up (see chapter V for a description of the physical examination and forensic evaluation). A psychological appraisal of the alleged torture victim is always necessary and may be part of the physical exami- nation, or where there are no physical signs, may be per- formed by itself (see chapter VI for a description of the psychological evaluation). 105. In formulating a clinical impression for the pur- pose of reporting physical and psychological evidence of torture, there are six important questions to ask: (a) Are the physical and psychological findings con- sistent with the alleged report of torture? (b) What physical conditions contribute to the clinical picture? (c) Are the psychological findings expected or typical reactions to extreme stress within the cultural and social context of the individual? (d) Given the fluctuating course of trauma-related mental disorders over time, what is the time frame in rela- tion to the torture events? Where in the course of recovery is the individual? (e) What other stressful factors are affecting the indi- vidual (e.g. ongoing persecution, forced migration, exile, loss of family and social role, etc.)? What impact do these issues have on the victim? (f) Does the clinical picture suggest a false allegation of torture? 5. Photography 106. Colour photographs should be taken of the inju- ries of persons alleging that they have been tortured, of the premises where torture has allegedly occurred (inte- rior and exterior) and of any other physical evidence found there. A measuring tape or some other means of showing scale on the photograph is essential. Photographs must be taken as soon as possible, even with a basic cam- era, because some physical signs fade rapidly and loca- tions can be interfered with. Instantly developed photos may decay over time. More professional photos are pre- ferred and should be taken as soon as the equipment becomes available. If possible, photographs should be taken using a 35-millimetre camera with an automatic date feature. The chain of custody of the film, negatives and prints must be fully documented. D. Commission of inquiry 1. Defining the scope of the inquiry 107. States and organizations establishing commis- sions of inquiry need to define the scope of the inquiry by including terms of reference in their authorization. Defin- ing the commission’s terms of reference can greatly increase its success by giving legitimacy to the proceed- ings, assisting commission members in reaching a con- sensus on the scope of the inquiry and providing a meas- ure by which the commission’s final report can be judged. Recommendations for defining terms of reference are as follows: (a) They should be neutrally framed so that they do not suggest a predetermined outcome. To be neutral, terms of reference must not limit investigations in areas that might uncover State responsibility for torture; (b) They should state precisely which events and issues are to be investigated and addressed in the commis- sion’s final report; (c) They should provide flexibility in the scope of inquiry to ensure that thorough investigation by the com- 23 mission is not hampered by overly restrictive or overly broad terms of reference. The necessary flexibility may be accomplished, for example, by permitting the commis- sion to amend its terms of reference as necessary. It is important, however, for the commission to keep the pub- lic informed of any amendments to its mandate. 2. The power of the commission 108. Principles should set out the powers of the com- mission in a general manner. The commission specifically needs the following: (a) Authority to obtain all information necessary to the inquiry including the authority to compel testimony under legal sanction, to order the production of docu- ments including State and medical records, and to protect witnesses, families of the victim and other sources; (b) Authority to issue a public report; (c) Authority to conduct on-site visits, including at the location where the torture is suspected to have occurred; (d) Authority to receive evidence from witnesses and organizations located outside the country. 3. Membership criteria 109. Commission members should be chosen for their recognized impartiality, competence and independ- ence as individuals as defined as follows: (a) Impartiality. Commission members should not be closely associated with any individual, State entity, po- litical party or other organization potentially implicated in the torture. They should not be too closely connected to an organization or group of which the victim is a member, as this may damage the commission’s credibility. This should not, however, be an excuse for blanket exclusions from the commission, for instance, of members of large organizations of which the victim is also a member or of persons associated with organizations dedicated to the treatment and rehabilitation of torture victims; (b) Competence. Commission members must be ca- pable of evaluating and weighing evidence and exercising sound judgement. If possible, commissions of inquiry should include individuals with expertise in law, medicine and other appropriate specialized fields; (c) Independence. Members of the commission should have a reputation in their community for honesty and fair- ness. 110. The objectivity of the investigation and the commission’s findings may, among other things, depend on whether it has three or more members rather than one or two. A single commissioner should in general not con- duct investigations into torture. A single, isolated com- missioner will generally be limited in the depth of the investigation that he or she can conduct alone. In addition, a single commissioner will have to make controversial and important decisions without debate and will be par- ticularly vulnerable to State and other outside pressure. 4. The commission’s staff 111. Commissions of inquiry should have impartial, expert counsel. Where the commission is investigating allegations of State misconduct, it would be advisable to appoint counsel outside the Ministry of Justice. The chief counsel to the commission should be insulated from po- litical influence, through civil service tenure or as a wholly independent member of the bar. The investigation will often require expert advisers. Technical expertise should be available to the commission in areas such as pathology, forensic science, psychiatry, psychology, gy- naecology and paediatrics. To conduct a completely im- partial and thorough investigation, the commission would almost always need its own investigators to pursue leads and develop evidence. The credibility of an inquiry would thus be significantly enhanced to the extent that the com- mission would be able to rely on its own investigators. 5. Protection of witnesses 112. The State shall protect complainants, witnesses, those conducting the investigation and their families from violence, threats of violence or any other form of intimi- dation (see section C.2 (d) above). If the commission con- cludes that there is a reasonable fear of persecution, har- assment or harm to any witness or prospective witness, the commission may find it advisable to hear the evidence in camera, keep the identity of an informant or witness confidential, use only evidence that will not risk identify- ing the witness and take other appropriate measures. 6. Proceedings 113. It follows from general principles of criminal procedure that hearings should be conducted in public, unless in-camera proceedings are necessary to protect the safety of a witness. In-camera proceedings should be recorded and the sealed, unpublished record kept in a known location. Occasionally, complete secrecy may be required to encourage testimony, and the commission may want to hear witnesses privately, informally or with- out recording testimony. 7. Notice of inquiry 114. Wide notice of the establishment of a commis- sion and the subject of the inquiry should be given. The notice should include an invitation to submit relevant information and written statements to the commission and instructions to persons willing to testify. Notice can be disseminated through newspapers, magazines, radio, tele- vision, leaflets and posters. 8. Receipt of evidence 115. Commissions of inquiry should have the power to compel testimony and produce documents, plus the authority to compel testimony from officials allegedly involved in torture. Practically, this authority may involve the power to impose fines or sentences if government offi- cials or other individuals refuse to comply. Commissions 24 of inquiry should invite persons to testify or submit writ- ten statements as a first step in gathering evidence. Writ- ten statements may become an important source of evi- dence if their authors are afraid to testify, cannot travel to proceedings or are otherwise unavailable. Commissions of inquiry should review other proceedings that could provide relevant information. 9. Rights of parties 116. Those alleging that they have been tortured and their legal representatives should be informed of and have access to any hearing and all information relevant to the investigation and must be entitled to present evidence. This particular emphasis on the role of the survivor as a party to the proceedings reflects the especially important role his/her interests play in the conduct of the investiga- tion. However, all other interested parties should also have an opportunity to be heard. The investigative body must be entitled to issue summonses to witnesses, includ- ing the officials allegedly involved, and to demand the production of evidence. All these witnesses should be per- mitted legal counsel if they are likely to be harmed by the inquiry, for example, when their testimony could expose them to criminal charges or civil liability. Witnesses may not be compelled to testify against themselves. There should be an opportunity for the effective questioning of witnesses by the commission. Parties to the inquiry should be allowed to submit written questions to the commission. 10. Evaluation of evidence 117. The commission must assess all information and evidence it receives to determine reliability and pro- bity. The commission should evaluate oral testimony, tak- ing into account the demeanour and overall credibility of the witness. The commission must be sensitive to social, cultural and gender issues that affect demeanour. Corrob- oration of evidence from several sources will increase the probative value of such evidence and the reliability of hearsay evidence. The reliability of hearsay evidence must be considered carefully before the commission accepts it as fact. Testimony not tested by cross-examina- tion must also be viewed with caution. In-camera testi- mony preserved in a closed record or not recorded at all is often not subject to cross-examination and, therefore, may be given less weight. 11. Report of the commission 118. The commission should issue a public report within a reasonable period of time. Furthermore, when the commission is not unanimous in its findings, the minority commissioners should file a dissenting opinion. Commis- sion of inquiry reports should contain, at a minimum, the following information: (a) The scope of inquiry and terms of reference; (b) The procedures and methods of evaluating evi- dence; (c) A list of all witnesses, including age and gender, who have testified, except for those whose identities are withheld for protection or who have testified in camera, and exhibits received as evidence; (d) The time and place of each sitting (this might be annexed to the report); (e) The background of the inquiry, such as relevant social, political and economic conditions; (f) The specific events that occurred and the evidence upon which such findings are based; (g) The law upon which the commission relied; (h) The commission’s conclusions based on appli- cable law and findings of fact; (i) Recommendations based on the findings of the commission. 119. The State should reply publicly to the commis- sion’s report and, where appropriate, indicate which steps it intends to take in response to the report. 27 131. Other more subtle forms of torture, psychologi- cal or sexual, for example, clearly cannot be dealt with in the same way. In these cases, it may be necessary for investigators to refrain from comment for one or several visits until the circumstances allow or encourage detain- ees to be less afraid and to authorize the use of their sto- ries. The physician and interpreter should provide their names and explain their role in conducting the evaluation. Documentation of medical evidence of torture requires specific knowledge by licensed health practitioners. Knowledge of torture and its physical and psychological consequences can be gained through publications, train- ing courses, professional conferences and experience. In addition, knowledge about regional practices of torture and ill-treatment is important because such information may corroborate an individual’s accounts of these. Ex- perience in interviewing and examining individuals for physical and psychological evidence of torture and in documenting findings should be acquired under the supervision of experienced clinicians. 132. Those still in custody may sometimes be too trusting in situations where the interviewer simply cannot guarantee that there will be no reprisals, if a repeat visit has not been negotiated and fully accepted by the author- ities or if the person’s identity has not been recorded so as to ensure follow-up, for example. Every precaution should be taken to be sure that prisoners do not place themselves at risk unnecessarily, naively trusting an out- sider to protect them. 133. Ideally, when visits are made to people still in custody the interpreters should be outsiders and not recruited locally. This is mainly to avoid them or their families being put under pressure from inquisitive author- ities wanting to know what information was given to the investigators. The issue may be more complex when the detainees are from a different ethnic group than their jail- ers. Should the local interpreter be from the same ethnic group as the prisoner, so as to gain his/her trust, but at the same time arousing the mistrust of the authorities who would possibly attempt to intimidate the interpreter? Furthermore, the interpreter may be reluctant to work in a hostile environment, which would potentially place him or her at risk. Or should the interpreter come from the same ethnic group as the captors, thereby gaining trust, but losing that of the prisoner, while still leaving the inter- preter vulnerable to intimidation by the authorities? The answer is obviously and ideally neither of the above. Interpreters should be from outside the region and seen by all to be as independent as the investigators. 134. A person interviewed at 8 p.m. deserves as much attention as one seen at 8 a.m. Investigators should arrange to have enough time and not overwork them- selves. It is unfair to the 8 p.m. person (who in addition has been waiting all day to tell his or her story) to be cut short because of the time. Similarly, the nineteenth story about falanga deserves as much attention as the first. Pris- oners who do not often see outsiders may never have had a chance to talk about their torture. It is an erroneous assumption to think that prisoners talk constantly among themselves about torture. Prisoners who have nothing new to offer the investigation deserve as much time as the other prisoners. D. Techniques of questioning 135. Several basic rules must be respected (see chap- ter III, sect. C.2 (g)). Information is certainly important, but the person being interviewed is even more so, and lis- tening is more important than asking questions. If only questions are asked, all that are obtained are answers. To the detainee, it may be more important to talk about family than to talk about torture. This should be duly con- sidered, and time should be allowed for some discussion of personal matters. Torture, particularly sexual torture, is a very intimate subject and may not come up before a fol- low-up visit or even later. Individuals should not be forced to talk about any form of torture if they feel uncomfortable about it. E. Documenting the background 1. Psychosocial history and pre-arrest 136. If an alleged torture victim is no longer in cus- tody, the examiner should inquire into the person’s daily life, relations with friends and family, work or school, occupation, interests, future plans and use of alcohol and drugs. Information should also be elicited regarding the person’s post-detention psychosocial history. When an individual is still in custody, a more limited psychosocial history regarding occupation and literacy is sufficient. Inquire about prescription medication being taken by the patient; this is particularly important because such medi- cations may be denied to a person in custody, with sig- nificant adverse health consequences. Inquiries into political activities, beliefs and opinions are relevant inso- far as they help to explain why a person was detained or tortured, but such inquiries are best made indirectly by asking the person which accusations were made or why they think they were detained and tortured. 2. Summary of detention and abuse 137. Before obtaining a detailed account of events, elicit summary information, including dates, places, dura- tion of detention, frequency and duration of torture ses- sions. A summary will help to make effective use of time. In some cases in which survivors have been tortured on multiple occasions, they may be able to recall what hap- pened to them, but often they cannot recall exactly where and when each event occurred. In such circumstances, it may be advisable to elicit the historical account according to methods of abuse rather than relating a series of events during specific arrests. Similarly, in writing up the story it may often be useful to have “what happened where” documented as much as possible. Holding places are operated by different security, police or armed forces, and what happened in different places may be useful for a full picture of the torture system. Obtaining a map of where the torture occurred may be useful in piecing together the stories of different people. This will often prove very useful for the overall investigation. 28 3. Circumstances of detention 138. Consider the following questions: what time was it? Where were you? What were you doing? Who was there? Describe the appearance of those who detained you. Were they military or civilian, in uniform or in street clothes? What type of weapons were they carrying? What was said? Any witnesses? Was this a formal arrest, admin- istrative detention or disappearance? Was violence used, threats spoken? Was there any interaction with family members? Note the use of restraints or blindfold, means of transportation, destination and names of officials, if known. 4. Place and conditions of detention 139. Include access to and descriptions of food and drink, toilet facilities, lighting, temperature and ventila- tion. Also, document any contact with family, lawyers or health professionals, conditions of overcrowding or soli- tary confinement, dimensions of the detention place and whether there are other people who can corroborate the detention. Consider the following questions: what hap- pened first? Where were you taken? Was there an identi- fication process (personal information recorded, finger- prints, photographs)? Were you asked to sign anything? Describe the conditions of the cell or room (note size, oth- ers present, light, ventilation, temperature, presence of insects, rodents, bedding and access to food, water and toilet). What did you hear, see and smell? Did you have any contact with people outside or access to medical care? What was the physical layout of the place where you were detained? 5. Methods of torture and ill-treatment 140. In obtaining background information on torture and ill-treatment, caution should be used about suggesting forms of abuse to which a person may have been sub- jected. This may help separate potential embellishment from valid experiences. However, eliciting negative responses to questions about various forms of torture may also help establish the credibility of the person. Questions should be designed to elicit a coherent narrative account. Consider the following questions. Where did the abuse take place, when and for how long? Were you blind- folded? Before discussing forms of abuse, note who was present (give names, positions). Describe the room or place. Which objects did you observe? If possible, describe each instrument of torture in detail; for electrical torture, the current, device, number and shape of elec- trodes. Ask about clothing, disrobing and change of cloth- ing. Record quotations of what was said during interroga- tion, insults hurled at the victim, etc. What was said among the perpetrators? 141. For each form of abuse, note: body position, restraint, nature of contact, including duration, frequency, anatomical location and the area of the body affected. Was there any bleeding, head trauma or loss of consciousness? Was the loss of consciousness due to head trauma, asphyxiation or pain? The investigator should also ask about how the person was at the end of the “session”. Could he or she walk? Did he or she have to be helped or carried back to the cell? Could he or she get up the next day? How long did the feet stay swollen? All this gives a certain completeness to the description, which a checklist of methods does not. The history should include the date of positional torture, how many times and for how many days the torture lasted, the period of each episode, the style of the suspension (reverse-linear, being covered by thick cloth-blanket or being tied directly with a rope, putting weight on the legs or pulling down) or position. In cases of suspension torture, ask which sort of material was used (rope, wire and cloth leave different marks, if any, on the skin after suspension). The examiner must remember that statements on the length of the torture ses- sion by the torture survivor are subjective and may not be correct, since disorientation of time and place during tor- ture is a generally observed finding. Was the person sex- ually assaulted in any manner? Elicit what was said dur- ing the torture. For example, during electric shock torture to the genitals, perpetrators often tell their torture victims that they will no longer have normal sexual relations or something similar. For a detailed discussion of the assess- ment of an allegation of sexual torture, including rape, see chapter V, sect. D.8. F. Assessment of the background 142. Torture survivors may have difficulty recount- ing the specific details of the torture for several important reasons, including: (a) Factors during torture itself, such as blindfolding, drugging, lapses of consciousness, etc.; (b) Fear of placing themselves or others at risk; (c) A lack of trust in the examining clinician or inter- preter; (d) The psychological impact of torture and trauma, such as high emotional arousal and impaired memory, secondary to trauma-related mental illnesses, such as depression and post-traumatic stress disorder (PTSD); (e) Neuropsychiatric memory impairment from beat- ings to the head, suffocation, near drowning or starvation; (f) Protective coping mechanisms, such as denial and avoidance; (g) Culturally prescribed sanctions that allow trau- matic experiences to be revealed only in highly confiden- tial settings.72 143. Inconsistencies in a person’s story may arise from any or all of these factors. If possible, the investiga- tor should ask for further clarification. When this is not possible, the investigator should look for other evidence that supports or refutes the story. A network of consistent supporting details can corroborate and clarify the person’s story. Although the individual may not be able to provide the details desired by the investigator, such as dates, times, frequencies and exact identities of perpetrators, a broad outline of the traumatic events and torture will emerge and stand up over time. 72 R. F. Mollica and Y. Caspi-Yavin, “Overview: the assessment and diagnosis of torture events and symptoms”, in Torture and Its Consequences: Current Treatment Approaches, M. Başoglu, ed. (Cambridge, Cambridge University Press, 1992), pp. 38-55. ^ 29 G. Review of torture methods 144. After eliciting a detailed narrative account of events, it is advisable to review other possible torture methods. It is essential to learn about regional practices of torture and modify local guidelines accordingly. Ques- tioning about specific forms of torture is helpful when: (a) Psychological symptoms cloud recollections; (b) The trauma was associated with impaired sensory capabilities; (c) There is a case of possible organic brain damage; (d) There are mitigating educational and cultural factors. 145. The distinction between physical and psycho- logical methods is artificial. For example, sexual torture generally causes both physical and psychological symp- toms, even when there has been no physical assault. The following list of torture methods is given to show some of the categories of possible abuse. It is not meant to be used by investigators as a checklist or as a model for listing tor- ture methods in a report. A method-listing approach may be counter-productive, as the entire clinical picture pro- duced by torture is much more than the simple sum of lesions produced by methods on a list. Indeed, experience has shown that when confronted with such a “package- deal” approach to torture, perpetrators often focus on one of the methods and argue about whether that particular method is a form of torture. Torture methods to consider include, but are not limited to: (a) Blunt trauma, such as a punch, kick, slap, whip- ping, a beating with wires or truncheons or falling down; (b) Positional torture, using suspension, stretching limbs apart, prolonged constraint of movement, forced positioning; (c) Burns with cigarettes, heated instruments, scalding liquid or a caustic substance; (d) Electric shocks; (e) Asphyxiation, such as wet and dry methods, drowning, smothering, choking or use of chemicals; (f) Crush injuries, such as smashing fingers or using a heavy roller to injure the thighs or back; (g) Penetrating injuries, such as stab and gunshot wounds, wires under nails; (h) Chemical exposure to salt, chilli pepper, gasoline, etc. (in wounds or body cavities); (i) Sexual violence to genitals, molestation, instru- mentation, rape; (j) Crush injury or traumatic removal of digits and limbs; (k) Medical amputation of digits or limbs, surgical removal of organs; (l) Pharmacological torture using toxic doses of seda- tives, neuroleptics, paralytics, etc.; (m) Conditions of detention, such as a small or over- crowded cell, solitary confinement, unhygienic condi- tions, no access to toilet facilities, irregular or contami- nated food and water, exposure to extremes of temperature, denial of privacy and forced nakedness; (n) Deprivation of normal sensory stimulation, such as sound, light, sense of time, isolation, manipulation of brightness of the cell, abuse of physiological needs, restriction of sleep, food, water, toilet facilities, bathing, motor activities, medical care, social contacts, isolation within prison, loss of contact with the outside world (vic- tims are often kept in isolation in order to prevent bonding and mutual identification and to encourage traumatic bonding with the torturer); (o) Humiliation, such as verbal abuse, performance of humiliating acts; (p) Threats of death, harm to family, further torture, imprisonment, mock executions; (q) Threats of attack by animals, such as dogs, cats, rats or scorpions; (r) Psychological techniques to break down the indi- vidual, including forced betrayals, accentuating feelings of helplessness, exposure to ambiguous situations or contradictory messages; (s) Violation of taboos; (t) Behavioural coercion, such as forced engagement in practices against the religion of the victim (e.g. forcing Muslims to eat pork), forced harm to others through tor- ture or other abuses, forced destruction of property, forced betrayal of someone placing them at risk of harm; (u) Forcing the victim to witness torture or atrocities being inflicted on others. H. Risk of re-traumatization of the interviewee 146. Taking into consideration that lesions of differ- ent types and levels may occur according to the methods of torture practised, the data acquired subsequent to a comprehensive medical history and physical examination should be assessed together with appropriate laboratory and radiological examinations. Providing information and making explanations for each process to be applied during the medical examination and ensuring detailed awareness about the laboratory methods play a significant role (see chapter VI, sect. B.2 (a)). 147. The presence of psychological sequelae in tor- ture survivors, particularly the various manifestations of PTSD, may cause the torture survivor to fear experiencing a re-enactment of his or her torture experience during the interview, physical examination or laboratory test. Explaining to the torture survivor what he or she should expect prior to the medical examination is an important component of the process. Those who survive torture and remain in their country may experience intense fear and suspicion about being re-arrested, and they are often forced to go underground to avoid being arrested again. Those who are exiled or refugees may leave behind their native language, culture, family, friends, work and every- thing that is familiar to them. 148. The torture survivor’s personal reactions to the interviewer (and the interpreter, in cases where one is used) can have an effect on the interview process and, in 33 161. Witness and survivor testimony are necessary components in the documentation of torture. To the extent that physical evidence of torture exists, it provides impor- tant confirmatory evidence that a person has been tor- tured. However, the absence of such physical evidence should not be construed to suggest that torture did not occur, since such acts of violence against persons fre- quently leave no marks or permanent scars. 162. A medical evaluation for legal purposes should be conducted with objectivity and impartiality. The evaluation should be based on the physician’s clinical expertise and professional experience. The ethical obliga- tion of beneficence demands uncompromising accuracy and impartiality in order to establish and maintain profes- sional credibility. When possible, clinicians who conduct evaluations of detainees should have specific essential training in forensic documentation of torture and other forms of physical and psychological abuse. They should have knowledge of prison conditions and torture methods used in the particular region where the patient was impris- oned and the common after-effects of torture. The medi- cal report should be factual and carefully worded. Jargon should be avoided. All medical terminology should be defined so that it is understandable to lay persons. The physician should not assume that the official requesting a medical-legal evaluation has related all the material facts. It is the physician’s responsibility to discover and report upon any material findings that he or she considers rel- evant, even if they may be considered irrelevant or adverse to the case of the party requesting the medical examination. Findings that are consistent with torture or other forms of ill-treatment must not be excluded from a medical-legal report under any circumstance. A. Interview structure 163. These comments apply especially to interviews conducted with persons no longer in custody. The location of the interview and examination should be as safe and comfortable as possible. Sufficient time should be allotted to conduct a detailed interview and examination. A two- to-four-hour interview may be insufficient to conduct an evaluation for physical or psychological evidence of tor- ture. Furthermore, at any given time of an evaluation, situation-specific variables, such as the dynamics of the interview, a patient’s feelings of powerlessness in the face of having his/her intimacy intruded upon, fear of future persecution, shame about events and survivor guilt may simulate the circumstances of a torture experience. This may increase the patient’s anxiety and resistance to dis- close relevant information. A second, and possibly a third, interview may have to be scheduled to complete the evaluation. 164. Trust is an essential component of eliciting an accurate account of abuse. Earning the trust of someone who has experienced torture or other forms of abuse requires active listening, meticulous communication, courtesy and genuine empathy and honesty. Physicians must have the capacity to create a climate of trust in which disclosure of crucial, though perhaps very painful or shameful, facts can occur. It is important to be aware that those facts are sometimes intimate secrets that the person may reveal at that moment for the first time. In addition to providing a comfortable setting, adequate time for the interviews, refreshments and access to toilet facilities, the clinician should explain what the patient can expect in the evaluation. The clinician should be mindful of the tone, phrasing and sequencing of questions (sensitive questions should be asked only after some degree of rapport has been developed) and should acknowledge the patient’s ability to take a break if needed or to choose not to respond to any question. 165. Physicians and interpreters have a duty to main- tain confidentiality of information and to disclose infor- mation only with the patient’s consent (see chapter III, sect. C). Each person should be examined individually with privacy. He or she should be informed of any limits on the confidentiality of the evaluation that may be imposed by State or judicial authorities. The purpose of the interview needs to be made clear to the person. Physi- cians must ensure that informed consent is based on ad- equate disclosure and understanding of the potential ben- efits and adverse consequences of a medical evaluation and that consent is given voluntarily without coercion by others, particularly law enforcement or judicial author- ities. The person has the right to refuse the evaluation. In such circumstances, the clinician should document the reason for refusal of an evaluation. Furthermore, if the person is a detainee, the report should be signed by his or her lawyer and another health official. 166. Patients may fear that information revealed in the context of an evaluation may not be safely kept from being accessed by persecuting governments. Fear and mistrust may be particularly strong in cases where physi- cians or other health workers were participants in the tor- ture. In many circumstances, the evaluator will be a mem- ber of the majority culture and ethnicity, whereas the patient, in the situation and location of the interview, is likely to belong to a minority group or culture. This dynamic of inequality may reinforce the perceived and real imbalance of power and may increase the potential CHAPTER V PHYSICAL EVIDENCE OF TORTURE 34 sense of fear, mistrust and forced submission in the patient. 167. Empathy and human contact may be the most important thing that people still in custody receive from the investigator. The investigation itself may contribute nothing of specific benefit to the person being inter- viewed, as in most cases their torture will be over. The meagre consolation of knowing that the information may serve a future purpose will however be greatly enhanced if the investigator shows appropriate empathy. While this may seem self-evident, all too often investigators in prison visits are so concerned about obtaining informa- tion that they fail to empathize with the prisoner being interviewed. B. Medical history 168. Obtain a complete medical history, including information about prior medical, surgical or psychiatric problems. Be sure to document any history of injuries before the period of detention and any possible after- effects. Avoid leading questions. Structure inquiries to elicit an open-ended, chronological account of the events experienced during detention. 169. Specific historical information may be useful in correlating regional practices of torture with individual allegations of abuse. Examples of useful information include descriptions of torture devices, body positions, methods of restraint, descriptions of acute or chronic wounds and disabilities and identifying information about perpetrators and places of detention. While it is essential to obtain accurate information regarding a torture survi- vor’s experiences, open-ended interviewing methods require that patients should disclose these experiences in their own words using free recall. An individual who has survived torture may have trouble expressing in words his or her experiences and symptoms. In some cases, it may be helpful to use these trauma event and symptom check- lists or questionnaires. If the interviewer believes it may be helpful to use these, there are numerous questionnaires available; however, none are specific to torture victims. All complaints made by a torture survivor are significant. Although there may be no correlation with the physical findings, they should be reported. Acute and chronic symptoms and disabilities associated with specific forms of abuse and the subsequent healing processes should be documented. 1. Acute symptoms 170. The individual should be asked to describe any injuries that may have resulted from the specific methods of alleged abuse. These can be, for example, bleeding, bruising, swelling, open wounds, lacerations, fractures, dislocations, joint stress, haemoptysis, pneumothorax, tympanic membrane perforation, genito-urinary system injuries, burns (colour, bulla or necrosis according to the degree of burn), electrical injuries (size and number of lesions, their colour and surface characteristics), chemical injuries (colour, signs of necrosis), pain, numbness, con- stipation and vomiting. The intensity, frequency and dura- tion of each symptom should be noted. The development of any subsequent skin lesions should be described indi- cating whether or not they left scars. Ask about health on release; was he or she able to walk or confined to bed? If confined, for how long? How long did wounds take to heal? Were they infected? What treatment was received? Was it a physician or a traditional healer? Be aware that the detainee’s ability to make such observations may have been compromised by the torture itself or its after-effects and should be documented. 2. Chronic symptoms 171. Elicit information on physical ailments that the individual believes were associated with torture or ill- treatment. Note the severity, frequency and duration of each symptom and any associated disability or need for medical or psychological care. Even if the after-effects of acute lesions cannot be seen months or years later, some physical findings may still remain, such as electrical cur- rent or thermal burn scars, skeletal deformities, incorrect healing of fractures, dental injuries, loss of hair and myofibrosis. Common somatic complaints include head- ache, back pain, gastrointestinal symptoms, sexual dys- function and muscle pain. Common psychological symp- toms include depressive affect, anxiety, insomnia, nightmares, flashbacks and memory difficulties (see chapter VI, sect. B.2). 3. Summary of an interview 172. Torture victims may have injuries that are sub- stantially different from other forms of trauma. Although acute lesions may be characteristic of the alleged injuries, most lesions heal within about six weeks of torture, leav- ing no scars or, at the most, non-specific scars. This is often the case when torturers use techniques that prevent or limit detectable signs of injury. Under such circum- stances, the physical examination may be within normal limits, but this in no way negates allegations of torture. A detailed account of the patient’s observations of acute lesions and the subsequent healing process often repre- sents an important source of evidence in corroborating specific allegations of torture or ill-treatment. C. The physical examination 173. Subsequent to the acquisition of background information and after the patient’s informed consent has been obtained, a complete physical examination by a qualified physician should be performed. Whenever pos- sible, the patient should be able to choose the gender of the physician and, where used, of the interpreter. If the doctor is not of the same gender as the patient, a chaper- one who is should be used unless the patient objects. The patient must understand that he or she is in control and has the right to limit the examination or to stop it at any time (see chapter IV, sect. J). 174. In this section, there are many references to spe- cialist referral and further investigations. Unless the patient is in detention, it is important for physicians to have access to physical and psychological treatment facil- ities, so that any identified need can be followed up. In many situations, certain diagnostic test techniques will 35 not be available, and their absence must not invalidate the report (see annex II for further details of possible diagnos- tic tests). 175. In cases of alleged recent torture and when the clothes worn during torture are still being worn by the tor- ture survivor, they should be taken for examination with- out having been washed, and a fresh set of clothes should be provided. Wherever possible, the examination room should be equipped with sufficient light and medical equipment for the examination. Any deficiencies should be noted in the report. The examiner should note all perti- nent positive and negative findings, using body diagrams to record the location and nature of all injuries (see annex III). Some forms of torture such as electrical shock or blunt trauma may be initially undetectable, but may be detected during a follow-up examination. Although it will rarely be possible to record photographically lesions of prisoners in custody of their torturers, photography should be a routine part of examinations. If a camera is available, it is always better to take poor quality photo- graphs than to have none. They should be followed up with professional photographs as soon as possible (see chapter III, sect. C.5). 1. Skin 176. The examination should include the entire body surface in order to detect signs of generalized skin disease including signs of vitamin A, B and C deficiency, pre-tor- ture lesions or lesions inflicted by torture, such as abra- sions, contusions, lacerations, puncture wounds, burns from cigarettes or heated instruments, electrical injuries, alopecia and nail removal. Torture lesions should be described by their localization, symmetry, shape, size, colour and surface (e.g. scaly, crusty, ulcerating) as well as their demarcation and level in relation to the surround- ing skin. Photography is essential whenever possible. Ultimately, the examiner must offer an opinion as to the origin of the lesions: inflicted or self-inflicted, accidental or the result of a disease process.73, 74 2. Face 177. Facial tissues should be palpated for evidence of fracture, crepitation, swelling or pain. The motor and sensory components, including smell and taste of all cra- nial nerves, should be examined. Computerized tomogra- phy (CT), rather than routine radiography, is the best modality to diagnose and characterize facial fractures, determine alignment and diagnose associated soft tissue injuries and complications. Intracranial and cervical spinal injuries are often associated with facial trauma. 73 O. V. Rasmussen, “Medical aspects of torture”, Danish Medical Bulletin, vol. 37, supplement No. 1 (1990), pp. 1-88. 74 R. Bunting, “Clinical examinations in the police context”, Clinical Forensic Medicine, W. D. S. McLay, ed. (London, Greenwich Medical Media, 1996), pp. 59-73. (a) Eyes 178. There are many forms of trauma to the eyes, including conjunctival haemorrhage, lens dislocation, subhyeloid haemorrhage, retrobulbar haemorrhage, reti- nal haemorrhage and visual field loss. Given the serious consequences of lack of treatment or improper treatment, ophthalmologic consultation should be obtained when- ever there is a suspicion of ocular trauma or disease. CT is the best modality to diagnose orbital fractures and soft tissue injuries to the bulbar and retrobulbar contents. Nuclear magnetic resonance imaging (MRI) may be an adjunct for identifying soft tissue injury. High resolution ultrasound is an alternative method for evaluation of trauma to the eye globe. (b) Ears 179. Trauma to the ears, especially rupture of the tympanic membrane, is a frequent consequence of harsh beatings. The ear canals and tympanic membranes should be examined with an otoscope and injuries described. A common form of torture, known in Latin America as telefono, is a hard slap of the palm to one or both ears, rapidly increasing pressure in the ear canal, thus rupturing the drum. Prompt examination is necessary to detect tym- panic membrane ruptures less than 2 millimetres in diam- eter, which may heal within 10 days. Fluid may be observed in the middle or external ear. If otorrhea is con- firmed by laboratory analysis, MRI or CT should be per- formed to determine the fracture site. The presence of hearing loss should be investigated, using simple screen- ing methods. If necessary, audiometric tests should be conducted by a qualified audiometric technician. The radiographic examination of fractures of the temporal bone or disruption of the ossicular chain is best deter- mined by CT, then hypocycloidal tomography and, lastly, linear tomography. (c) Nose 180. The nose should be evaluated for alignment, crepitation and deviation of the nasal septum. For simple nasal fractures, standard nasal radiographs should be suf- ficient. For complex nasal fractures and when the carti- laginous septum is displaced, CT should be performed. If rhinorrhea is present, CT or MRI is recommended. (d) Jaw, oropharynx and neck 181. Mandibular fractures or dislocations may result from beatings. Temporomandibular joint syndrome is a frequent consequence of beatings about the lower face and jaw. The patient should be examined for evidence of crepitation of the hyoid bone or laryngeal cartilage result- ing from blows to the neck. Findings concerning the oropharynx should be noted in detail, including lesions consistent with burns from electrical shock or other trauma. Gingival haemorrhage and the condition of the gums should also be noted. (e) Oral cavity and teeth 182. Examination by a dentist should be considered a component of periodic health examination in detention. This examination is often neglected, but it is an important 38 the proximal nail fold, resulting in the formation of ptery- gium. Changes in the nail caused by Lichen planus consti- tute the only relevant differential diagnosis, but they will usually be accompanied by widespread skin injury. On the other hand, fungus infections are characterized by thick- ened, yellowish, crumbling nails, different from the above changes. 196. Sharp trauma wounds are produced when the skin is cut with a sharp object, such as a knife, bayonet or broken glass and include stab wounds, incised or cut wounds and puncture wounds. The acute appearance is usually easy to distinguish from the irregular and torn appearance of lacerations and scars found upon later examination that may be distinctive. Regular patterns of small incisional scars could be due to traditional heal- ers.82 If pepper or other noxious substances are applied to open wounds, the scars may become hypertrophic. An asymmetrical pattern and different sizes of scars are prob- ably significant in the diagnosis of torture. (b) Fractures 197. Fractures produce a loss of bone integrity due to the effect of a blunt mechanical force on various vector planes. A direct fracture occurs at the site of impact or at the site where the force was applied. The location, contour and other characteristics of a fracture reflect the nature and direction of the applied force. It is sometimes possible to distinguish fracture inflicted from accidental injury by the radiological appearance of the fracture. Radiographic dating of relatively recent fractures should be done by an experienced trauma radiologist. Speculative judgements should be avoided in the evaluations of the nature and age of blunt traumatic lesions, since a lesion may vary accord- ing to the age, sex, tissue characteristics, the condition and health of the patient and the severity of the trauma. For example, well-conditioned, muscularly fit, younger individuals are more resistant to bruising than frail, older individuals. (c) Head trauma 198. Head trauma is one of the most common forms of torture. In cases of recurring head trauma, even if not always of serious dimensions, cortical atrophy and diffuse axonal damage can be expected. In cases of trauma caused by falls, countercoup (location in opposition to the trauma) lesions of the brain may be observed. Whereas in cases of direct trauma, contusions of the brain may be observed directly under the region in which the trauma is inflicted. Scalp bruises are frequently invisible externally unless there is swelling. Bruises may be difficult to see in dark-skinned individuals, but will be tender upon palpa- tion. 199. Having been exposed to blows to the head, a torture survivor may complain of continuous headaches. These are often somatic or may be referred from the neck (see section C above). The victim may claim to suffer pain when touched in that region, and diffuse or local fullness or increased firmness may be observed by means of pal- pation of the scalp. Scars can be observed in cases where there have been lacerations of the scalp. Headaches may 82 See footnote 76 above. be the initial symptom of an expanding subdural haematoma. They may be associated with the acute onset of mental status changes, and a CT scan must be per- formed urgently. Soft tissue swelling or haemorrhage will usually be detected with CT or MRI. It may also be appro- priate to arrange psychological or neuropsychological assessment (see chapter VI, sect. C.4). 200. Violent shaking as a form of torture may pro- duce cerebral injury without leaving any external marks, although bruises may be present on the upper chest or shoulders where the victim or his clothing has been grabbed. At its most extreme, shaking can produce inju- ries identical to those seen in the shaken baby syndrome: cerebral oedema, subdural haematoma and retinal haem- orrhages. More commonly, victims complain of recurrent headaches, disorientation or mental status changes. Shak- ing episodes are usually brief, only a few minutes or less, but may be repeated many times over a period of days or weeks. (d) Chest and abdominal trauma 201. Rib fractures are a frequent consequence of beatings to the chest. If displaced, they can be associated with lacerations of the lung and possible pneumothorax. Fractures of the vertebral pedicles may result from direct use of blunt force. 202. In cases of acute abdominal trauma, the physi- cal examination should seek evidence of abdominal organ and urinary tract injury. However, the examination is often negative. Gross haematuria is the most significant indication of kidney contusion. Peritoneal lavage may detect occult abdominal haemorrhage. Free abdominal fluid detected by CT after peritoneal lavage may be from the lavage or haemorrhage; thus invalidating the finding. On a CT, acute abdominal haemorrhage is usually iso- intense or reveals water density unlike acute central nerv- ous system (CNS) haemorrhage, which is hyperintense. Organ injury may be present as free air, extraluminal fluid or areas of low attenuation, which may represent oedema, contusion, haemorrhage or a laceration. Peripancreatic oedema is one of the signs of acute traumatic and non- traumatic pancreatitis. Ultrasound is particularly useful in detecting subcapsular haematomas of the spleen. Renal failure due to crush syndrome may be acute after severe beatings. Renal hypertension can be a late complication of renal injury. 2. Beatings to the feet 203. Falanga is the most common term for repeated application of blunt trauma to the feet (or more rarely to the hands or hips), usually applied with a truncheon, a length of pipe or similar weapon. The most severe com- plication of falanga is closed compartment syndrome, which can cause muscle necrosis, vascular obstruction or gangrene of the distal portion of the foot or toes. Perma- nent deformities of the feet are uncommon but do occur, as do fractures of the carpal, metacarpal and phalanges. Because the injuries are usually confined to soft tissue, CT or MRI are the preferred methods for radiological documentation of the injury, but it must be emphasized that physical examination in the acute phase should be 39 diagnostic. Falanga may produce chronic disability. Walking may be painful and difficult. The tarsal bones may be fixed (spastic) or have increased motion. Squeez- ing the plantar (sole) of the foot and dorsiflexion of the great toe may produce pain. On palpation, the entire length of the plantar aponeurosis may be tender and the distal attachments of the aponeurosis may be torn, partly at the base of the proximal phalanges, partly at the skin. The aponeurosis will not tighten normally, making walk- ing difficult and muscle fatigue may follow. Passive extension of the big toe may reveal whether the aponeuro- sis has been torn. If it is intact, the beginning of tension in the aponeurosis should be felt on palpation when the toe is dorsiflexed to 20 degrees; maximum normal extension is about 70 degrees. Higher values suggest injury to the attachments of the aponeurosis.83, 84, 85, 86 On the other hand, limited dorsiflexion and pain on hyperextension of the large toe are findings of Hallux rigidus, which results from dorsal osteophyte at the first metatarsal head and/or base of the proximal phalanx. 204. Numerous complications and syndromes can occur: (a) Closed compartment syndrome. This is the most severe complication. An oedema in a closed compartment results in vascular obstruction and muscle necrosis, which may result in fibrosis, contracture or gangrene in the distal foot or toes. It is usually diagnosed by measuring pres- sures in the compartment; (b) Crushed heel and anterior footpads. The elastic pads under the calcaneus and proximal phalanxes are crushed during falanga, either directly or as a result of oedema associated with the trauma. Also, the connective tissue bands that extend through adipose tissue and con- nect bone to the skin are torn. Adipose tissue is deprived of its blood supply and atrophies. The cushioning effect is lost and the feet no longer absorb the stresses produced by walking; (c) Rigid and irregular scars involving the skin and subcutaneous tissues of the foot after the application of falanga. In a normal foot, the dermal and sub-dermal tis- sues are connected to the planter aponeurosis through tight connective tissue bands. However, these bands can be partially or completely destroyed due to the oedema that ruptures the bands after exposure to falanga; (d) Rupture of the plantar aponeurosis and tendons of the foot. An oedema in the post-falanga period may rup- ture these structures. When the supportive function neces- sary for the arch of the foot disappears, the act of walking becomes more difficult and foot muscles, especially the quadratus plantaris longus, are excessively forced; 83 G. Sklyv, “Physical sequelae of torture”, in Torture and Its Consequences: Current Treatment Approaches, M. Başoglu, ed. (Cambridge, Cambridge University Press, 1992), pp. 38-55. 84 See footnote 76. 85 K. Prip, L. Tived, N. Holten, Physiotherapy for Torture Survivors: A Basic Introduction (Copenhagen, International Rehabilitation Council for Torture Victims, 1995). 86 F. Bojsen-Moller and K. E. Flagstad, “Plantar aponeurosis and internal architecture of the ball of the foot”, Journal of Anatomy, vol. 121 (1976), pp. 599-611. (e) Planter fasciitis. May occur as a further complica- tion of this injury. In cases of falanga, irritation is often present throughout the whole aponeurosis, causing chronic aponeurositis. Studies on the subject have shown that in prisoners released after 15 years of detention and who claimed to have been subjected to falanga applica- tion when first arrested, positive bone scans of hyperac- tive points in the calcaneus or metatarsal bones were observed.87 205. Radiological methods such as MRI, CT scan and ultrasound can often confirm cases of trauma occur- ring as a result of the application of falanga. Positive radiological findings may also be secondary to other dis- eases or trauma. Routine radiographs are recommended as the initial examination. MRI is the preferred radiologi- cal examination for detecting soft tissue injury. MRI or scintigraphy can detect bone injury in the form of a bruise, which may not be detected by routine radiographs or CT.88 3. Suspension 206. Suspension is a common form of torture that can produce extreme pain, but which leaves little, if any, visible evidence of injury. A person still in custody may be reluctant to admit to being tortured, but the finding of peripheral neurological deficits, diagnostic of brachial plexopathy, virtually proves the diagnosis of suspension torture. Suspension can be applied in various forms: (a) Cross suspension. Applied by spreading the arms and tying them to a horizontal bar; (b) Butchery suspension. Applied by fixation of hands upwards, either together or one by one; (c) Reverse butchery suspension. Applied by fixation of feet upward and the head downward; (d) “Palestinian” suspension. Applied by suspending the victim with the forearms bound together behind the back, the elbows flexed 90 degrees and the forearms tied to a horizontal bar. Alternatively, the prisoner is sus- pended from a ligature tied around the elbows or wrists with the arms behind the back; (e) “Parrot perch” suspension. Applied by suspending a victim by the flexed knees from a bar passed below the popliteal region, usually while the wrists are tied to the ankles. 207. Suspension may last from l5 to 20 minutes to several hours. “Palestinian” suspension may produce per- manent brachial plexus injury in a short period. The “par- rot perch” may produce tears in the cruciate ligaments of the knees. Victims will often be beaten while suspended or otherwise abused. In the chronic phase, it is usual for pain and tenderness around the shoulder joints to persist, 87 V. Lök and others, “Bone scintigraphy as clue to previous torture”, The Lancet, vol. 337, No. 8745 (1991), pp. 846-847. See also M. Tunca and V. Lök, “Bone scintigraphy in screening of torture survivors”, The Lancet, vol. 352, No. 9143 (1998), p. 1859. 88 See footnotes 76 and 83 and V. Lök and others, “Bone scintigraphy as an evidence of previous torture”, Treatment and Rehabilitation Center Report of the Human Rights Foundation of Turkey (Ankara, 1994), pp. 91-96. ^ 40 as the lifting of weight and rotation, especially internal, will cause severe pain many years later. Complications in the acute period following suspension include weakness of the arms or hands, pain and parasthesias, numbness, insensitivity to touch, superficial pain and tendon reflex loss. Intense deep pain may mask muscle weakness. In the chronic phase, weakness may continue and progress to muscle wasting. Numbness and, more frequently, paras- thesia are present. Raising the arms or lifting weight may cause pain, numbness or weakness. In addition to neuro- logic injury, there may be tears of the ligaments of the shoulder joints, dislocation of the scapula and muscle injury in the shoulder region. On visual inspection of the back, a “winged scapula” (prominent vertebral border of the scapula) may be observed with injury to the long tho- racic nerve or dislocation of the scapula. 208. Neurologic injury is usually asymmetrical in the arms. Brachial plexus injury manifests itself in motor, sensory and reflex dysfunction. (a) Motor examination. Asymmetrical muscle weak- ness, more prominent distally, is the most expected find- ing. Acute pain may make the examination for muscle strength difficult to interpret. If the injury is severe, mus- cle atrophy may be seen in the chronic phase; (b) Sensory examination. Complete loss of sensation or parasthesias along the sensory nerve pathways is com- mon. Positional perception, two-point discrimination, pinprick evaluation and perception of heat and cold should all be tested. If at least three weeks later, defi- ciency or reflex loss or decrease is present, appropriate electrophysiological studies should be performed by a neurologist experienced in the use and interpretation of these methodologies; (c) Reflex examination. Reflex loss, a decrease in reflexes or a difference between the two extremities may be present. In “Palestinian” suspension, even though both brachial plexi are subjected to trauma, asymmetric plex- opathy may develop due to the manner in which the tor- ture victim has been suspended, depending on which arm is placed in a superior position or the method of binding. Although research suggests that brachial plexopathies are usually unilateral, that is at variance with experience in the context of torture, where bilateral injury is common. 209. Among the shoulder region tissues, the brachial plexus is the structure most sensitive to traction injury. “Palestinian” suspension creates brachial plexus damage due to forced posterior extension of the arms. As observed in the classical type of “Palestinian” suspension, when the body is suspended with the arms in posterior hyperexten- sion, typically the lower plexus and then the middle and upper plexus fibres, if the force on the plexus is severe enough, are damaged, respectively. If the suspension is of a “crucifixion” type, but does not include hyperextension, the middle plexus fibres are likely to be the first ones damaged due to hyperabduction. Brachial plexus injuries may be categorized as follows: (a) Damage to the lower plexus. Deficiencies are localized in the forearm and hand muscles. Sensory defi- ciencies may be observed on the forearm and at the fourth and fifth fingers of the hand’s medial side in an ulnar nerve distribution; (b) Damage to the middle plexus. Forearm, elbow and finger extensor muscles are affected. Pronation of the forearm and radial flexion of the hand may be weak. Sen- sory deficiency is found on the forearm and on the dorsal aspects of the first, second and third fingers of the hand in a radial nerve distribution. Triceps reflexes may be lost; (c) Damage to the upper plexus. Shoulder muscles are especially affected. Abduction of the shoulder, axial rota- tion and forearm pronation-supination may be deficient. Sensory deficiency is noted in the deltoid region and may extend to the arm and outer parts of the forearm. 4. Other positional torture 210. There are many forms of positional torture, all of which tie or restrain the victim in contorted, hyperex- tended 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. 211. All positional torture is directed towards ten- dons, joints and muscles. There are various methods: “parrot suspension”, “banana stand” or the classic “banana tie” over a chair just on the ground, or on a motorcycle, forced standing, forced standing on a single foot, prolonged standing with arms and hands stretched high on a wall, prolonged forced squatting and forced immobilization in a small cage. In accordance with the characteristics of these positions, complaints are charac- terized as pain in a region of the body, limitation of joint movement, back pain, pain in the hands or cervical parts of the body and swelling of the lower legs. The same prin- ciples of neurologic and musculoskeletal examination apply to these forms of positional torture as apply to sus- pension. MRI is the preferred radiologic modality for evaluation of injuries associated with all forms of posi- tional torture. 5. Electric shock torture 212. Electric current is transmitted through elec- trodes placed on any part of the body. The most common areas are the hands, feet, fingers, toes, ears, nipples, mouth, lips and genital area. The power source may be a hand-cranked or combustion generator, wall source, stun gun, cattle prod or other electric device. Electric current follows the shortest route between the two electrodes. The symptoms that occur when electric current is applied have this characteristic. For example, if electrodes are placed on a toe of the right foot and on the genital region, there will be pain, muscle contraction and cramps in the right thigh and calf muscles. Excruciating pain will be felt in the genital region. Since all muscles along the route of the electric current are tetanically contracted, dislocation of the shoulder, lumbar and cervical radiculopathies may be observed when the current is moderately high. However, the type, time of application, current and voltage of the energy used cannot be determined with certainty upon physical examination of the victim. Torturers often use water or gels in order to increase the efficiency of the tor- 43 226. Appropriate laboratory tests and treatment should be prescribed in all cases of sexual abuse. In the case of gonorrhoea and chlamydia, concomitant infection of the anus or oropharynx should be considered at least for examination purposes. Initial cultures and serologic tests should be obtained in cases of sexual assault, and appropriate therapy initiated. Sexual dysfunction is com- mon among survivors of torture, particularly among vic- tims who have suffered sexual torture or rape, but not exclusively. Symptoms may be physical or psychological in origin or a combination of both and include: (i) Aversion to members of the opposite sex or decreased interest in sexual activity; (ii) Fear of sexual activity because a sexual partner will know that the victim has been sexually abused or fear of having been damaged sexually. Torturers may have threatened this and instilled fear of homosexuality in men who have been anally abused. Some heterosexual men have had an erection and, on occasion, have ejaculated during non-consensual anal intercourse. They should be reassured that this is a physiological response; (iii) Inability to trust a sexual partner; (iv) Disturbance in sexual arousal and erectile dys- function; (v) Dyspareunia (painful sexual intercourse in women) or infertility due to acquired sexually transmitted disease, direct trauma to reproduc- tive organs or poorly performed abortions of pregnancies following rape. (e) Genital examination of women 227. In many cultures, it is completely unacceptable to penetrate the vagina of a woman who is a virgin with anything, including a speculum, finger or swab. If the woman demonstrates clear evidence of rape on external inspection, it may be unnecessary to conduct an internal pelvic examination. Genital examination findings may include: (i) Small lacerations or tears of the vulva. These may be acute and are caused by excessive stretching. They normally heal completely, but, if repeatedly traumatized, there may be scarring; (ii) Abrasions of the female genitalia. Abrasions can be caused by contact with rough objects such as fingernails or rings; (iii) Vaginal lacerations. These are rare, but, if present, may be associated with atrophy of the tissues or previous surgery. They cannot be dif- ferentiated from incisions caused by inserted sharp objects. 228. It is rare to find any physical evidence when examining female genitalia more than one week after an assault. Later on, when the woman may have had subse- quent sexual activity, whether consensual or not, or given birth, it may be almost impossible to attribute any find- ings to a specific incident of alleged abuse. Therefore, the most significant component of a medical evaluation may be the examiner’s assessment of background information (for example, correlation between allegations of abuse and acute injuries observed by the individual) and demeanour of the individual, bearing in mind the cultural context of the woman’s experience. (f) Genital examination of men 229. Men who have been subjected to torture of the genital region, including the crushing, wringing or pulling of the scrotum or direct trauma to that region, usually complain of pain and sensitivity in the acute period. Hyperaemia, marked swelling and ecchymosis can be observed. The urine may contain a large number of eryth- rocytes and leucocytes. If a mass is detected, it should be determined whether it is a hydrocele, haematocele or inguinal hernia. In the case of an inguinal hernia, the examiner cannot palpate the spermatic cord above the mass. With a hydrocele or a haematocele, normal sper- matic cord structures are usually palpable above the mass. A hydrocele results from excessive accumulation of fluid within the tunica vaginalis due to inflammation of the tes- tis and its appendages or to diminished drainage second- ary to lymphatic or venous obstruction in the cord or retroperitoneal space. A haematocele is an accumulation of blood within the tunica vaginalis, secondary to trauma. Unlike the hydrocele, it does not transilluminate. 230. Testicular torsion may also result from trauma to the scrotum. With this injury, the testis becomes twisted at its base, obstructing blood flow to the testis. This causes severe pain and swelling and constitutes a surgical emergency. Failure to reduce the torsion immediately will lead to infarction of the testis. Under conditions of deten- tion, where medical care may be denied, late sequelae of this lesion may be observed. 231. Individuals who were subject to scrotal torture may suffer from chronic urinary tract infection, erectile dysfunction or atrophy of the testes. Symptoms of PTSD are not uncommon. In the chronic phase, it may be impos- sible to distinguish between scrotal pathology caused by torture and that caused by other disease processes. Failure to discover any physical abnormalities on full urological examination suggests that urinary symptoms, impotence or other sexual problems may be explained on psycho- logical grounds. Scars on the skin of the scrotum and penis may be very difficult to visualize. For this reason, the absence of scarring at these specific locations does not demonstrate the absence of torture. On the other hand, the presence of scarring usually indicates that substantial trauma was sustained. (g) Examination of the anal region 232. 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 deten- tion. Gastrointestinal and urinary symptoms may also occur. In the acute phase, any examination beyond visual inspection may require local or general anaesthesia and should be performed by a specialist. In the chronic phase, several symptoms may persist, and they should be inves- tigated. There may be anal scars of unusual size or posi- tion, and these should be documented. Anal fissures may persist for many years, but it is normally impossible to 44 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 docu- mented: (i) 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 a more specific finding and can be considered evidence of penetration; (ii) Rectal tears with or without bleeding may be noted; (iii) 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; (iv) Skin tags, which can be the result of healing trauma; (iv) 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. E. Specialized diagnostic tests 233. Diagnostic tests are not an essential part of the clinical assessment of a person alleging having been tor- tured. In many cases, a medical history and physical examination are sufficient. However, there are circum- stances in which such tests are valuable supporting evi- dence. For example, where there is a legal case against members of the authorities or a claim for compensation. In these cases, a positive test might make the difference between a case succeeding or failing. Additionally, if diagnostic tests are performed for therapeutic reasons, the results should be added to the clinical report. It must be recognized that the absence of a positive diagnostic test result, as with physical findings, must not be used to sug- gest that torture has not occurred. There are many situa- tions in which diagnostic tests are not available for tech- nical reasons, but their absence should never invalidate an otherwise properly written report. It is inappropriate to use limited diagnostic facilities to document injuries for legal reasons alone, when there are greater clinical needs for those facilities (for further details, see annex II). 45 A. General considerations 1. The central role of the psychological evaluation 234. It is a widely held view that torture is an extraor- dinary life experience capable of causing a wide range of physical and psychological suffering. Most clinicians and researchers agree that the extreme nature of the torture event is powerful enough on its own to produce mental and emotional consequences, regardless of the individ- ual’s pre-torture psychological status. The psychological consequences of torture, however, occur in the context of personal attribution of meaning, personality development and social, political and cultural factors. For this reason, it cannot be assumed that all forms of torture have the same outcome. For example, the psychological conse- quences 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. Nevertheless, there are clusters of symptoms and psychological reactions that have been observed and documented in torture survivors with some regularity. 235. Perpetrators often attempt to justify their acts of torture and ill-treatment by the need to gather informa- tion. Such conceptualizations obscure the purpose of tor- ture and its intended consequences. One of the central aims of torture is to reduce an individual to a position of extreme helplessness and distress that can lead to a de- terioration of cognitive, emotional and behavioural func- tions.92 Thus, torture is a means of attacking an individ- ual’s fundamental modes of psychological and social functioning. Under such circumstances, the torturer strives not only to incapacitate a victim physically but also to disintegrate the individual’s personality. The tor- turer attempts to destroy a victim’s sense of being grounded in a family and society as a human being with dreams, hopes and aspirations for the future. By dehu- manizing and breaking the will of their victims, torturers set horrific examples for those who later come in contact with the victim. In this way, torture can break or damage the will and coherence of entire communities. In addition, torture can profoundly damage intimate relationships between spouses, parents, children, other family members and relationships between the victims and their commu- nities. 92 G. Fischer and N. F. Gurris, “Grenzverletzungen: Folter und sexuelle Traumatisierung”, Praxis der Psychotherapie–Ein integratives Lehrbuch für Psychoanalyse und Verhaltenstherapie, W. Senf and M. Broda, eds. (Stuttgart, Thieme, 1996). 236. It is important to recognize that not everyone who has been tortured develops a diagnosable mental ill- ness. However, many victims experience profound emo- tional reactions and psychological symptoms. The main psychiatric disorders associated with torture are PTSD and major depression. While these disorders are present in the general population, their prevalence is much higher among traumatized populations. The unique cultural, social and political implications that torture has for each individual influence his or her ability to describe and speak about it. These are important factors that contribute to the impact that torture inflicts psychologically and socially and that must be considered when performing an evaluation of an individual from another culture. Cross- cultural research reveals that phenomenological or descriptive methods are the most rational approaches to use when attempting to evaluate psychological or psychi- atric disorders. What is considered disordered behaviour or a disease in one culture may not be viewed as patho- logical in another.93, 94, 95 Since the Second World War, progress has been made towards understanding the psychological consequences of violence. Certain psycho- logical symptoms and clusters of symptoms have been observed and documented among survivors of torture and other types of violence. 237. In recent years, the diagnosis of PTSD has been applied to an increasingly broad array of individuals suf- fering from the impact of widely varying types of vio- lence. However, the utility of this diagnosis in non-West- ern cultures has not been established. Nevertheless, evidence suggests that there are high rates of PTSD and depression symptoms among traumatized refugee popula- tions from many different ethnic and cultural back- grounds.96, 97, 98 The World Health Organization’s cross- 93 A. Kleinman, “Anthropology and psychiatry: the role of culture in cross-cultural research on illness and care”, paper delivered at the World Psychiatric Association regional symposium on psychiatry and its related disciplines, 1986. 94 H. T. Engelhardt, “The concepts of health and disease”, Evaluation and Explanation in the Biomedical Sciences, H. T. Engelhardt and S. F. Spicker, eds. (Dordrecht, D. Reidel Publishing Co., 1975), pp. 125-141. 95 J. Westermeyer, “Psychiatric diagnosis across cultural boundaries”, American Journal of Psychiatry, vol. 142 (7) (1985), pp. 798-805. 96 R. F. Mollica and others, “The effect of trauma and confinement on functional health and mental health status of Cambodians living in Thailand-Cambodia border camps”, Journal of the American Medical Association (JAMA), vol. 270 (1993), pp. 581-586. 97 J. D. Kinzie and others. “The prevalence of posttraumatic stress disorder and its clinical significance among Southeast Asian refugees”, American Journal of Psychiatry, vol. 147 (7) (1990), pp. 913-917. 98 K. Allden and others, “Burmese political dissidents in Thailand: trauma and survival among young adults in exile”, American Journal of Public Health, vol. 86 (1996), pp. 1561-1569. CHAPTER VI PSYCHOLOGICAL EVIDENCE OF TORTURE 48 her cultural, social and political context, it is wise for evaluators to become familiar with the most commonly diagnosed disorders among trauma and torture survivors. Also, it is not uncommon for more than one mental disor- der to be present, as there is considerable co-morbidity among trauma-related mental disorders. Various manifes- tations of anxiety and depression are the most common symptoms resulting from torture. Not infrequently, the symptomatology described above will be classified within the categories of anxiety and mood disorders. The two prominent classification systems are the International Classification of Disease (ICD-10)103 classification of mental and behavioural disorders and the American Psy- chiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).104 For complete descrip- tions of diagnostic categories, the reader should refer to ICD-10 and DSM-IV. This review will focus on the most common trauma-related diagnoses: PTSD, major depres- sion and enduring personality changes. (a) Depressive disorders 251. Depressive states are almost ubiquitous among survivors of torture. In the context of evaluating the con- sequences of torture, it is problematic to assume that PTSD and major depressive disorder are two separate dis- ease entities with clearly distinguishable aetiologies. Depressive disorders include major depressive disorder, single episode or major depressive disorder and recurrent (more than one episode). Depressive disorders can be present with or without psychotic, catatonic, melancholic or atypical features. According to DSM-IV, in order to make a diagnosis of major depressive episode, five or more of the following symptoms must be present during the same two-week period and represent a change from previous functioning (at least one of the symptoms must be depressed mood or loss of interest or pleasure): (1) depressed mood; (2) markedly diminished interest or pleasure in all or almost all activities; (3) weight loss or change of appetite; (4) insomnia or hypersomnia; (5) psychomotor agitation or retardation; (6) fatigue or loss of energy; (7) feelings of worthlessness or excessive or inappropriate guilt; (8) diminished ability to think or concentrate; and (9) recurrent thoughts of death or sui- cide. To make this diagnosis the symptoms must cause significant distress or impaired social or occupational functioning, not be due to a physiological disorder and unaccounted for by another DSM-IV diagnosis. (b) Post-traumatic stress disorder 252. The diagnosis most commonly associated with the psychological consequences of torture is PTSD. The association between torture and this diagnosis has become very strong in the minds of health providers, immigration courts and the informed lay public. This has created the mistaken and simplistic impression that PTSD is the main psychological consequence of torture. 103 World Health Organization, The ICD-10 Classification of Mental and Behavioural Disorders (Geneva, 1994). 104 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, 4th ed. (Washington, D.C., 1994). 253. The DSM-IV definition of PTSD relies heavily on the presence of memory disturbances in relation to the trauma, such as intrusive memories, nightmares and the inability to recall important aspects of the trauma. The individual may be unable to recall with precision specific details of the torture events but will be able to recall the major themes of the torture experiences. For example, the victim may be able to recall being raped on several occa- sions but not be able to give the exact dates, locations and details of the setting or the perpetrators. Under such cir- cumstances, the inability to recall precise details supports, rather than discounts, the credibility of a survivor’s story. Major themes in the story will be consistent upon re-inter- viewing. The ICD-10 diagnosis of PTSD is very similar to that of DSM-IV. According to DSM-IV, PTSD can be acute, chronic or delayed. The symptoms must be present for more than one month and the disturbance must cause significant distress or impairment in functioning. In order to diagnose PTSD, the individual must have been exposed to a traumatic event that involved life-threatening experi- ences for the victim or others and produced intense fear, helplessness or horror. The event must be re-experienced persistently in one or more of the following ways: intru- sive distressing recollections of the event, recurrent dis- tressing dreams of the event, acting or feeling as if the event were happening again including hallucinations, flashbacks and illusions, intense psychological distress at exposure to reminders of the event and physiological reactivity when exposed to cues that resemble or symbol- ize aspects of the event. 254. The individual must persistently demonstrate avoidance of stimuli associated with the traumatic event or show general numbing of responsiveness as indicated by at least three of the following: (1) efforts to avoid thoughts, feelings or conversations associated with the trauma; (2) efforts to avoid activities, places or people that remind the victim of the trauma; (3) inability to recall an important aspect of the event; (4) diminished interest in significant activities; (5) detachment or estrangement from others; (6) restricted affect; and (7) foreshortened sense of future. Another reason to make a DSM-IV diag- nosis of PTSD is the persistence of symptoms of increased arousal that were not present before the trauma, as indi- cated by at least two of the following: difficulty falling or staying asleep, irritability or angry outbursts, difficulty concentrating, hypervigilance and exaggerated startle response. 255. Symptoms of PTSD can be chronic or fluctuate over extended periods of time. During some intervals, symptoms of hyperarousal and irritability dominate the clinical picture. At these times, the survivor will usually also report increased intrusive memories, nightmares and flashbacks. At other times, the survivor may appear rela- tively asymptomatic or emotionally constricted and with- drawn. It must be kept in mind that not meeting diagnostic criteria of PTSD does not mean that torture was not inflicted. According to ICD-10, in a certain proportion of cases PTSD may follow a chronic course over many years with eventual transition to an enduring personality change. 49 (c) Enduring personality change 256. After catastrophic or prolonged extreme stress, disorders of adult personality may develop in persons with no previous personality disorder. The types of extreme stress that can change the personality include concentration camp experiences, disasters, prolonged captivity with an imminent possibility of being killed, exposure to life-threatening situations, such as being a victim of terrorism, and torture. According to ICD-10, the diagnosis of an enduring change in personality should be made only when there is evidence of a definite, significant and persistent change in the individual’s pattern of per- ceiving, relating or thinking about the environment and him or herself, associated with inflexible and maladaptive behaviours not present before the traumatic experience. The diagnosis excludes changes that are a manifestation of another mental disorder or a residual symptom of any antecedent mental disorder, as well as personality and behavioural changes due to brain disease, dysfunction or damage. 257. To make the ICD-10 diagnosis of enduring per- sonality change after catastrophic experience, the changes in personality must be present for at least two years fol- lowing exposure to catastrophic stress. ICD-10 specifies that the stress must be so extreme that “it is not necessary to consider personal vulnerability in order to explain its profound effect on the personality”. This personality change is characterized by a hostile or distrustful attitude towards the world, social withdrawal, feelings of empti- ness or hopelessness, a chronic feeling of “being on edge”, as if constantly threatened, and estrangement. (d) Substance abuse 258. Clinicians have observed that alcohol and drug abuse often develop secondarily in torture survivors as a way of suppressing traumatic memories, regulating unpleasant affects and managing anxiety. Although co- morbidity of PTSD with other disorders is common, sys- tematic research has seldom studied the abuse of sub- stances by torture survivors. The literature on populations that suffer from PTSD may include torture survivors, such as refugees, prisoners of war and veterans of armed con- flicts, and may provide some insight. Studies of these groups reveal that prevalence of substance abuse varies by ethnic or cultural group. Former prisoners of war with PTSD were at increased risk of substance abuse, and com- bat veterans have high rates of co-morbidity of PTSD and substance abuse.105, 106, 107, 108, 109, 110, 111, 112 In sum- 105 P. J. Farias, “Emotional distress and its socio-political correlates in Salvadoran refugees: analysis of a clinical sample”, Culture, Medicine and Psychiatry, vol. 15 (1991), pp. 167-192. 106 A. Dadfar, “The Afghans: bearing the scars of a forgotten war”, Amidst Peril and Pain: The Mental Health and Well-being of the World’s Refugees, A. Marsella and others (Washington, D. C., American Psychological Association, 1994). 107 G. W. Beebe, “Follow-up studies of World War II and Korean war prisoners: II. Morbidity, disability, and malajustments”, American Journal of Epidemiology, vol. 101 (1975), pp. 400-422. 108 B. E. Engdahl and others, “Comorbidity and course of psychiatric disorders in a community sample of former prisoners of war”, American Journal of Psychiatry, vol. 155 (1998), pp. 1740-1745. 109 T. M. Keane and J. Wolfe, “Comorbidity in post-traumatic stress disorder: an analysis of community and clinical studies”, Journal of Applied Social Psychology, vol. 20 (21) (1990), pp. 1776-1788. mary, there is considerable evidence from other popula- tions at risk of PTSD that substance abuse is a potential co-morbid diagnosis for torture survivors. (e) Other diagnoses 259. As is evident from the catalogue of symptoms described in this section, there are other diagnoses to be considered in addition to PTSD, such as major depressive disorder and enduring personality change. The other pos- sible diagnoses include but are not limited to: (i) Generalized anxiety disorder features excessive anxiety and worry about a variety of different events or activities, motor tension and increased autonomic activity; (ii) Panic disorder is manifested by recurrent and unexpected attacks of intense fear or discomfort, including symptoms such as sweating, choking, trembling, rapid heart rate, dizziness, nausea, chills or hot flushes; (iii) Acute stress disorder has essentially the same symptoms as PTSD but is diagnosed within one month of exposure to the traumatic event; (iv) Somatoform disorders featuring physical symp- toms that cannot be accounted for by a medical condition; (v) Bipolar disorder featuring manic or hypomanic episodes with elevated, expansive or irritable mood, grandiosity, decreased need for sleep, flight of ideas, psychomotor agitation and associ- ated psychotic phenomena; (vi) Disorders due to a general medical condition often in the form of brain impairment with resultant fluctuations or deficits in level of con- sciousness, orientation, attention, concentration, memory and executive functioning; (vii) Phobias such as social phobia and agoraphobia. C. The psychological/psychiatric evaluation 1. Ethical and clinical considerations 260. Psychological evaluations can provide critical evidence of abuse among torture victims for several rea- sons: torture often causes devastating psychological symptoms, torture methods are often designed to leave no physical lesions and physical methods of torture may result in physical findings that either resolve or lack specificity. 110 R. A. Kulka and others, Trauma and the Vietnam War Generation: Report of Findings from the National Vietnam Veterans Readjustment Study (New York, Brunner/Mazel, 1990). 111 B. K. Jordan and others, “Lifetime and current prevalence of specific psychiatric disorders among Vietnam veterans and controls”, Archives of General Psychiatry, vol. 48, No. 3 (1991), pp. 207-215. 112 A. Y. Shalev, A. Bleich and R. J. Ursano, “Posttraumatic stress disorder: somatic comorbidity and effort tolerance”, Psychosomatics, vol. 31 (1990), pp.197-203. 50 261. Psychological evaluations provide useful evi- dence for medico-legal examinations, political asylum applications, establishing conditions under which false confessions may have been obtained, understanding regional practices of torture, identifying the therapeutic needs of victims and as testimony in human rights inves- tigations. The overall goal of a psychological evaluation is to assess the degree of consistency between an individ- ual’s account of torture and the psychological findings observed during the course of the evaluation. To this end, the evaluation should provide a detailed description of the individual’s history, a mental status examination, an assessment of social functioning and the formulation of clinical impressions (see chapters III, sect. C, and IV, sect. E). A psychiatric diagnosis should be made, if appropriate. Because psychological symptoms are so prevalent among survivors of torture, it is highly advis- able for any evaluation of torture to include a psycholog- ical assessment. 262. The assessment of psychological status and the formulation of a clinical diagnosis should always be made with an awareness of the cultural context. Awareness of culture-specific syndromes and native language-bound idioms of distress through which symptoms are commu- nicated is of paramount importance for conducting the interview and formulating the clinical impression and conclusion. When the interviewer has little or no knowl- edge of the victim’s culture, the assistance of an inter- preter is essential. Ideally, an interpreter from the victim’s country knows the language, customs, religious traditions and other beliefs that must be taken into account during the investigation. The interview may induce fear and mis- trust on the part of the victim and possibly remind him or her of previous interrogations. To reduce the effects of re- traumatization, the clinician should communicate a sense of understanding of the individual’s experiences and cul- tural background. It is inappropriate to observe the strict “clinical neutrality” that is used in some forms of psycho- therapy, during which the clinician is inactive and says lit- tle. The clinician should communicate that he or she is an ally of the individual and adopt a supportive, non-judge- mental approach. 2. The interview process 263. The clinician should introduce the interview process in a manner that explains in detail the procedures to be followed (questions asked about psychosocial his- tory, including history of torture and current psychologi- cal functioning) and that prepares the individual for the difficult emotional reactions that the questions may pro- voke. The individual needs to be given an opportunity to request breaks, interrupt the interview at any time and be able to leave if the stress becomes intolerable, with the option of a later appointment. Clinicians need to be sensi- tive and empathic in their questioning, while remaining objective in their clinical assessment. At the same time, the interviewer should be aware of potential personal reactions to the survivor and the descriptions of torture that might influence the interviewer’s perceptions and judgements. 264. The interview process may remind the survivor of interrogation during torture. Therefore, strong negative feelings towards the clinician may develop, such as fear, rage, revulsion, helplessness, confusion, panic or hatred. The clinician should allow for the expression and expla- nation of such feelings and express understanding for the individual’s difficult predicament. In addition, the pos- sibility that the person may still be persecuted or oppressed has to be kept in mind. When necessary, ques- tions about forbidden activities should be avoided. It is important to consider the reasons for the psychological evaluation, as they will determine the level of confidenti- ality to which the expert is bound. If an evaluation of the credibility of an individual’s report of torture is requested within the framework of a judicial procedure by a State authority, the person to be evaluated must be told that this implies lifting medical confidentiality for all the informa- tion presented in the report. However, if the request for the psychological evaluation comes from the tortured per- son, the expert must respect medical confidentiality. 265. Clinicians who conduct physical or psychologi- cal evaluations should be aware of the potential emotional reactions that evaluations of severe trauma may elicit in the interviewee and interviewer. These emotional reac- tions are known as transference and countertransference. Mistrust, fear, shame, rage and guilt are among the typical reactions that torture survivors experience, particularly when being asked to recount or remember details of their trauma. Transference refers to the feelings a survivor has towards the clinician that relate to past experiences but which are misunderstood as directed towards the clinician personally. In addition, the clinician’s emotional response to the torture survivor, known as countertransference, may affect the psychological evaluation. Transference and countertransference are mutually interdependent and interactive. 266. The potential impact of transference reactions on the evaluation process becomes evident when it is con- sidered that an interview or examination that involves recounting and remembering the details of a traumatic history will result in exposure to distressing and unwanted memories, thoughts and feelings. Thus, even though a tor- ture victim may consent to an evaluation with the hope of benefiting from it, the resulting exposure may renew the trauma experience itself. This may include the following phenomena. 267. The evaluator’s questions may be experienced as forced exposure akin to an interrogation. The evaluator may be suspected of having voyeuristic or sadistic moti- vations, and the interviewee may ask him or herself ques- tions such as: “Why does he or she make me reveal every last terrible detail of what happened to me? Why would a normal person choose to listen to stories like mine in order to make a living? The evaluator must have some strange kind of motivation.” There may be prejudices towards the evaluator because he or she has not been arrested and tortured. This may lead the subject to per- ceive the evaluator as being on the side of the enemy. 268. The evaluator is perceived as a person in a posi- tion of authority, which is often the case, and for that rea- son may not be trusted with certain aspects of the trauma history. Alternatively, as is often the case with subjects still in custody, the subject may be too trusting in situa- tions where the interviewer cannot guarantee that there 53 cultural factors, severity and duration of the traumatic events, genetic and biological vulnerabilities, develop- mental phase and age of the victim, prior history of trauma and pre-existing personality. In many interview situations, because of time limitations and other prob- lems, it may be difficult to obtain this information. It is important, nonetheless, to obtain enough data about the individual’s previous mental health and psychosocial functioning to form an impression of the degree to which torture has contributed to psychological problems. (e) Medical history 281. The medical history summarizes pre-trauma health conditions, current health conditions, body pain, somatic complaints, use of medication and its side effects, relevant sexual history, past surgical procedures and other medical data (see chapter V, sect. B). (f) Psychiatric history 282. Inquiries should be made about a history of mental or psychological disturbances, the nature of prob- lems and whether they received treatment or required psy- chiatric hospitalization. The inquiry should also cover prior therapeutic use of psychotropic medication. (g) Substance use and abuse history 283. The clinician should inquire about substance use before and after the torture, changes in the pattern of use and whether substances are being used to cope with insomnia or psychological/psychiatric problems. These substances are not only alcohol, cannabis and opium but also regional substances of abuse such as betel nut and many others. (h) Mental status examination 284. The mental status examination begins the moment the clinician meets the subject. The interviewer should make note of the person’s appearance, such as signs of malnutrition, lack of cleanliness, changes in motor activity during the interview, use of language, pres- ence of eye contact, ability to relate to the interviewer and the means the individual uses to establish communication. The following components should be covered, and all aspects of the mental status examination should be included in the report of the psychological evaluation; aspects such as general appearance, motor activity, speech, mood and affect, thought content, thought pro- cess, suicidal and homicidal ideation and a cognitive examination (orientation, long-term memory, intermedi- ate recall and immediate recall). (i) Assessment of social function 285. Trauma and torture can directly and indirectly affect a person’s ability to function. Torture can also indi- rectly cause loss of functioning and disability, if the psychological consequences of the experience impair the individual’s ability to care for himself or herself, earn a living, support a family and pursue an education. The cli- nician should assess the individual’s current level of func- tioning by inquiring about daily activities, social role (as housewife, student, worker), social and recreational activ- ities and perception of health status. The interviewer should ask the individual to assess his or her own health condition, to state the presence or absence of feelings of chronic fatigue and to report potential changes in overall functioning. (j) Psychological testing and the use of checklists and questionnaires 286. Little published data exist on the use of psycho- logical testing (projective and objective personality tests) in the assessment of torture survivors. Also, psychologi- cal tests of personality lack cross-cultural validity. These factors combine to limit severely the utility of psycho- logical testing in the evaluation of torture victims. Neu- ropsychological testing may, however, be helpful in assessing cases of brain injury resulting from torture (see section C.4 below). An individual who has survived tor- ture may have trouble expressing in words his or her experiences and symptoms. In some cases, it may be help- ful to use trauma event and symptom checklists or ques- tionnaires. If the interviewer believes it may be helpful to use these, there are numerous questionnaires available, although none are specific to torture victims. (k) Clinical impression 287. In formulating a clinical impression for the pur- poses of reporting psychological evidence of torture, the following important questions should be asked: (i) Are the psychological findings consistent with the alleged report of torture? (ii) Are the psychological findings expected or typi- cal reactions to extreme stress within the cultural and social context of the individual? (iii) Given the fluctuating course of trauma-related mental disorders over time, what is the time frame in relation to the torture events? Where is the individual in the course of recovery? (iv) What are the coexisting stressors impinging on the individual (e.g. ongoing persecution, forced migration, exile, loss of family and social role)? What impact do these issues have on the individ- ual? (v) Which physical conditions contribute to the clinical picture? Pay special attention to head injury sustained during torture or detention; (vi) Does the clinical picture suggest a false allega- tion of torture? 288. Clinicians should comment on the consistency of psychological findings and the extent to which these findings correlate with the alleged abuse. The emotional state and expression of the person during the interview, his or her symptoms, the history of detention and torture and the personal history prior to torture should be described. Factors such as the onset of specific symptoms related to the trauma, the specificity of any particular psychological findings and patterns of psychological functioning should be noted. Additional factors should be considered, such as forced migration, resettlement, diffi- culty of acculturation, language problems, unemploy- ment, loss of home, family and social status. The relation- 54 ship and consistency between events and symptoms should be evaluated and described. Physical conditions, such as head trauma or brain injury, may require further evaluation. Neurological or neuropsychological assess- ment may be recommended. 289. If the survivor has symptom levels consistent with a DSM-IV or ICD-10 psychiatric diagnosis, the diag- nosis should be stated. More than one diagnosis may be applicable. Again, it must be stressed that even though a diagnosis of a trauma-related mental disorder supports the claim of torture, not meeting criteria for a psychiatric diagnosis does not mean the person was not tortured. A survivor of torture may not have the level of symptoms required to meet diagnostic criteria for a DSM-IV or ICD- 10 diagnosis fully. In these cases, as with all others, the symptoms that the survivor has and the torture story that he or she claims to have experienced should be considered as a whole. The degree of consistency between the torture story and the symptoms that the individual reports should be evaluated and described in the report. 290. It is important to recognize that some people falsely allege torture for a range of reasons and that others may exaggerate a relatively minor experience for personal or political reasons. The investigator must always be aware of these possibilities and try to identify potential reasons for exaggeration or fabrication. The clinician should keep in mind, however, that such fabrication requires detailed knowledge about trauma-related symp- toms that individuals rarely possess. Inconsistencies in testimony can occur for a number of valid reasons, such as memory impairment due to brain injury, confusion, dis- sociation, cultural differences in perception of time or fragmentation and repression of traumatic memories. Effective documentation of psychological evidence of torture requires clinicians to have a capacity to evaluate consistencies and inconsistencies in the report. If the interviewer suspects fabrication, additional interviews should be scheduled to clarify inconsistencies in the report. Family or friends may be able to corroborate details of the story. If the clinician conducts additional examinations and still suspects fabrication, the clinician should refer the individual to another clinician and ask for the colleague’s opinion. The suspicion of fabrication should be documented with the opinion of two clinicians. (l) Recommendations 291. The recommendations resulting from the psychological evaluation depend on the question posed at the time the evaluation was requested. The issues under consideration may concern legal and judicial matters, asy- lum, resettlement or a need for treatment. Recommenda- tions can be for further assessment, such as neuropsycho- logical testing, medical or psychiatric treatment, or a need for security or asylum. 4. Neuropsychological assessment 292. Clinical neuropsychology is an applied science concerned with the behavioural expression of brain dys- function. Neuropsychological assessment, in particular, is concerned with the measurement and classification of behavioural disturbances associated with organic brain impairment. The discipline has long been recognized as useful in discriminating between neurological and psychological conditions and in guiding treatment and rehabilitation of patients suffering from the consequences of various levels of brain damage. Neuropsychological evaluations of torture survivors are performed infre- quently and to date there are no neuropsychological studies of torture survivors available in the literature. The following remarks are, therefore, limited to a discussion of general principles to guide health providers in under- standing the utility of, and indications for, neuropsycho- logical assessment of subjects suspected of being tor- tured. Before discussing the issues of utility and indications, it is essential to recognize the limitations of neuropsychological assessment in this population. (a) Limitations of neuropsychological assessment 293. There are a number of common factors compli- cating the assessment of torture survivors in general that are outlined elsewhere in this manual. These factors apply to neuropsychological assessment in the same way as to a medical or psychological examination. Neuropsychologi- cal assessments may be limited by a number of additional factors, including lack of research on torture survivors, reliance on population-based norms, cultural and linguis- tic differences and re-traumatization of those who have experienced torture. 294. As mentioned above, very few references exist in the literature concerning the neuropsychological assessment of torture victims. The pertinent body of lit- erature concerns various types of head trauma and the neuropsychological assessment of PTSD in general. Therefore, the following discussion and subsequent inter- pretations of neuropsychological assessments are neces- sarily based on the application of general principles used with other subject populations. 295. Neuropsychological assessment as it has been developed and practised in Western countries relies heavily on an actuarial approach. This approach typically involves comparing the results of a battery of standard- ized tests to population-based norms. Although norm-ref- erenced interpretations of neuropsychological assess- ments may be supplemented by a Lurian approach of qualitative analysis, particularly when the clinical situa- tion demands it, a reliance on the actuarial approach pre- dominates.115, 116 Moreover, a reliance on test scores is greatest when brain impairment is mild to moderate in severity, rather than severe, or when neuropsychological deficits are thought to be secondary to a psychiatric dis- order. 296. Cultural and linguistic differences may signifi- cantly limit the utility and applicability of neuropsycho- logical assessment among suspected torture victims. Neuropsychological assessments are of questionable validity when standard translations of tests are unavail- able and the clinical examiner is not fluent in the subject’s 115 A. R. Luria and L. V. Majovski, “Basic approaches used in American and Soviet clinical neuropsychology”, American Psychologist, vol. 32 (11) (1977), pp. 959-968. 116 R. J. Ivnik, “Overstatement of differences”, American Psychologist, vol. 33 (8) (1978), pp. 766-767. 55 language. Unless standardized translations of tests are available and examiners are fluent in the subject’s lan- guage, verbal tasks cannot be administered at all and can- not be interpreted in a meaningful way. This means that only non-verbal tests can be used, and this precludes com- parison between verbal and non-verbal faculties. In addi- tion, an analysis of the lateralization (or localization) of deficits is more difficult. This analysis is often useful, however, because of the brain’s asymmetrical organiza- tion, with the left hemisphere typically being dominant for speech. If population-based norms are unavailable for the subject’s cultural and linguistic group, neuropsycho- logical assessment is also of questionable validity. An estimate of IQ is one of the central benchmarks that allow examiners to place neuropsychological test scores into proper perspective. Within the population of the United States, for example, these estimates are often derived from verbal subsets using the Wechsler scales, particu- larly the information subscale, because in the presence of organic brain impairment, acquired factual knowledge is less likely to suffer deterioration than other tasks and be more representative of past learning ability than other measures. Measurement may also be based on educa- tional and work history and demographic data. Obviously, neither one of these two considerations applies to subjects for whom population-based norms have not been estab- lished. Therefore, only very coarse estimates concerning pre-trauma intellectual functioning can be made. As a result, neuropsychological impairment that is anything less than severe or moderate may be difficult to interpret. 297. Neuropsychological assessments may re-trau- matize those who have experienced torture. Great care must be taken in order to minimize any potential re-trau- matization of the subject in any form of diagnostic pro- cedure (see chapter IV, sect. H). To cite only one obvious example specific to neuropsychological testing, it would be potentially very damaging to proceed with a standard administration of the Halstead-Reitan Battery, in particu- lar the Tactual Performance Test (TPT), and routinely blindfold the subject. For most torture victims who have experienced blindfolding during detention and torture, and even for those who were not blindfolded, it would be very traumatic to introduce the experience of helplessness inherent in this procedure. In fact, any form of neuro- psychological testing in itself may be problematic, regardless of the instrument used. Being observed, timed with a stopwatch and asked to give maximum effort on an unfamiliar task, in addition to being asked to perform, rather than having a dialogue, may prove to be too stress- ful or reminiscent of the torture experience. (b) Indications for neuropsychological assessment 298. In evaluating behavioural deficits in suspected torture victims, there are two primary indications for neu- ropsychological assessment: brain injury and PTSD plus related diagnoses. While both sets of conditions overlap in some aspects, and will often coincide, it is only the former that is a typical and traditional application of clin- ical neuropsychology, whereas the latter is relatively new, not well researched and rather problematic. 299. Brain injury and resulting brain damage may result from various types of head trauma and metabolic disturbances inflicted during periods of persecution, detention and torture. This may include gunshot wounds, the effects of poisoning, malnutrition as a result of starva- tion or forced ingestion of harmful substances, the effects of hypoxia or anoxia resulting from asphyxiation or near drowning and, most commonly, from blows to the head suffered during beatings. Blows to the head are frequently inflicted during periods of detention and torture. For example, in one sample of torture survivors, blows to the head were the second most frequently cited form of bodily abuse (45 per cent) behind blows to the body (58 per cent).117 The potential for brain damage is high among torture victims. 300. Closed head injuries resulting in mild to moder- ate levels of long-term impairment are perhaps the most commonly assessed cause of neuropsychological abnor- mality. While signs of injury may include scars on the head, brain lesions cannot usually be detected by diagnos- tic imaging of the brain. Mild to moderate levels of brain damage might be overlooked or underestimated by men- tal health professionals because symptoms of depression and PTSD are likely to figure prominently in the clinical picture, resulting in less attention being paid to the poten- tial effect of head trauma. Commonly, the subjective com- plaints of survivors include difficulties with attention, concentration and short-term memory, which can be the result of either brain impairment or PTSD. Since these complaints are common in survivors suffering from PTSD, the question whether they are actually due to head injury may not even be asked. 301. The diagnostician must rely, in an initial phase of the examination, on reported history of head trauma and the course of symptomatology. As is usually the case with brain-injured subjects, information from third par- ties, particularly relatives, may prove helpful. It must be remembered that brain-injured subjects often have great difficulty articulating or even appreciating their limita- tions because they are, so to speak, “inside” the problem. In gathering first impressions regarding the difference between organic brain impairment and PTSD, an assess- ment concerning the chronicity of symptoms is a helpful starting point. If symptoms of poor attention, concentra- tion and memory are observed to fluctuate over time and to co-vary with levels of anxiety and depression, this is more likely due to the phasic nature of PTSD. On the other hand, if impairment seems to appear chronic, lacks fluc- tuation and is confirmed by family members, the possibil- ity of brain impairment should be entertained, even in the initial absence of a clear history of head trauma. 302. Once there is a suspicion of organic brain impairment, the first step for a mental health professional is to consider a referral to a physician for further neuro- logical examination. Depending on initial findings, the physician may then consult a neurologist or order diag- nostic tests. An extensive medical work-up, specific neu- rological consultation and neuropsychological evaluation 117 H. C. Traue, G. Schwarz-Langer and N. F. Gurris, “Extremtraumatisierung durch Folter: Die psychotherapeutische Arbeit der Behandlungszentren für Folteropfer”, Verhaltenstherapie und Verhaltensmedizin, vol. 18 (1) (1997), pp. 41-62. 58 and delegation of roles may occur. Family members, often children, can be assigned the role of patient and develop severe disorders. A child may be overly protected or important facts about the trauma may be hidden. Alterna- tively, the child can be parentified and expected to care for the parents. When the child is not the direct victim of tor- ture but only indirectly affected, adults often tend to underestimate the impact on the child’s psyche and devel- opment. When loved ones around a child have been per- secuted, raped and tortured or the child has witnessed severe trauma or torture, he or she may develop dysfunc- tional beliefs such as that he or she is responsible for the bad events or that he or she has to bear the parent’s bur- dens. This type of belief can lead to long-term problems with guilt, loyalty conflicts, personal development and maturing into an independent adult. 59 1. The purposes of effective investigation and documentation of torture and other cruel, inhuman or degrading treatment or punishment (hereinafter “torture or other ill- treatment”) include the following: (a) Clarification of the facts and establishment and acknowledgement of indi- vidual and State responsibility for victims and their families; (b) Identification of measures needed to prevent recurrence; (c) Facilitation of prosecution and/or, as appropriate, disciplinary sanctions for those indicated by the investigation as being responsible and demonstration of the need for full reparation and redress from the State, including fair and adequate financial compensation and provision of the means for medical care and rehabilitation. 2. States shall ensure that complaints and reports of torture or ill-treatment are promptly and effectively investigated. Even in the absence of an express complaint, an investigation shall be undertaken if there are other indications that torture or ill-treat- ment might have occurred. The investigators, who shall be independent of the sus- pected perpetrators and the agency they serve, shall be competent and impartial. They shall have access to, or be empowered to commission investigations by, impartial medical or other experts. The methods used to carry out such investigations shall meet the highest professional standards and the findings shall be made public. 3. (a) The investigative authority shall have the power and obligation to obtain all the information necessary to the inquiry.a The persons conducting the investigation shall have at their disposal all the necessary budgetary and technical resources for effective investigation. They shall also have the authority to oblige all those acting in an official capacity allegedly involved in torture or ill-treatment to appear and testify. The same shall apply to any witness. To this end, the investigative authority shall be entitled to issue summonses to witnesses, including any officials allegedly involved, and to demand the production of evidence. (b) Alleged victims of torture or ill-treatment, witnesses, those conducting the investigation and their families shall be protected from violence, threats of violence or any other form of intimidation that may arise pursuant to the investigation. Those potentially implicated in torture or ill-treatment shall be removed from any position of control or power, whether direct or indirect, over complainants, witnesses and their families, as well as those conducting the investigation. 4. Alleged victims of torture or ill-treatment and their legal representatives shall be informed of, and have access to, any hearing, as well as to all information relevant to the investigation, and shall be entitled to present other evidence. 5. (a) In cases in which the established investigative procedures are inadequate because of insufficient expertise or suspected bias, or because of the apparent existence of a pattern of abuse or for other substantial reasons, States shall ensure that investiga- ANNEX I Principles on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment* * The Commission on Human Rights, in its resolution 2000/43, and the General Assembly, in its resolution 55/89, drew the attention of Governments to the Principles and strongly encouraged Governments to reflect upon the Principles as a useful tool in efforts to combat torture.a Under certain circumstances, professional ethics may require information to be kept confidential. These requirements should be respected. 60 tions are undertaken through an independent commission of inquiry or similar procedure. Members of such a commission shall be chosen for their recognized impartiality, competence and independence as individuals. In particular, they shall be independent of any suspected perpetrators and the institutions or agencies they may serve. The commission shall have the authority to obtain all information necessary to the inquiry and shall conduct the inquiry as provided for under these Principles.b (b) A written report, made within a reasonable time, shall include the scope of the inquiry, procedures and methods used to evaluate evidence as well as conclusions and recommendations based on findings of fact and on applicable law. Upon comple- tion, the report shall be made public. It shall also describe in detail specific events that were found to have occurred and the evidence upon which such findings were based and list the names of witnesses who testified, with the exception of those whose iden- tities have been withheld for their own protection. The State shall, within a reasonable period of time, reply to the report of the investigation and, as appropriate, indicate steps to be taken in response. 6. (a) Medical experts involved in the investigation of torture or ill-treatment shall behave at all times in conformity with the highest ethical standards and, in particular, shall obtain informed consent before any examination is undertaken. The examination must conform to established standards of medical practice. In particular, examinations shall be conducted in private under the control of the medical expert and outside the presence of security agents and other government officials. (b) The medical expert shall promptly prepare an accurate written report, which shall include at least the following: (i) Circumstances of the interview: name of the subject and name and affilia- tion of those present at the examination; exact time and date; location, nature and address of the institution (including, where appropriate, the room) where the examination is being conducted (e.g., detention centre, clinic or house); circum- stances of the subject at the time of the examination (e.g., nature of any restraints on arrival or during the examination, presence of security forces during the examination, demeanour of those accompanying the prisoner or threatening statements to the examiner); and any other relevant factors; (ii) History: detailed record of the subject’s story as given during the interview, including alleged methods of torture or ill-treatment, times when torture or ill- treatment is alleged to have occurred and all complaints of physical and psycho- logical symptoms; (iii) Physical and psychological examination: record of all physical and psychological findings on clinical examination, including appropriate diagnostic tests and, where possible, colour photographs of all injuries; (iv) Opinion: interpretation as to the probable relationship of the physical and psychological findings to possible torture or ill-treatment. A recommendation for any necessary medical and psychological treatment and/or further examination shall be given; (v) Authorship: the report shall clearly identify those carrying out the examina- tion and shall be signed. (c) The report shall be confidential and communicated to the subject or his or her nominated representative. The views of the subject and his or her representative about the examination process shall be solicited and recorded in the report. It shall also be provided in writing, where appropriate, to the authority responsible for investigating the allegation of torture or ill-treatment. It is the responsibility of the State to ensure that it is delivered securely to these persons. The report shall not be made available to any other person, except with the consent of the subject or on the authorization of a court empowered to enforce such a transfer. b See footnote (a) above. 63 lesions were probably excised seven days after the injury, were alterations in the skin believed to be diagnostic of the electrical injuries observed (deposition of calcium salts on dermal fibres in viable tissue located around necrotic tissue). Lesions excised a few days after alleged electrical torture in other cases have shown segmental changes and deposits of calcium salts on cellular struc- tures highly consistent with the influence of an electrical current, but they are not diagnostic since deposits of cal- cium salts on dermal fibres were not observed. A biopsy taken one month after alleged electrical torture showed a conical scar, 1-2 millimetres wide, with an increased number of fibroblasts and tightly packed, thin collagen fibres, arranged parallel to the surface, consistent with but not diagnostic of electrical injury. (b) Method After receiving informed consent from the patient, and before biopsy, the lesion must be photographed using accepted forensic methods. Under local anaesthesia, a 3-4 millimetre punch biopsy is obtained, and placed in buffered formalin or a similar fixative. Skin biopsy should be performed as soon as possible after injury. Since elec- trical trauma is usually confined to the epidermis and su- perficial dermis, the lesions may quickly disappear. Biopsies can be taken from more than one lesion, but the potential distress to the patient must be taken into ac- l S. Gürpinar and S. Korur Fincanci, “Insan Haklari Ihlalleri ve Hekim Sorumlulugu” (Human rights violations and responsibility of the physician), Birinci Basamak Için Adli Tip El Kitabi (Handbook of Forensic Medicine for General Practitioners) (Ankara, Turkish Medical Association, 1999). m See footnote (h) above. count.l Biopsy material should be examined by a patholo- gist experienced in dermatopathology. (c) Diagnostic findings for electrical injury Diagnostic findings for electrical injury include ve- sicular nuclei in epidermis, sweat glands and vessel walls (only one differential diagnosis: injuries via basic solu- tions) and deposits of calcium salts distinctly located on collagen and elastic fibres (the differential diagnosis, Calcinosis cutis, is a rare disorder only found in 75 of 220,000 consecutive human skin biopsies, and the cal- cium deposits are usually massive without distinct loca- tion on collagen and elastic fibres).m Typical, but not diagnostic, findings for electrical injury are lesions appearing in conical segments, often 1-2 millimetres wide, deposits of iron or copper on epi- dermis (from the electrode) and homogenous cyto- plasm in epidermis, sweat glands and vessel walls. There may also be deposits of calcium salts on cellu- lar structures in segmental lesions or no abnormal his- tologic observations. ^ 65 ANNEX III Anatomical drawings for documentation of torture and ill-treatment FU L L BO D Y, FE M ALE — A N TER IO R A N D PO STER IO R V IEW S FU LL B O D Y, FEM ALE— LATER AL V IEW N am e C a se N o. D ate N am e C a se N o. D ate R IG H T AR M LEFT A R M 68 TH O R A C IC A B D O M IN AL , M ALE — AN TER IO R AN D PO STER IO R V IE W S FEE T— LE FT AN D R IG H T P LAN TAR SU R FA C E S N am e C a se N o. D at e N a m e C a se N o . D a te 69 R IG H T H A N D — PA LM A R AN D D O R S AL LE FT H AN D — P A LM AR AN D D O R SAL N a m e C as e N o . D a te N am e C a se N o. D ate 70 H EA D — SU R FAC E AN D S KEL ETAL A N AT O M Y, SU P E R IO R VIEW — IN F ER IO R VIEW O F N E C K H EA D — SU R FAC E A N D SKELETAL AN ATO M Y, L ATER AL VIE W N a m e C as e N o . D a te N am e C a se N o. D at e 73 The following guidelines are based on the Istanbul Protocol: Manual on the Effective Investigation and Documen- tation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. These guidelines are not intended to be a fixed prescription, but should be applied taking into account the purpose of the evaluation and after an assessment of available resources. Evaluation of physical and psychological evidence of torture and ill-treatment may be conducted by one or more clinicians, depending on their qualifications. I. Case information Date of exam: Exam requested by (name/position): Case or report No.: Duration of evaluation: hours, minutes Subject’s given name: Birth date: Birth place: Subject’s family name: Gender: male/female: Reason for exam: Subject’s ID No.: Clinician’s name: Interpreter (yes/no), name: Informed consent: yes/no If no informed consent, why?: Subject accompanied by (name/position): Persons present during exam (name/position): Subject restrained during exam: yes/no; If “yes”, how/why? Medical report transferred to (name/position/ID No.): Transfer date: Transfer time: Medical evaluation/investigation conducted without restriction (for subjects in custody): yes/no Provide details of any restrictions: II. Clinician’s qualifications (for judicial testimony) Medical education and clinical training Psychological/psychiatric training Experience in documenting evidence of torture and ill-treatment Regional human rights expertise relevant to the investigation Relevant publications, presentations and training courses Curriculum vitae. ANNEX IV Guidelines for the medical evaluation of torture and ill-treatment 74 III. Statement regarding veracity of testimony (for judicial testimony) For example: “I personally know the facts stated below, except 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.” IV. Background information General information (age, occupation, education, family composition, etc.) Past medical history Review of prior medical evaluations of torture and ill-treatment Psychosocial history pre-arrest. V. Allegations of torture and ill-treatment 11. Summary of detention and abuse 12. Circumstances of arrest and detention 13. Initial and subsequent places of detention (chronology, transportation and detention conditions) 14. Narrative account of ill-treatment or torture (in each place of detention) 15. Review of torture methods. VI. Physical symptoms and disabilities Describe the development of acute and chronic symptoms and disabilities and the subsequent healing processes. 11. Acute symptoms and disabilities 12. Chronic symptoms and disabilities. VII. Physical examination 11. General appearance 12. Skin 13. Face and head 14. Eyes, ears, nose and throat 15. Oral cavity and teeth 16. Chest and abdomen (including vital signs) 17. Genito-urinary system 18. Musculoskeletal system 19. Central and peripheral nervous system. VIII. Psychological history/examination 11. Methods of assessment 12. Current psychological complaints 13. Post-torture history 14. Pre-torture history 15. Past psychological/psychiatric history 16. Substance use and abuse history 17. Mental status examination 18. Assessment of social functioning 19. Psychological testing: (see chapter VI, sect. C.1, for indications and limitations) 10. Neuropsychological testing (see chapter VI, sect. C.4, for indications and limitations). 75 IX. Photographs X. Diagnostic test results (see annex II for indications and limitations) XI. Consultations XII. Interpretation of findings 1. Physical evidence A. Correlate the degree of consistency between the history of acute and chronic physical symptoms and disabil- ities with allegations of abuse. B. 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 torture or ill-treatment was inflicted.) C. 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 A. Correlate the degree of consistency between the psychological findings and the report of alleged torture. B. 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. C. 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? D. 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. E. Mention physical conditions that may contribute to the clinical picture, especially with regard to possible evidence of head injury sustained during torture or detention. XIII. 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 disabilities from which the individual continues to suffer as a result of the alleged abuse. 3. Provide any recommendations for further evaluation and care for the individual. XIV. Statement of truthfulness (for judicial testimony) For example: “I declare under penalty of perjury, pursuant to the laws of ........ (country), that the foregoing is true and correct and that this affidavit was executed on ................. (date) at ............. (city), ............ (State or province).” XV. Statement of restrictions on the medical evaluation/investigation (for subjects in custody) For example: “The undersigned clinicians personally certify that they were allowed to work freely and independ- ently 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 “The undersigned clinician(s) had to carry out his/her/ their evaluation with the following restrictions: ...........” XVI. Clinician’s signature, date, place XVII. Relevant annexes A copy of the clinician’s curriculum vitae, anatomical drawings for identification of torture and ill-treatment, photographs, consultations and diagnostic test results, among others.