APPENDIX B
STANDARDS FOR THE EFFECTIVE DOCUMENTATION
OF TORTURE AND ILL-TREATMENT

The following recommendations are intended to serve as possible guidelines for the effective documentation of torture and ill-treatment among detainees. Please note that the following recommendations are based largely on material contained in a publication entitled, "Torture in Turkey & Its Unwilling Accomplices."¹

General comments

Medical evaluations of detainees for legal purposes should be conducted with objectivity and impartiality. The evaluations should be based on the physician's clinical expertise and professional experience. The physician's ethical obligation of beneficence demands uncompromising accuracy and impartiality in order to establish and maintain professional credibility.

Doctors who conduct evaluations of detainees should have specific 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 their particular region and their common after-effects.

The medical report should be factual and carefully worded. Medical jargon should be avoided. All medical terminology should be defined so that it is understandable to lay persons.

The doctor should not assume that the official requesting a medical-legal evaluation has related all the material facts. It is the doctor's responsibility to discover and report upon any material findings which he or she considers relevant, 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, including the omission of the possibility of torture by the requesting official.
Purpose of inquiry, examination and documentation

• To assess for possible injuries and abuse of detainees, even in the absence of specific allegations by detainees, or law enforcement and judicial officials.
• To document physical and psychological evidence of injuries and abuse.
• To correlate the degree of consistency between examination findings and specific allegations of abuse by the detainee.
• To correlate the degree of consistency between examination findings of an individual detainee with the knowledge of torture methods and their common after-effects used in a particular region.
• To render expert interpretations of the findings in medical-legal evaluations and provide expert opinions regarding possible causes of abuse. The purpose of testimony is not to provide unequivocal proof of a detainee's allegation of abuse. The purpose is to provide expert opinions on the degree to which one's findings correlate with the detainee's allegation of abuse.
• To effectively communicate the physician's medical findings and interpretations to the judiciary. In addition, medical testimony often serves to educate the judiciary on the physical and psychological sequelae of torture.

Interview considerations

Physicians must ensure that patients understand the potential benefits and adverse consequences of an evaluation, to form the basis of informed consent. Physicians have a duty to maintain confidentiality of information and to disclose information only with the detainee's consent. Each detainee should be examined individually, in privacy. The detainee has the right to refuse the examination.

The location of the interview and examination should be as safe and comfortable as possible, including access to toilet facilities. Sufficient time should be allotted to conduct a detailed interview and examination.

Establish the identity of the detainee. The physician should provide his or her name and explain his or her role in conducting the evaluation.
Proceed only with an official request by a legal authority, such as a public prosecutor.

Notify police that they must leave the room. Note police presence if they refuse to leave.

Explain to the detainee the need to ask specific and detailed questions. Acknowledge the detainee's ability to take a break if needed or to choose not to respond to any question he or she may not wish to.

Trust is an essential component of eliciting an accurate account of abuse. Earning the trust of one who has experienced torture and other forms of abuse requires active listening, meticulous communication, courteousness, genuine empathy and honesty.

Translation: Interpreters should have professional training. The physician should be aware that various characteristics of the interpreter may affect the translation process, such as differences in gender, ethnicity, economic status, ideology, cultural sensitivity, professional experience, and development of rapport with the detainee.

Transference and Countertransference Issues: Clinicians who conduct medical evaluations of detainees should be familiar with common transference reactions (i.e., mistrust, fear, shame, rage and guilt) that victims of trauma experience and the potential impact of such reactions on the evaluation process.

In addition, the clinician's responses to working with victims of torture and other forms of abuse (countertransference) may compromise the effectiveness of the medical evaluation. Common countertransference issues include: disillusionment, avoidance, withdrawal, helplessness, hopelessness, over-identification, idealization, anger and guilt. Clinicians may experience symptoms of "vicarious traumatization" such as nightmares, anxiety, and fearfulness over hearing the experiences told to them. Effective documentation of torture and other forms of ill-treatment requires significant understanding of the motivations for working in this area. It is important that a clinician not use the population to work out unresolved issues in himself/herself, as these issues can clearly get in the way of effectiveness.
Medical history

Obtain a complete medical history, including prior medical and 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. 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 and methods of restraint, descriptions of acute and chronic wounds and disabilities, and identifying information about perpetrators and the place of detention.

Pursuit of Information. Torture victims may have difficulty recounting past events because of: 1) blindfolding, 2) disorientation, 3) lapses in consciousness, 4) organic brain damage, 5) psychological sequelae of abuse, 6) fear of placing oneself or others at risk, and 7) lack of trust of the examining physician. Clarify any inconsistencies as they may have bearing on the detainee's credibility.

General Information. Name, age, residence, education, occupation, family history, political activity, duration of the interview, name of translator.

Psychosocial History, Pre-arrest. daily life, relations with friends and family, work/school, entertainment, future plans, political activities, beliefs and opinions regarding the conflict, knowledge of torture, prior psychiatric history, use of alcohol and drugs.

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

Arrest(s). Consider the following questions: What time was it? Where were you? What were you doing? Who was there? Describe appearances, whether they wore uniforms and carried weapons. What was said? Any witnesses? 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.

Prison Conditions. Including access to and descriptions of food and drink, toilet facilities, lighting, temperature, ventilation. Also, document any contact with family or health professionals, and conditions of crowding or solitary confinement.

Consider the following questions: What happened first? Where were you taken? Identification process (personal information recorded, fingerprints, photographs). Were you asked to sign anything? Describe the conditions of the cell/room (note size, others present, light, ventilation, temperature, presence of insects, rodents, bedding, access to food, water and toilet). What did you hear, see and smell? Any contact with people outside or access to medical care? What was the physical layout of the place where you were detained?

Methods of Torture and Ill Treatment. In obtaining historical information on torture it is important to avoid suggesting forms of abuse that the detainee may not have been subjected to. This may help to separate potential embellishments from valid experiences. 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 blindfolded? Before discussing forms of abuse, note who was present (give names, positions). Describe the room/place. What objects did you observe? Describe each instrument of torture in detail. Note clothing/disrobing. Record quotations of what was said during "interrogation," insults to one's identity. What was said among them? For each form of abuse, note: body position/restraint, nature of contact, including duration, frequency, anatomical location, and the area of the body affected. Note any bleeding, head trauma, or loss of consciousness. Was the loss of consciousness associated with head trauma, asphyxiation, or vaso-vagal tone related to pain? Note sexual violations. Elicit what was said during the torture. For example, during electric shock torture to the genitals, perpetrators often tell their victims that they will no longer have normal sexual functions, or something similar.

Review of Torture Methods. After eliciting a detailed narrative account of events, it is advisable to review other possible torture methods. Reviewing different forms of torture is especially helpful when: psychological symptoms cloud recollections, the trauma was associated with impaired sensory capabilities (i.e., blindfolding, extreme fear and anxiety, sleep deprivation, loud noises, intense lights or the use of psychotropic drugs), when there is possible organic brain damage, or when there are mitigating educational and cultural factors. It is important to learn about regional practices of torture and modify the Review of Torture Methods accordingly.

Physical Abuse (partial list of general categories):

• Blunt trauma: punch, kick, slap, whips, wires, truncheons,
  falling down
• Suspension/stretching limbs apart
• Burns: electric shock, cigarettes, heated instrument, chemical
• Asphyxiation: wet and dry methods
• Crush injuries: smashing fingers, heavy roller to thighs/back
• Penetrating injuries: stab and gunshot wounds, wires under nails
• Sexual: humiliations, molestation, instrumentation, rape
• Exposure to extremes of temperature
• Prolonged constraint of movement
• Chemical exposures: salt, chili, gasoline (in wounds, body cavities)
• Traumatic removal of appendages and organs: hair, digits, limbs, kidneys, etc.

Psychological Abuse (partial list of general categories):

• Deprivation of normal sensory stimulation (sound, light, sense of time via hooding, isolation, and manipulating lightness of cell); physiological needs (sleep, food, water, toilet facilities, bathing, motor activities, medical care); social contacts (isolation within prison, loss of contact with outside world). Such deprivations often result in disorientation of time and space; they may induce exhaustion and debility, difficulty concentrating, decreased memory, hallucinations/other psychotic reactions, depression, hopelessness, and despair.
• Humiliations: including verbal abuse, denial of privacy (e.g., toileting), prevention of personal hygiene, detailed set of regulations and rules over insignificant issues, overcrowding of cell, forced nakedness, filth in food, infected surroundings (lice, rats), being forced to perform humiliating acts, and sexual abuse. (Note: sexual assault is grossly underreported.)
• Threats: of death, harm to family, further torture, mock executions, or witnessing torture of others.
• Various psychological techniques designed to create an illusion of betrayal and to break down the individual. For example, forcing individuals to make impossible choices, to act against their ethics or ideology; inducing helplessness, confusion, mistrust and intense fear. This may be achieved by forcing individuals to witness or participate in the torture of others, by revealing certain information, mock executions, or by continuing the torture whether or not the individual cooperates.
• Pharmacology: Pharmaceutical agents may be used to create profound anxiety and disorientation. For example, sedatives and neuroleptics may be used to blunt and distort the senses. Curare and other paralytics may be used to cause near or complete suffocation.
• Post-release: Those who survive torture and remain in their country may experience intense fear and suspicion about being re-arrested. They are often forced to go "underground" to avoid being arrested again. Those who are exiled or are refugees may leave behind their native language, culture, families, friends, work and everything that is familiar to them.

Symptoms and Disabilities Following Trauma:

Acute and chronic symptoms and disabilities associated with specific forms of abuse and the subsequent healing processes should be documented.

• Acute symptoms: The detainee should be asked to describe any injuries that may have resulted from the specific methods of abuse alleged. For example, bleeding, bruising, swelling, open wounds, pain, numbness, and marks on the skin, difficulties with movement, vomiting, etc. The intensity, frequency and duration of each symptom should be noted. Note 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.
• Chronic symptoms: Elicit information about physical ailments that the detainee believes are associated with torture or ill-treatment. Note the severity, frequency and duration of each symptom and any associated disability or need for medical and/or psychological care.
• Psychological symptoms: review symptoms that constitute post-traumatic stress disorder (PTSD), anxiety and depression.

Physical examination

Conduct a thorough physical examination noting pertinent positive and negative findings. Although the physical manifestations of torture may involve all organ systems, there should be special attention to the possibility of the following findings:

Skin: dermatologic evidence of abrasions; contusions; lacerations; puncture wounds; burns from electric shock, cigarettes or heated instruments; alopecia; and nail removal.

Musculoskeletal: mobility of the joints, spine and the extremities; pain with range of motion; contractures; fibrositis; compartment syndrome; healed fractures with or without deformities; ostitis; periostitis; fibrosis in muscles, fascia, and connective tissue; injury to tendons and ligaments; and osteoarthritis.

Neurologic: mental status changes; plexopathies; radiculopathies; neuropathies; cranial nerve deficits; hyperalgesia; parasthesias; hyperaesthesia; change in position and temperature sensation, motor function, gait and coordination.

HEENT: tympanic membrane rupture, sensorineural hearing loss, tinnitis, conjunctivitis, dental and mandibular trauma.

Gynecological: injuries to external genitalia and breasts, pain on internal pelvic and rectal examinations, pregnancy, and sexually transmitted diseases.

Other: examination of the pulmonary, cardiovascular, gastrointestinal, and genitourinary systems should follow a standard medical examination.
Psychological examination

The examiner needs to be qualified. Non-therapists need to develop qualifications to assess psychological evidence.

Assess for PTSD, depression, anxiety, suicidal ideation, and other DSM categories.

Assess specificity of psychological symptoms in the context of the traumatic experience. Is the overall picture consistent?

Clinicians need to educate lawyers, prosecutors, adjudicators and governmental representatives about the importance and validity of psychological consequences of torture.

Interrelate psychological and medical testimony.

Photographic evidence

Photographs are crucial for thorough documentation of visible physical findings of torture. Photographs should be in color, in focus, adequately illuminated, and taken by a professional or good quality camera. Each photograph should contain a ruled reference scale, an identifying case name or number, and a sample of standard gray.

Supplement photographs with distant and/or immediate range photographs to permit orientation and identification of the close-up photographs.

Photographs should be comprehensive in scope and must confirm the presence of all demonstrable signs of injury or disease commented upon in the medical report.

Diagnostic tests

Consider the indications and utility of any test before obtaining it. Some diagnostic studies that may be useful in establishing evidence of torture, among others, include: X-rays, CAT scan, MRI, bone scan (scintillography), testicular perfusion scan, skin biopsy for evaluation of electromyogram for nerve injuries; blood tests (such as a complete blood count; creatine phosphokinase; serologic tests to evaluate renal, hepatic and thyroid function; tests for pregnancy and sexually transmitted diseases), neuropsychiatric testing.

Indications for referral

Specialists: Referrals should be requested as indicated by individual diagnostic limitations. Referrals to psychology/psychiatry, neurology, orthopedics, and gynecology, are quite common.

Rehabilitation Services: In the course of documenting medical evidence of torture and ill treatment, physicians are not absolved of their ethical obligations. Those who appear to be in need of further medical or psychological care should be referred to appropriate services.

Interpretations of findings and conclusions

General Comments.

a) Individual variation

• Physical manifestations of torture may vary according to the intensity, frequency and duration of abuse, the victim's ability to protect himself/herself, the accuracy of the account of events, and the physical condition of the detainee prior to the torture.
• Psychological manifestations of torture also may vary according to the intensity, frequency, and duration of the abuse.
  However, psychological sequelae of torture typically vary
  according to the meaning or psychological impact of the
  torture for an individual. The personality or identity of the individual detainee must be assessed in conjunction with the presenting psychological symptoms.

b) Scars

• Scars associated with torture: review of scars commonly associated with beating, suspension, burns, electric shock, lacerations, penetrating injuries, contusions, abrasions, and lacerations, dating of scars.
• "Innocent" scars: stretch marks, ritual practices

c) Physical evidence

• A particular method of torture, its severity and the anatomical location of the injury often indicate the likelihood of specific physical findings. For example, beating the soles of the feet (falaka) may result in subcutaneous fibrosis and a compartment syndrome of the feet; the use of electricity and various methods of burning may also leave highly characteristic skin changes; whipping may also produce a highly characteristic pattern of scars; different forms of body suspension and stretching of limbs may result in characteristic musculoskeletal and nerve injuries.
• Other forms of torture may not produce physical findings, but are strongly associated with other conditions. Beatings to the head that result in loss of consciousness are particularly important to the clinical diagnosis of organic brain dysfunction. Trauma to the genitals is often associated with subsequent sexual dysfunction.
• It is important to realize that torturers may attempt to conceal their acts. To avoid physical evidence of beating, torture is often performed with wide, blunt objects, and victims are sometimes covered by a rug, or shoes in the case of falaka, to distribute the force of individual blows. Stretching, crushing injuries and asphyxiation are also form of torture which have the intent of producing maximal pain and suffering with minimal evidence. For the same reason, wet towels may be used with electric shocks.

Date:
Translator (Yes / No) Name:
Case ID #:
Detainee Name:

Source of Request for Medical Report:

Name:
Position:
Request type: Written / Verbal

Reason For Request:

Signs of Injury / Violence
# of days off from work
No request
Other:

Detainee accompanied by:

Name:
Police: Yes / No
Security Forces: Yes / No
Other:

Present During Examination:

Detainee: Yes / No Police: Yes / No
Doctor: Yes / No Security Forces: Yes / No
Other Detainees: Yes / No (#___ ) Other:

Medical Report Transferred to Prosecutor Via:

Police Courier
Soldier Other:
Mail

Review of Prior Medical Reports:

Date	Findings	Conclusions
1.
2.

EXAMINATION

1. Complaints

2. Alleged Methods of Injuries (give approximated dates of injuries)

3. Examination Findings

4. Assessment of correlation between physical findings and alleged methods of injury.

Alleged Method of Injury	Correlation Findings	Photo NC/PC/C/HC/DO*	(Yes / No)
1.
2.
3.
4.
5.

* NC = not consistent with; PC = possibly consistent with; C = consistent with; HC = highly consistent with; DO = diagnostic of.

Referrals:

Diagnostic Tests / Studies Requested:

Physician's Name:

Signature:

Medical reports and verbal testimony must be objective and impartial. All information presented in the medical testimony should be relevant and defensible in court. Do not include irrelevant information. Do not overstate the client's degree of certainty regarding exact dates or the precise sequence of events. The inclusion of "hearsay" information may undermine the credibility of the clinician's testimony and conflict with the detainee's account of the events.

Present various sources of evidence: physical, psychological and historical and interrelate them. The testimony should reflect the entirety of one's experience and individual reactions to it.

The quality of medical testimony, whether written or oral, can only be as good as the quality of the interview and examination that were conducted and the degree of adherence to procedural safeguards.

Components of the Testimony:

1. Qualifications

• Medical education and clinical training (provide curriculum vitae)
• Psychological training
• Regional human rights expertise
• Relevant publications, presentations, courses
• Experience in documenting evidence of torture: specific knowledge and training regarding methods, physical and psychological consequences of torture, and relevant human rights conditions: i.e. course study, conferences, reading, experience.

2. Statement regarding the veracity of testimony: For example, "I personally know the facts recited below, except as to those stated on information and belief, which I believe to be true. I would be prepared to testify to the above statements based on my personal knowledge and belief."

3. Background information

• Name, age, gender, family, education, work, political activity
• Circumstances of the interview: Duration of evaluation, translator's name, etc.

4. Medical History

• General Information
• Psychosocial History
• Summary of arrest(s) and/or abuse
• Arrest(s)
• Prison conditions
• Methods of torture and/or ill-treatment
• Review of torture methods
• Physical abuse
• Psychological abuse

5. Symptoms and disabilities following trauma:

• Acute symptoms
• Chronic symptoms

6. Physical examination

7. Psychological examination

8. Photographic evidence

9. Diagnostic tests

10. Referrals

11. Interpretations of findings and conclusions

12. Statement of truthfulness: 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 X/X/X at (City), (State or Province)."

13. Signature, date, place

Note: You have the opportunity and the responsibility to educate judicial officials and attorneys. Explain variability of sequelae of torture so adjudicators do not anticipate the presence or absence of a particular finding in every case that may appear similar.
Note: Cite published references to support conclusions (scientific publications, UN and non-governmental organization reports, state party reports on human rights).

NOTE

¹ Iacopino V, Heisler M, and Kirschner R. Torture in Turkey & Its Unwilling Accomplices. Physicians for Human Rights. 1996