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Identifying and reporting ill-treatmentPrinciples of the Istanbul Protocol
Hans Draminsky Petersen, MD,
Member of the SPT & the IMAP
The Istanbul Protocol, 2004Manual on the Effective Investigation and Documentation of Torture & CIDT
• International and regional legal standards, instruments and bodies
• Ethical codes, incl. medical:– Compassionate care, moral independence, respect dignity,
– Informed consent,
– Confidentiality
– Dual obligations: Best interest of the patient vs. duty to society /justice:
• Legal fundament, no contravention of medical norms, do no harm, • Inform the person! Keep record!• Seek advise and support, e.g. with the Medical Association
• Legal investigation of torture– State responsibility and obligation
• Independent, prompt and effective, incl. expert health professionals
The Istanbul Protocol, 2004Manual on the Effective Investigation and Documentation of Torture & CIDT
• The interview in private: – History of social background and pre-detention health
– Detention and abuse
– Circumstances of detention, place and conditions
– Methods of torture and ill-treatment
– Immediate reactions and acute symptoms
– Sub-acute and chronic symptoms
• The physical examination
• The psychological assessment
The description of the individual lesion
• Description:– Localisation and orientation
– Single or in groups
– Size
– Shape
– Border
– Colour
– Surface
• Classification:• Bruises, lacerations, incisions /stabs, abrasions,
Para-clinical investigations:
– Ultrasound, MR, CT, bone scintigraphy
– Biopsy of the skin: – Experimental– invasive procedure, requires injection of local anaesthesia, leaves marks– What to do with a negative result
– Muscular enzymes,
• even without visible lesions and
• with forced physical exercise
Assessment of the individual lesion as to age and origin
• Colour (yellow* /red**), crust, pigmentation, etc
• Region of the body, shape, surface, etc
– “Not consistent” = not caused by the trauma described
– “Consistent with” = non-specific, may have been caused as stated
– “Highly consistent” = may have been caused as stated, and there are few other possible causes
– “Typical of” = appearance usually found with this type of trauma, but there are other possible causes
– “Diagnostic for” = could not have been caused in other way than stated
• Could be commented, e.g. – Localised in body regions often exposed to everyday traumas– Remarkable shapes of lesions, evt multiplicity and in groups
• *If yellow colour is present: the age of the lesion is at least 18 hours• **If red only: age not more than 48 hours
Psychological consequences of torture
– Re-experiences of the traumatic event, awake and at sleep– Avoidance of thoughts and activities – incl. talking about
torture– Hyper-arousal:
• Sleep disturbances
• Irritability and outburst of anger, startled responses
• Impaired concentration and memory
– Depression– Anxiety– Damaged self-concept and foreshortened future– Sexual dysfunction and somatic symptoms– Substance abuse
The psychological assessment
• Social background• Medical and psychiatric history, incl. substance use and abuse• History of detention, torture and ill-treatment• Current psychological complaints• Current medication and substance abuse• Post-torture history, social situation and functioning, stress factors
• Assessment of mental status
• Scales and questionnaires?
Questions for the psychological assessmentThe Istanbul Protocol
• Are psychological findings consistent with alleged torture?• Are psychological findings expected and typical for extreme
stress in the given context?• Given the fluctuating course of trauma related mental disorders, what is the time
frame in relation to the torture event?• Where is the individual in the course of recovery?*
• What are the coexisting stressors impinging on the individual (ongoing persecution, migration, exile?
• What impact do these issues have on the individual?**
• Which physical conditions contribute to the clinical picture? Head injuries?
• Does the clinical picture suggest false allegations? ***
Some reservations /caveats
• The torture situation is extremely complex and designed to cause more fear and confusion. Observations may be perceived wrongly.
• Impaired concentration and memory are common with survivors *• The detainee may have lost consciousness**• Individual elements of the event may be overridden by others
• The survivor may not want to talk about all details***:– It may be too painful– It may cause harm to others– may think that seemingly absurd details shall be inferred as fabrications– May fear that torture / rape shall cause stigmatisation or ostracism– +
– May explain some discrepancies in statements given to different interviewers
Photos
• Identical scarification of nails in two individuals,
one alleging torture as origin, the other refusing torture
The overall conclusion of the expert examination
• The degree of consistency between the:
– History of torture /ill-treatment - Knowledge of local practices /HR record– The physical symptoms, immediate, intermediate and chronic– The observed physical evidence (or lack of evidence) – The psychological symptoms and signs– (diagnostic tests)
• Suggestion for classification:
– Beyond any reasonable doubt– High, no reservations and significant corroborative clinical findings– Moderate, some reservations / no or few unspecific corroborative clinical
findings– Low, many reservations and no corroborative clinical findings
Substantiation of the overall conclusion
• Is the history of torture may be qualified as e.g. being detailed and complex and consistent with the general pattern (in the region /country /institution in question) known from other sources (named)
• Acute, intermediate and chronic physical and psychological symptoms may be qualified as commonly seen /typical after torture as alleged
• The specificity of findings should be mentioned: “Typical”, “diagnostic”
• If inconsistencies are deemed insignificant, the reasons should be given
• The absence of torture related scars does not contradict the consistency of torture considering the reported methods of torture
• Do not be too cocksure, neither in assessment of lesions, nor in rejection of allegations
The assessment of the generalist, the doctor in the detention centre, a gatekeepers
• Informed consent 1-2
• Brief history of ill-treatment• Physical and psychological symptoms• Physical signs and psychological observations• Opinion as to consistency• Identification of health needs, • Start treatment /refer for further examination /treatment, if appropr
• Informed consent 3
• Report to higher authority, incl. the director, who must– protect the complainant against reprisals and – prevent recurrence– Refer to expert examination
The assessment of the generalist
• A preliminary medical assessment
• The basis for referral to expert examination
• Often done shortly after ill-treatment, i.e. lesions are still present• While the expert examination may be delayed considerably
• The document of the doctor should be part of the case file
• Requires high quality, often great space for improvement
Study groups
1991-1994 2000-2005
Number of persons 100 124
Number of documents 318 425
Allegations of ill-treatment
1991-1995 2000-2005
Number of persons 46 (46%) 76 (59%)
P>0.05
Number of documents 77 (24%) 127 (30%)
Allegations of ill-treatmentNumber of documents = examinations
1991-94N=77
2000-5N=127
Physical, incl.beatings 78% 52%
Asphyxiation, a plastic bag 31% 21%
Asphyxiation, water 4% 0
Electrical shocks 8% 2%
Forcible physical exercise 6% 43% P<0,0001
Psychological, incl. threats 17% 48% P<0,0005
Lacking information
1991-94
N=318
2000-05
N=425
Formal structure 98% 98%
Subjection to ill-treatment 43% 40%
Relevant symptoms
Physical examination
53%
36%
34%
49%
P<0.0001
P<o.0005
Overall conclusion on allegations of ill-treatment
96% 100%
Conclusions on age and origin of described lesions
74% 36%
Reporting alleged ill-treatment to higher authority
100% 100%
Quality of conclusions on age and origin of lesions
1991-1991
N=31
2000-2005
N=64
Acceptable 3% 39%
P<0.001
Unacceptable 29% 25%
Insufficient premises 52% 27%
Questionable 16% 9%
Obligation to report torture and ill-treatment
• With informed consent and considering the risk of reprisals
• Report to– The director of the institution– Ministry, register
• Refer to independent expert examination
• Inform detainee about the possibility to address a complaint body or the Ombudsman
• Directors obligation:– Initiate inquiry by independent body or General Prosecutor
Hierarchy of responsibility
GovernmentMinistries of
Interior, Justice, Health
Director ofinstitution
Police officers The doctorsVisiting
mechanisms
Referral to expert examination in accordance with
the Istanbul Protocol
• The doctor in the detention centre• The doctor in the prison• The personal doctor of the person• The judge• The (doctor of the) NPM• The Ombudsman• +
• Informed consent
A prompt and impartial investigation
• .. competent authorities shall proceed a prompt and impartial investigation to whenever there is reasonable ground to believe that an act of torture has taken place (CAT § 12)
• Medical /expert documentation of torture must amount to
“reasonable ground”
Counter-reactive use of the result of the expert examination
• In case that the examiners do not positively document torture the complainant shall be prosecuted for defaming the police(e.g. Mexico, Spain)
• (Many) vulnerable persons who have been subjected to TCIDT would hardly run the risk of – another confrontation with the body that committed the torture – A sentence
• Which level of consistency in the medical assessment should be the critical cut-off point?
If allegations are not convincingly documented to be fabricated* such an approach amounts to judicial reprisals
A central register on allegations of torture
Recommended by the UN General assembly, November 11th, 2011
• All cases of alleged torture or ill-treatment, whether documented or not
• Cases of multi traumatisation
? Cases where the doctor for other reasons – e.g., presence of multiple symptoms indicating possible exposure to torture?
The central register of the ministryFighting impunity and preventing torture
• A tool to ensure that allegations of torture are investigated
• A tool to give a overview of allegations of torture with a view to identify risk institutions and risk situations - with the aim to remedy risks
• Knowing that information, documents have to be read and inferred before filing them would encourage doctors and other local actors to comply with standards set by the ministry
• The NPM and the Ombudsman should have access to the register.
• No access for police authorities
The central register of the ministry
• Hour, date and place for alleged torture• Security body implicated, if possible ID of implicated officers• Place of apprehension and detention• Nature of the allegations, forms of torture and reasons for its use• Relevant findings and conclusions of the doctor in the police station. • Most important findings and conclusions of the expert examination• Details of the body that did the criminal /disciplinary inquiry,• The result of the inquiry and any prosecution• The implementation of sanctions
Principles for the effective investigation and documentation of TCIDT
• Clarification of facts and establishment of individual and state responsibility• Means to prevent recurrence• Facilitation of prosecution and indication of needs for redress and health
care• Experts health professionals are part of the investigation team
• State responsibilities – investigation is prompt, independent and competent; that resources and
powers of investigative body are appropriate– Victims and witnesses are protected– Victims have access to all information and can present other evidence– Agents possibly implicated in TCIDT removed from position of power– Respond to the written report and indicate steps to be taken
• With some additional tools and practices the implementation of the Istanbul Protocol will be useful in the prevention of torture
Thank you for your attention
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