Identifying and reporting ill-treatment Principles of the Istanbul Protocol

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Identifying and reporting ill-treatmentPrinciples
of the Istanbul Protocol

• Hans Draminsky Petersen, MD,
• Member of the SPT the IMAP

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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

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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

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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,

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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

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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

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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

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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?

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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?

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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

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Photos

• Identical scarification of nails in two
  individuals,
• one alleging torture as origin, the other
  refusing torture

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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

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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

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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

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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

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Study groups
1991-1994 2000-2005
Number of persons 100 124
Number of documents 318 425
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Allegations of ill-treatment
1991-1995 2000-2005
Number of persons 46 (46) 76 (59) Pgt0.05
Number of documents 77 (24) 127 (30)
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Allegations of ill-treatmentNumber of documents
examinations
1991-94 N77 2000-5 N127
Physical, incl.beatings 78 52
Asphyxiation, a plastic bag 31 21
Asphyxiation, water 4 0
Electrical shocks 8 2
Forcible physical exercise 6 43 Plt0,0001
Psychological, incl. threats 17 48 Plt0,0005
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Lacking information
1991-94 N318 2000-05 N425
Formal structure 98 98
Subjection to ill-treatment 43 40
Relevant symptoms Physical examination 53 36 34 49 Plt0.0001 Plto.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
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Quality of conclusions on age and origin of
lesions
1991-1991 N31 2000-2005 N64
Acceptable 3 39 Plt0.001
Unacceptable 29 25
Insufficient premises 52 27
Questionable 16 9
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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

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Hierarchy of responsibility
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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

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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

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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

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A central register on allegations of
tortureRecommended 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?

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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

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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

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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

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Thank you for your attention

• ?