1. HRFT, TMA, SFMS-2004 MODULE 5 Prevention through Documentation Project Physical Evidence of Torture and Ill Treatment CONTRIBUTORS: Vincent Iacopino, MD, PhD, Physicians for Human Rights Önder Özkalıpçı MD, International Rehabilitation Council for Torture Victims Alejandro Moreno, MD, JD, Boston Center for Refugee Health and Human Rights Ole Vedel Rasmussen, MD, DMSc, International Rehabilitation Council for Torture Victims Lis Danielsen, MD, DMSc, International Rehabilitation Council for Torture Victims

2. HRFT, TMA, SFMS-2004 Module 5 Outline Physical Evidence of Torture Medical History The Physical Examination Diagnostic Tests

3. HRFT, TMA, SFMS-2004 Physical Evidence of Torture Medical evaluation : – for legal purposes should be objectivie and impartia l – should be based on physician’s clinical expertise and professional experience Clinicians who conduct evaluations of detainees should have specific essential training in forensic documentation of torture and other forms of abuse Detailed account of patient’s observations of acute lesions and subsequent healing process often represent important source of evidence in corroborating specific allegations of torture or ill- treatment

4. HRFT, TMA, SFMS-2004 Physical Evidence of Torture Absence of physical evidence does not mean torture did not occur: – Noted in Istanbul Protocol – Such acts might not leave marks or permanent scars Clinicians should have knowledge of – prison conditions – torture methods used in the particular region of imprisonment – common after-effects of torture Clinicians should not assume that official requesting medical-legal evaluation has related all material facts

5. HRFT, TMA, SFMS-2004 Medical History Obtain a complete medical history: prior medical, surgical or psychiatric problems, details of torture, acute and chronic symptoms Document any history of injuries before period of detention and any possible after­effects Avoid leading questions Structure inquiries to elicit an open-ended, chronological account of events experienced during detention

6. HRFT, TMA, SFMS-2004 Medical History Specific historical information may be useful in correlating regional practices of torture with individual allegations of abuse – descriptions of torture devices – body positions – methods of restraint – descriptions of acute or chronic wounds and disabilities – identifying information about perpetrators and places of detention

7. HRFT, TMA, SFMS-2004 Medical History Acute Symptoms – Types of symptoms (i.e. bleeding, bruising, swelling, open wounds, lacerations, fractures, dislocations, pain, numbness) – Intensity, frequency & duration of each symptom – Development of any subsequent skin lesions or scars – Health condition on release – Description of healing process – Details of any medical treatment

8. HRFT, TMA, SFMS-2004 Medical History Chronic Symptoms: – Elicit information about physical ailments that individual believes were associated with torture – Make note of: severity, frequency, duration of each symptom associated disability need for medical or psychological care – Common somatic complaints include headache, back pain, gastrointestinal symptoms, sexual dysfunction and muscle pain. – Common psychological symptoms include depressive affect, anxiety, insomnia, nightmares, flashbacks and memory difficulties

9. HRFT, TMA, SFMS-2004 The Physical Examination – Dermatologic Evaluation – Head and neck – Eyes, Ears, Nose – Jaw, Oropharynx and Teeth – Chest and Abdomen – Musculoskeletal System – Neurologic Examination – Examination of Women – Genital Examination of Men – Perianal Examination – Medical Photography – Assessment for Referral

10. HRFT, TMA, SFMS-2004 Dermatologic Evaluation Description of skin lesions should include: – Localisation (use body diagram): symmetrical, asymmetrical – Shape: round, oval, linear, circumferential, etc – Size: (use ruler) – Colour – Surface: scaly, crusty, ulcerative, bullous, necrotic – Periphery: regular or irregular, zone in the periphery – Demarcation: sharply, poorly – Level in relation to surrounding skin: atrophic, hypertrophic, macular

11. HRFT, TMA, SFMS-2004 Dermatologic Evaluation Common injuries to the skin can be classified as : – Abrasions (or grazes) – Contusions (commonly known as bruises) – Lacerations (also, commonly but confusingly, known as cuts) – Incisions (including stab wounds) – Burns and scalds

12. HRFT, TMA, SFMS-2004 Abrasions

13. Contusions

14. HRFT, TMA, SFMS-2004 Contusions

15. HRFT, TMA, SFMS-2004 Contusions

16. HRFT, TMA, SFMS-2004 Lacerations Caused by tangential force such as a blow or a fall and produce tears of the skin Wound edges tend to be irregular and may be bruised or/and abraded There might be tissue bridges (where the skin has not separated along the entire length of the wound). Develop easily on the protruding parts of body because skin is compressed between blunt object and bone surface under subdermal tissues

17. HRFT, TMA, SFMS-2004 Incisions

18. HRFT, TMA, SFMS-2004 Burns & Scalds

19. HRFT, TMA, SFMS-2004 Burns & Scalds

20. HRFT, TMA, SFMS-2004 Burns & Scalds

21. HRFT, TMA, SFMS-2004 Burns & Scalds

22. HRFT, TMA, SFMS-2004 Complex Lesions Injuries can result in different types of wounds : – example: wounds caused by broken glass may be mixture of incision and laceration – example: human bites tend to be mixture of laceration and crush injury with or with out petechiae from sucking

23. HRFT, TMA, SFMS-2004 Scarring Most common late physical finding Healing influenced and often impaired by many factors i.e.: – persistent, untreated infection – repeated trauma to the same area – malnutrition Healing by primary intention: top down, small scar Healing by secondary intention: from below, wide “biconvex” scar, gaping edges, prone to infection Self-inflicted: usually using dominant hand to accessible parts of the body, not severe

24. HRFT, TMA, SFMS-2004 Scarring Keloid scars: – exceed the boundaries of the original wound Post-inflammatory hyperpigmentation – can follow inflammation in darker skins, irrespective of cause – retains the shape of the original inflammation classic tramline bruising can leave distinctive patterns of hyperpigmentation (usually 5-10 yrs) whipping can sometimes leave lines of hyperpigmentation, especially in darker skin (rarely confused with striae distensae) tight ropes or handcuffs may leave hyperpigmented circumferential scars due to marks around wrists, and marks following

25. HRFT, TMA, SFMS-2004 Striae distensae

26. HRFT, TMA, SFMS-2004 Head & Neck Most traumatic scars on the face tend to be relatively small and may be difficult to distinguish from disease processes Lesions are common over bony points, especially the eyebrows and the cheekbones and may be associated with fractures Broken or missing teeth are commonly observed Petechiae of the palate may be evidence of forced oral intercourse Slaps to the ear can sometimes rupture the eardrum

27. HRFT, TMA, SFMS-2004 Eyes Findings may include: – Conjunctival hemorrhage – Lens dislocation – Subhyeloid hemorrhage, – Retrobulbar hemorrhage – Retinal hemorrhage – Visual field loss – Lacerations (caused by a tangential force such as a blow or a fall and produce tears of the skin) Referral to an ophthalmologist is recommended whenever there is a suspicion of ocular trauma or disease

28. HRFT, TMA, SFMS-2004 Ears Findings may include: – External haematoma – Cartilage necrosis and infection – Rupture of tympanic membrane – Hearing loss – Vertigo – Tinnitus – Disequilibrium – Facial nerve paralysis Audiogram recommended for middle/inner ear injuries MRI for signs of skull fracture

29. HRFT, TMA, SFMS-2004 Nose Evaluate for alignment, crepitation, and deviation of nasal septum Deviation of nasal septum may result in nasal obstruction For simple nasal fractures, standard nasal radiographs should be sufficient For complex nasal fractures and when the cartilaginous septum is displaced, and when rhinorrhea is present, CT and/or MRI are recommended

30. HRFT, TMA, SFMS-2004 Jaw, Oropharynx & Teeth During application of electric current to the mouth, tongue, gingiva or lips may be bitten. Lesions might also be produced by forcing objects or materials into the mouth Refer to a dentist if there is any damage to the teeth Mandibular fractures, avulsions or fractures of teeth, broken prostheses, swelling of the gums, bleeding, pain, or loss of fillings from teeth can all result from direct trauma or electric shock torture X-rays and MRI are suggested for determining extent of soft tissue, mandibular and dental trauma

31. HRFT, TMA, SFMS-2004 Chest & Abdomen Rib fractures are frequent consequence of beatings to chest. If displaced, may be associated with lacerations of lung and possible pneumothorax. Fractures of vertebral pedicles may result from direct blunt force. Fractures of lower right ribs carry approximately 10% risk of hepatic injury Examiner must consider possibility of intramuscular, retroperitoneal and intra-abdominal hematomas, as well as laceration or rupture of an internal organ Ultrasonography, CT scans and bone scintigraphy should be used, when available, to confirm such injuries Gross haematuria is most significant indication of kidney contusion Renal failure due to crush syndrome may be seen acutely following severe beatings

32. HRFT, TMA, SFMS-2004 Musculoskeletal System Musculoskeletal complaints very common May result from beatings, suspension, or other positional torture or may also be somatic Physical examination of skeleton should include testing for mobility of joints, spine and extremities, pain with motion, contractures, strength, evidence of compartment syndrome, fractures with or without deformity, and dislocations Evaluate for trauma to muscle such as muscle rupture and muscle tearing. Specific clinical signs of ligament tear include swelling, bruising, muscle spasm, and painful stress test, often with joint laxity. May be palpable gap in the ligament. If completely torn, then considerable swelling and bruising occurs. Tendon ruptures, avulsions from insertion of bone.

33. HRFT, TMA, SFMS-2004 Neurological Examination Evaluate CNS and PNS for : – Neuropathies (i.e. brachial plexus from suspension) – Cranial nerve deficits – Hyperalgesia – Parasthesiae – Hyperaesthesia – Change in position and temperature sense – Sensation & motor function – Gait and coordination Head trauma is common – Scalp injuries – Brain injury and seizures Headaches: evaluate structural vs. psychosomatic

34. HRFT, TMA, SFMS-2004 Examination of Women Must seek specific consent – Give clear, unambiguous explanation of reason for genital examination while alleged victim is fully clothed – Note observations about patient’s demeanour Examination Following a Recent Assault – Rare that victim of rape during torture is released while still possible to identify acute signs of assault – Whenever possible, examination should be performed by an expert in documenting sexual assault – Chaperone if physician is of a different gender – cutaneous lesions: contusions, lacerations, abrasions, ecchymoses and petechiae from sucking or biting – Note: Genital lesions observed in < 50% of rape cases – Use rape kit (STD, pregnancy, DNA tests) – STD treatments and prophylaxis

35. HRFT, TMA, SFMS-2004 Examination of Women Examination after immediate phase – If alleged assault occurred more than a week earlier and tno signs of bruises or lacerations, then less immediacy to conduct pelvic examination In this setting rare to find physical evidence Still beneficial to photograph any residual lesions – Diagnostic findings are not likely in women who have delivered babies prior to the rape – Assessment and treatment for STDs: i.e. gonorrhoea, chlamydia, syphilis, HIV, hepatitis B and C, herpes simplex and Condyloma acuminatum (venereal warts), vulvovaginitis associated with sexual abuse, such as trichomoniasis, Moniliasis vaginitis, Gardnerella vaginitis and Enterobius vermicularis (pinworms), as well as urinary tract infections

36. HRFT, TMA, SFMS-2004 Genital Examination of Men Crushing/squeezing of the scrotum: may observe hyperaemia, marked swelling and ecchymosis Scrotal mass differential: – Hydrocele (fluid in tunica vaginalis, transilluminates) – Haematocele (blood in tunica vaginalis, does NOT transilluminate) – Inguinal hernia (cannot palpate the spermatic cord above the mass) Testicular torsion - a surgical emergency Erectile dysfunction - often psychosomatic Assess for sexually transmitted diseases, Hepatitis B and HIV and prophylaxis

37. HRFT, TMA, SFMS-2004 Perianal Examination After anal rape or insertion of objects into the anus of either gender, pain and bleeding can occur for days or weeks – If bleeding persists, may mean scarring of rectal mucosa, can be seen by proctoscopy Lacerations are caused by a tangential force such as a blow or a fall and produce tears of the skin Follow protocols for STDs If there is any possibility of the perpetrator being prosecuted, air dried internal and external anal swabs can be taken up to five days after the rape and stored for DNA testing, even if the survivor has defecated

38. HRFT, TMA, SFMS-2004 Medical Photography Document injuries as quickly as possible, before any change occurs Any photographic equipment can be used initially and more professional photographs can be taken later Forensic photos should : – Show current date (digital or newspaper in photo) – Identity of alleged victim (face) – Show scale (ruler or common object) – Use natural lighting instead of flash – Follow chain of custody

39. HRFT, TMA, SFMS-2004 Assessment for Referral Those who need further medical and/or psychological care should be referred to appropriate services – If rehabilitation centre for torture survivors in the region, contact for further support or advice – In countries systematic torture and pressure on health care professionals the examining clinician may also want to refer patients to specialists to increase number of medical witnesses to torture

40. HRFT, TMA, SFMS-2004 Diagnostic Tests Diagnostic tests may aid in corroborating allegations of torutre Before obtaining such tests,consider – potential value of tests – inherent limitations in light of the level of “proof” needed in a particular case – potential adverse consequences for individual – resource limitations Generally, not warranted unless likely to make a significant difference to a medical-legal case

41. HRFT, TMA, SFMS-2004 Radiologic Imaging X-Rays – Readily available – Can be very useful when searching for fractures, fissures, deformity and foreign bodies in osseous structures – When periosteal damage or minimal fractures are suspected, bone scintigraphy should be used in addition t – Soft tissue changes adjacent to fracture or deformity as well as foreign bodies in vicinity can contribute information – Percentage of x-rays will be negative even when there is an acute fracture or early osteomyelitis

42. HRFT, TMA, SFMS-2004 Radiologic Imaging Scintigraphy – High sensitivity but low specificity – Economic and effective examination to screen entire skeleton for disease processes such as osteomyelitis, trauma, testicular torsion – Scintigraphy can detect an acute fracture within twenty- four hours, but generally it takes two to three days and may occasionally take a week or more – Generally scan returns to normal after two years but may remain positive in both fractures and cured osteomyelitis for years – Often used to detect evidence of falanga and multiple skeletal injuries

43. HRFT, TMA, SFMS-2004 Radiologic Imaging Ultrasound – Inexpensive and without biologic hazard – Primarily used for evaluation of muscles and joints, especially shoulder joint, but can be more useful for contributions depending on skill of applicator administering it – At present high channel probes with multifrequencies (8-15 MHz) can be more sensitive than CT and MRI in showing changes in cutaneous, subcutaneous, osseous, soft tissues, muscles and joints – Sensitivity to pathology related to shoulder, knee and ankle joints and related lesions of joints, tendons and adjacent soft tissues is usually higher than MRI – Doppler studies: may demonstrate focal deficits of tissue perfusion and areas of reactive hyperaemia can be identified in injuries

44. HRFT, TMA, SFMS-2004 Radiologic Imaging CT scans – Excellent for imaging both soft tissue and bone diagnosing and evaluating fractures, especially temporal bone and facial bones – CT with and without intravenous infusion of a contrast agent should be the initial examination for acute, subacute and chronic central nervous system lesions. If negative, equivocal or does not explain the survivor’s CNS complaints or symptoms, proceed to an MRI – When CSF rhinorrhea is suspected, CT of the face with soft tissue and bone windows should be performed. Then CT should be obtained after contrast is injected into the spinal canal

45. HRFT, TMA, SFMS-2004 Radiologic Imaging MRI – More sensitive than CT in detecting central nervous system (CNS) abnormalities – Time course of CNS hemorrhage has ranges that correlate with imaging characteristics of the hemorrhage. Thus, imaging findings may allow estimation of timing of head injury and correlation to alleged incidents – MRI with Turbo STIR sequences, directed to whole body can demonstrate general body trauma and identify lesions and areas needing detailed evaluation. Minimal changes identified as bone bruise in pre-oedema stages can also be identified in osseous tissues within hours of traumatic injuries

46. HRFT, TMA, SFMS-2004 Biopsy for Electric Shock Injury Electric shock injuries can may exhibit microscopic changes that are highly diagnostic and specific for electric current trauma Absence of these findings does not mitigate diagnosis of electric shock torture, and judicial authorities must not be permitted to make this assumption Thus procedure currently be done in a clinical research setting only, not a diagnostic standard Individuals must be informed of the uncertainty of the results and permitted to weigh the potential benefit against the impact upon an already traumatized psyche Diagnostic findings for electrical injury include: – Vesicular nuclei in epidermis, sweat glands and vessel walls – Deposits of calcium salts distinctly located on collagen and elastic fibers

47. Microscopic Dermatological Findings After Alleged Torture HRFT, TMA, SFMS-2004

48. Microscopic Dermatological Findings After Alleged Torture HRFT, TMA, SFMS-2004

49. Microscopic Dermatological Findings After Alleged Torture HRFT, TMA, SFMS-2004