REVIEW

The role of doctors in investigation, prevention and treatment of

Helen McColl1 • Kamaldeep Bhui2 • Edgar Jones3 1Liaison Psychiatry, Sussex Partnership Foundation Trust, Hove BN3 1AS, UK 2Wolfson Institute for Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London EC1 M6BQ, UK 3King’s Centre for Military Research, Kings College, London SE5 9RJ, UK Correspondence to: Kamaldeep Bhui Email: [email protected]

DECLARATION Summary Doctors may assess and treat torture survivors; some may document Competing interests crucial evidence of torture in medico-legal reports. However, there is a Helen McColl is a lack of education on torture and related ethical and legal issues at Medical Advisor for undergraduate and postgraduate level and many doctors are not aware of Medical Justice opportunities to work with organisations for the prevention of torture. This Funding paper defines Torture, describes methods used, and sets out the human None rights instruments and codes of ethical practice that mandate efforts to prevent torture. Medical complicity in torture is discussed and the need for Ethical approval national and international medical associations to prevent torture by both Not applicable supporting doctors and recognising and tackling medial complicity. The Guarantor paper offers guidance for assessing and documenting torture, and for Helen McColl providing health care for survivors of torture.

Contributorship All authors helped construct, edit and Introduction of torture in medicolegal reports (MLR). refine the paper However, there is a lack of education on torture whilst HM led on Torture continues to be a subject of media head- and related ethical and legal issues at undergradu- writing the first and lines; this year was the 10th anniversary of the ate and postgraduate level and many doctors are final draft. All first prisoners arriving at Guantanamo, and not aware of opportunities to work with organiz- 4 authors contributed torture in countries such as Libya continues ations for the prevention of torture. This paper clinical and to be widely condemned. Amnesty International defines torture, describes methods used, and sets research expertise; reported that at least 81 world governments out the instruments and codes of 1 educational skills; practiced torture in 2008. The International Reha- ethical practice that mandate efforts to prevent bilitation Council for Torture Victims (IRCT) indi- torture. Medical complicity in torture is discussed, and made use of cated that torture is practiced in more than half of as is the need for national and international expertise in work all countries in the world.2 However, many cases medical associations to prevent torture by both with refugees and of torture do not hit the headlines, for example, supporting doctors and recognizing and tackling ethnic minorities torture stories from asylum seekers in the UK medial complicity. The paper offers guidance for (HM, KB), often go unheard. Even the UK Border Agency’s assessing and documenting torture, and for pro- international conflict detention of victims of torture and trafficking viding healthcare for survivors of torture. It does (EJ, KB), war studies was criticized earlier this year in the Vine report.3 not address controversies around the status of (EJ) and inequalities In the UK, doctors may assess and treat torture post-traumatic stress disorder (PTSD) as a legiti- survivors; some may document crucial evidence mate diagnosis and what evidence supports

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and human rights specific treatment for torture survivors, as these (HM, KB). issues have been the subject of previous reviews.5,6 Box 1 Definitions of torture Acknowledgements None Methods ‘Any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person The purpose of this clinical review is to inform information or a confession, punishing him for an act he or a doctors of the international guidelines and legis- third person has committed or is suspected of having lation on how to deal with torture victims and committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any issues related to torture more generally. The kind, when such pain or suffering is inflicted by or at the article is therefore based on the best known inter- instigation of or with the consent or acquiescence of a public national guidelines that were used by HM whilst official or other person acting in an official capacity’ (UNCAT). working with victims of torture, taking account the experiences of KB and EJ on wider issues ‘The deliberate, systematic or wanton infliction of physical or mental suffering by one or more persons acting alone or of torture, culture and war studies. We ident- on the orders of any authority, to force another person to ified by Google the website of the key organis- yield information, to make a confession or for any other ations that aim to prevent and protect against reason’ (WMA). torture: , International Committee UNCAT- United Nations Convention Against Torture and of the Red Cross, Amnesty International, World Other Cruel, Inhuman or Degrading Treatment or Medical Assocation, International Rehabilitation Punishment Council for Victims of Torture, Freedom from WMA - World Medical Association Torture, Physicians for Human Rights, Medical Justice, MEDACTand REDRESS. We also searched Pubmed and Google Scholar for guidelines related the past 40 years’ and said ‘several studies have to torture. We included information, reports and shown that coercive interrogation or torture also articles that provide direct guidance on what increases the risk of false confessions, since doctors should do to assess and to protect vulner- people will often say anything just to make it able populations. stop’.7,8

Definitions, methods and Torture is a global public health functions of torture issue

It is important to establish a definition of torture so In many circumstances torture is used against that estimates about prevalence, preventive groups of persons or an entire population actions and the treatment of the consequences for destructive purposes. The consequences of of torture inform a coherent response (Box 1). torture can be long-term physical and mental inju- Torture can be used to destroy dignity, gain infor- ries, with profound effects social and physical mation, draw a confession, create fear and punish. functioning. Imprisonment and related ill-health Knowledge of common torture methods is useful can contribute to loss of education and occupation for doctors (Box 2), although methods are over the life-course. Some survivors of often region specific (see www.amnesty.org.uk torture become internally or externally displaced for reports). Torture is commonly justified on the persons, for example, asylum seekers. A recent basis of security and safety; to gain information meta-analysis showed torture and other poten- to prevent terrorist attacks and so prevent casual- tially traumatic events are endemic in countries ties. However, there is little evidence that torture affected by ongoing conflict and that torture is actually leads to the disclosure of accurate infor- associated with mental disorder. The results sup- mation that can be used to protect the safety ported the moderating effects of the environment; or security of populations, or prevent threats internally or externally displaced populations had against the state. An American governmental higher rates of PTSD than those permanently report concluded ‘there had been almost no resettled.9 In another meta-analysis of refugee empirical research into interrogation methods in mental health, it was also found that contextual

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Instruments include the Universal Declaration of Box 2 Human Rights, the Geneva Conventions and the Torture methods and sequelae United Nations Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Blunt trauma: beating, kicking, ‘falanga’ (beating of the soles of the feet repeatedly) dragging along the ground, Punishment (UNCAT). UNCAT defines the obli- whipping and nail removal gations of governments to prevent torture and to Positional torture: suspension, forced positions and prosecute those responsible for the crime, to twisting of limbs provide training and education for professionals, Electric shocks and burns: use of acids, electrical and to ensure generous redress and rehabilitation instruments and cigarettes for victims of torture. As of March 2012 the con- Asphyxiation: use of chemicals, water boarding vention had 150 parties.11 (immobilization, inhalation of water, forced suffocation The Optional Protocol to the Convention against leads the person to experience a situation similar to drowning) and hangings Torture and other Cruel, Inhuman or Degrading Treat-

Penetrating and crush injuries: stab and gunshot wounds, ment or Punishment, or OPCAT, builds on the breaking digits UNCAT. OPCATobliges nations to set up indepen-

Sexual: rape, humiliation and direct trauma to genitalia dent preventive mechanisms. These examine the treatment of people in detention and make Amputation of digit or limbs recommendations to government authorities to Pharmacological torture: use of sedatives and paralytics strengthen protection against torture while com- Conditions of detention: deprivation of sensory stimulation menting on existing or proposed legislation. e.g. blindfolding, solitary confinement, cramped condition in cells, poor diet leading to nutritional deficiencies, As of March 2012, 62 countries are party to the 12 chaining and exposure to adverse weather protocol, including the UK. Psychological techniques and behavioural coercion: OPCATcountries agree to international inspec- religious and cultural humiliation, forced betrayal or harm to tions of places of detention by the United Nations others, threats of death, harm to family, mock executions Subcommittee on Prevention of Torture and other and witnessing the torture of others Cruel, Inhuman or Degrading Treatment or Sequelae: the distinction between physical and psychological methods of torture is artificial. Previously Punishment (SPT). The SPT is composed of 10 reported common physical symptoms and findings are independent members of different professional headaches, impaired hearing, joint pain, gastrointestinal backgrounds including lawyers, doctors and problems, fractures and scars.34 Common mental symptoms include insomnia, nightmares, flash backs, memory inspection experts; all have experience of human problems, lack of concentration, anxiety and low mood. rights work. The SPT visits any places of detention Increased rates of substance abuse, psychosis and suicidal including police stations, prisons (military and thoughts have also been reported. A recent systematic review of mental sequelae shows large variation in the civilian), detention centres (pretrial detention, data.35 Rape and other sexual violence may cause scars, immigration detention and juvenile justice estab- fissures, testis atrophy, sexual dysfunction, pregnancies, lishments), mental health and social care insti- sexually transmitted infections and mental health sequelae. Torture survivors may experience somatic symptoms30 such tutions and examines the treatment of detainees, as generalized weakness or chronic pain. This may have a recommending actions to be taken to improve psychological component but care must be taken to the treatment of detainees. It does not provide investigate a physical component, for example caused by repeated trauma or nutritional deficiencies. legal or financial aid.

factors after refugee displacement are moderators The Istanbul Protocol of mental health; economic opportunities and stable accommodation gave superior outcomes.10 The United Nations manual on the effective investigation and documentation of torture and International ethics and human other cruel, inhuman or degrading treatment or rights punishment (the ‘Istanbul Protocol’) was devel- oped over three years with the involvement of Torture is prohibited under a number of inter- more than 40 organizations, including the World national and regional human rights instruments, Medical Association (WMA).13 This followed the and most domestic laws. death of a Turkish university graduate and

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following specific forms of torture and in using the Box 3 documentation techniques foreseen in the Istanbul Baki Erdogan and the Istanbul protocol Protocol. The medical legal reports, using the

Baki Erdogan, a 29-year-old university graduate, was guidelines, can be used to support asylum pro- detained in western Turkey in 1993. He was taken to hospital cedures, requested where a victim of torture is after 11 days of interrogation at the police headquarters and seeking reparation or in cases where the perpetra- died the same day. The official autopsy stated that he died of acute pulmonary oedema as a result of a 10-day hunger tor is brought to trial and used collectively for strike. The Turkish Medical Association carried out an monitoring and advocacy campaigns by human independent investigation and produced an alternative rights organizations. Clearly, such campaigns medical report which disclosed numerous flaws in the autopsy and found that the official forensic examination did need firm actions by practitioners and their not follow the standards of the Minnesota Protocol. They respective professional bodies to ensure the spirit determined the cause of death to be adult respiratory and the letter of the various protocols are enacted. distress syndrome as a result of the use of torture. This successfully challenged case inspired the Turkish Medical Allegations of torture at detention facilities Association to host an international meeting and work around the world are numerous. Very few of began on a manual for the investigation and documentation these allegations have been substantiated by con- of torture and other forms of ill treatment. The result was the 14 production of the Istanbul Protocol. This is composed of crete evidence. A project led by Physicians for six chapters and four annexes: Human Rights (PHR) coordinated a team of

• Relevant international legal standards specialists to examine 11 former detainees from • Relevant ethical codes the US controlled Guanta´namo Bay, Abu Ghraib • Legal investigation of torture and Bagram Airbase detention facilities. These • General considerations for interviews • Physical evidence of torture examinations, following the Istanbul Protocol • Psychological evidence of torture principles, were made possible due to effective • Annex I: ‘Istanbul principles’ collaboration between the medical specialist • Annex II: Diagnostic tests • Annex III: Anatomical drawings team and lawyers representing the former • Annex IV: Guidelines for the medical evaluation detainees.

Medical complicity investigations by the Turkish Medical Association (see Box 3). Medical complicity in torture is active or passive The Istanbul Protocol is now an internationally participation by doctors in torture. Examples recognized guideline for medical and legal include use of medical knowledge to aid interrog- experts. It can be used as a tool to gather and docu- ation techniques, supervising use of chemicals to ment accurate and reliable evidence in connection torture, providing false medical reports and with cases where torture is alleged and to help failure to report torture. Passive participation, practitioners to assess the consistency between such as failure to report torture, is often less recog- allegations and medical findings. Crucially it nized and punished.15 One factor that can cause states that: ‘Witness and survivor testimony are medical complicity in torture is dual loyalty, necessary components in the documentation of whereby doctors put the perceived interests of torture. To the extent that physical evidence of their organization or state ahead of their absolute torture exists, it provides important confirmatory duty of care to their patient. The International evidence that a person was tortured. However, Committee of the Red Cross (ICRC), PHR and the absence of such physical evidence should not others have questioned the role of health pro- be construed to suggest that torture did not fessionals in torture; doctors in interrogations occur, since such acts of violence against persons ‘provide a moral shield that confers the aura of frequently leave no marks or permanent scars respectability on practices that may involve (Paragraph 161)’. torture’.16 The WMA promotes the dissemination of the All medical complicity in torture, whether Istanbul Protocol and training of physicians on active or passive, fundamentally violates medical the identification of different modes of torture, in ethics and human rights law. Medical ethical recognizing physical and psychological symptoms codes prohibit health professionals assisting in

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torture. These have a basis in the hippocratic oath Agency-employed doctors were present in Guan- and the principle of ‘do no harm’, and in more tanamo to monitor methods of torture including recent years include the Nuremberg Code which water boarding and shackling.20 The report con- emerged from the trials of Nazi doctors, and the cluded that ‘the alleged participation of health WMA declarations of Geneva and Tokyo. In personnel in the interrogation process and, either March 2009, a resolution was passed by the directly or indirectly, in the infliction of ill- United Nationals Humans Rights Council on the treatment constituted a gross breach of medical role and responsibility of medical and other ethics and, in some cases, amounted to partici- health professionals in ‘torture and other cruel, pation in torture and/or cruel inhuman or degrad- inhuman or degrading treatment or punish- ing treatment’. ment’.17 A BMJ article stated the importance of In the UK, Medical Justice have documented the resolution targeting states, urging them to act the failure of ‘Rule 35’, the detention centre rule to prevent health workers from becoming that should ensure vulnerable people, including involved in torture and to protect those who torture victims, are not detained.21 Medical stand out against it.18 The UN special rapporteur Justice also reports on the inadequate documen- on torture examines international practice relating tation of torture by health professionals working to torture in any state and reports to the UN Com- in detention centres and subsequent lack of appro- mission on Human Rights. The 2009 resolution priate treatment. Medact’s recent report ‘Prevent- tasks the special rapporteur on torture to give ing Torture’22 addresses the gap between the special attention to medical complicity in torture. ethical codes and medical practice. The report It is vital that national and international gives recommendations to National Medical medical organizations recognize and prevent Associations and the WMA on how they can medical complicity in torture. Although many of work more effectively towards eliminating these organizations endorse the ethical codes torture, both through the support they give and human rights instruments that prevent members and in their response to medical compli- medical complicity, only few of these organiz- city. Recommendations include education in ations implement action against medical compli- diagnostic skills and ethical duties, access to con- city. In Chile after the end of the Pinochet fidential advice for doctors and a clear referral regime, during which hundreds of citizens were system to the UN special rapporteur. tortured, the Chilean Medical Association investi- Although medical complicity in torture should gated and expelled a number of doctors who were be condemned and prevented, a BMJ editorial involved in torture. In South Africa two doctors reported ‘more doctors abet torture than treat the were punished after failing to treat or report the millions of victims’.23 This view overlooks the injuries of antiapartheid activist Steve Biko, who larger number of health professionals, who are died in police custody from torture-related inju- involved in the prevention of torture, the investi- ries. However, the doctors were only punished gation of torture and the treatment of torture eight years later, during which time the South survivors. African Medical Association failed to respond as it should have done. One result of the pressure from the international campaign was the with- Doctors Treating Torture Survivors drawal of the South African Medical Association in the UK: ‘What to do and know’ from the WMA, to pre-empt their expulsion. Examples of medical complicity in torture and Globally, doctors’ voices can make a difference. the failure of medical organizations to act on this By joining human rights organizations including are not only historical. The PHR report ‘Aiding Amnesty, Medact and PHR, doctors can Torture’ called for an independent investigation advocate for the prevention of torture. The WMA into the role of health professionals (doctors encourages medical associations and other and psychologists) in known instances of torture health professionals to participate in the OPCAT in prisons holding terrorist suspects.19 This process in order to ensure: the ratification of the report made use of a leaked document from protocol by their country, and the participation the ICRC, which claimed Central Intelligence of health professionals in the national preventative

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mechanisms to address health issues related to torture and the impact of detention. Box 4 In the UK, doctors can volunteer for organiz- Points for medical reports ations working with torture survivors and receive training from them (e.g. Medical Justice • Clinicians qualifications • Statement regarding veracity of testimony [www.medicaljustice.org.uk], Freedom from • Documents reviewed, e.g. Statement of Evidence Form Torture [www.toturecare.org.uk] and the Helen • History, including details of alleged torture Bamber Foundation [www.helenbamber.org]). As • Physical and psychological examination • Appropriate investigations, results, photos of injuries well as the Istanbul Protocol, there are other • Diagnosis guidelines on documentation of torture and • Interpretation of the relationship between the physical and working with torture survivors.24– 27 The Human psychological findings and reported torture (Paragraph 187 Istanbul Protocol) Rights Foundation of Turkey published an illus- (a) Not consistent: the lesion could not have been caused trated ‘Atlas of Torture’, which is an excellent by the trauma described resource.28 (b) Consistent with: the lesion could have been caused by the trauma described but it is non-specific and there are Many torture survivors in the UK will be many other possible causes asylum seekers or refugees. They are entitled to (c) Highly consistent: the lesion could have been caused by register with a GP and access all National the trauma described and there are few other possible causes Health Service services. Asylum seekers who (d) Typical of: this is an appearance that is usually found have had their case rejected and are at the end with this type of trauma but there are other possible of the appeal process may also be entitled. causes (e) Diagnostic of: this appearance could not have been Torture survivors can have complex needs and caused in any way other than that described may require a package of treatment including • Conclusion and recommendations medical care (for both physical and mental health needs); physiotherapy, counselling and (For further information see Annex IV Istanbul Protocol) psychotherapy. For many torture survivors’ packages of treatment should also include legal services; practical help with basic needs (food, shelter and language lessons); further social care ‘although retelling the trauma story for reframing and integration, including living skills, building and reworking has been a central tenet in treat- networks, education and employment training. ment, recovering memories of the torture must It is essential not to underestimate the time be done in a safe setting, with the appropriate taken to assess needs and implement a good timing and with acknowledgment of cultural vari- package of treatment, and important to effectively ations in the expression and interpretation of these coordinate with other professionals involved; memories. If done within a therapeutic setting, including GPs, legal aides and refugee organiz- this can lead to anxiety reduction and cognitive ations. Redress, a human rights organization change … in some therapies the torture story is that helps torture survivors obtain justice, is a transformed into a testimony, to transform the good source of legal information for both survivor’s story of shame and humiliation into a health professionals and torture survivors public story about dignity and courage, returning (www.redress.org). meaning to life’.30 Records of testimonies can Testimonies can be used for MLR, to direct pre- also provide valuable evidence of the types and ventive efforts and can have a therapeutic effect. context of torture, which can direct preventive Doctors may receive a request from a legal repre- efforts.31 sentative to provide an MLR on an asylum If an MLR on a torture survivor is requested, it seeker who has a history of torture, and use of is important to provide the torture survivor with a the Istanbul Protocol can guide this report clear explanation of the doctor’s role, responsibil- (Box 4). Torture survivors sometimes find that ities and the examination procedures. It is also the giving of testimony and the pursuit of justice necessary to gain informed consent and explain is as important to them as physical and mental to the torture survivor the extent of the confidenti- rehabilitation and can have a healing effect.29 ality and who can have access to his/her case file. Quiroga and Jaranson’s review found that Working with professional interpreters, meeting

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needs (e.g. female patients often prefer female and the treatment of survivors of torture. In the interpreters) is crucial, as is avoiding interpret- UK, doctors see torture survivors, many of ation by family or friends, for confidentiality, whom are asylum seekers, and not only provide quality of interpretation and explanation of direct treatment of their medical and psychologi- relevant socio-cultural facts. cal health needs, but may coordinate complex When documenting, one should not assume packages of care and be requested to write MLR. that memory inconsistencies mean the history is Medical schools, postgraduate deaneries and falsified. Research on memory shows that discre- medical royal colleges need to do more to ensure pant accounts can be reconstructed from autobio- promotion of existing guidelines on both the docu- graphical memories in the general population and mentation of torture and work with torture survi- in the case of torture survivors, the normal vari- vors, and to support further training. Joint ation in memory may be exacerbated.32,33 It may training with legal professionals, asylum case- be difficult for the survivor to discuss their workers and human rights organizations could history of torture in the first interview; time since ensure more effective practice that prevents the torture may give rise to confusion over dates; torture and provides a rapid and effective they may not wish to disclose details that they treatment where needed. view as politically sensitive or that may endanger them or others further; and the memory impair- ment could be due to a mental disorder, such as References depression, or a physical disorder, such as post- 1 See http://archive.amnesty.org/air2008/eng/Homepage. head injury. In one study of Kosovan and html (last accessed 30 May 2012) 2 See http://www.irct.org/ (last accessed 30 May 2012) Bosnian asylum seekers autobiographical mem- 3 Asylum, a thermatic investigation of the detained fast ories, those with high levels of post-traumatic track. See http://icinspector.independent.gov.uk/ stress were more likely to give inconsistent wp-content/uploads/2012/02/Asylum_A-thematic- accounts if they had to wait a long time between inspection-of-Detained-Fast-Track1.pdf (last accessed 1 March 2012) interviews, and more likely to be inconsistent 4 Nathanson V. Editorials. Doctors and torture. BMJ with details they rated as peripheral to their 1999;319:397–8 experience.33 The use of a safe environment, suffi- 5 Basoglu M. Editorial. Rehabilitation of traumatised 333 cient time and scheduling repeat appointments refugees and survivors of torture. BMJ 2006; :1230 6 Stein DJ, Seedat S, Iversen A, Wessely S. Post-traumatic enables trust to be built. The history can be stress disorder: medicine and politics. Lancet checked with other available documents and any 2007;369:139–44 discrepancies discussed with the torture survivor 7 Bond M. Wanted: interrogation that works and isn’t torture. New Scientist 28 August 2009 to seek their explanation. 8 See http://www.fas.org/irp/dni/educing.pdf Clinicians need up-to-date knowledge of the (last accessed 1 March 2012) various protocols, skills to ensure their assess- 9 Steel Z, Chey T, Silove D, Marnane C, Bryant RA, ments and reports are of the highest standard, van Ommersen M. Association of torture and other potentially traumatic events with mental health outcomes and the courage to not turn a blind eye and be among populations exposed to mass conflict and complicit, however far removed, from acts of displacement: a systematic review and meta-analysis. torture by state or non-state organizations. JAMA 2009;302:537–49 10 Porter M, Haslam N. Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons, a meta-analysis. Conclusion JAMA 2005;294:602–12 11 See http://treaties.un.org/Pages/ViewDetails.aspx? Torture remains a common practice globally. src=TREATY&mtdsg_no=IV-9&chapter=4&lang=en National and international medical organizations, (last accessed 01 2012) 12 See http://treaties.un.org/Pages/ViewDetails.aspx? in partnership with others, need to aid implemen- src=TREATY&mtdsg_no=IV-9-b&chapter=4&lang=en tation of the codes and instruments prohibiting (last accessed 01 March 2012) torture and address medical complicity. Medical 13 Istanbul Protocol. Manual on the effective investigation bodies can also support more doctors to get and documentation of torture and other cruel, inhuman or degrading treatment or punishment 2001. involved in international advocacy and prevention See www.ohchr.org/Documents/Publications/ campaigns, the investigation of alleged torture training8Rev1en.pdf

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