International Protocol for Documentation of Torture (Istanbul Protocol)

Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (The Istanbul Protocol) Submitted to the: United Nations High Commissioner for Human Rights August 9, 1999 PARTICIPATING ORGANIZATIONS: Action for Torture Survivors (HRFT), Geneva Amnesty International, London Association for the Prevention of Torture, Geneva Behandlungszentrum fuer Folteropfer Berlin, Berlin British Medical Association, London Center for Victims of Torture, Minneapolis Center for the Study of Society and Medicine, Columbia University, New York Center for Research and Application of Philosophy and Human Rights, Hacettepe University, Ankara Centre G. Devereux, University of Paris, Paris Committee Against Torture, Geneva Danish Medical Association, Copenhagen Department of Forensic Medicine and Toxicology, University of Colombo, Colombo Dokuz Eylül Medical Faculty, Ethics Department, Izmir Gaza Community Mental Health Programme, Gaza German Medical Association Human Rights Foundation of Turkey (HRFT), Ankara Human Rights Watch, New York Indian Medical Association and the IRCT, New Delhi Indochinese Psychiatric Clinic, Boston Institute for Global Studies, University of Minnesota, Minneapolis Instituto Latinoamericano de Salud Mental, Santiago Inter-American Institute of Human Rights, Program for the Prevention of Torture, San José International Committee of the Red Cross, Geneva International Federation of Health and Human Rights Organizations, Amsterdam International Rehabilitation Council for Torture Victims (IRCT), Copenhagen Johannes Wier Foundation, Amsterdam Lawyers Committee for Human Rights, New York Medical Foundation for the Care of Victims of Torture, London Physicians for Human Rights-Israel, Tel Avi v Physicians for Human Rights-Palestine, Palestine Physicians for Human Rights-USA, Boston Society of Forensic Medicine Specialists, Istanbul Survivors International, San Francisco Trauma Centre for Survivors of Violence and Torture, Cape Town Turkish Medical Association, Ankara United Nations Special Rapporteur on Torture, Geneva World Medical Association, Ferney-Voltaire 1 CONTENTS Page I. INTRODUCTION 6 II. RELEVANT INTERNATIONAL LEGAL STANDARDS 9 A. International Humanitarian Law 9 B. United Nations 9 1. Legal Obligations to Prevent Torture 10 2. Bodies and mechanisms 11 2a) Committee Against Torture (CAT) 11 2b) Human Rights Committee 12 2c) Commission on Human Rights 12 2d) Special Rapporteur on Torture 13 2d) Special Rapporteur on Violence Against Women 13 C. Regional Organizations 14 1. Inter-American Commission on Human Rights and Inter-American Court on Human Rights 14 2. European Court and European Commission of Human Rights 15 3. The European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) 17 4. African Commission on Human and People’s Rights 17 D. International Criminal Court 18 III. RELEVANT ETHICAL CODES 19 A. Ethics of the Legal Profession 19 B. Health Care Ethics 19 1. UN Statements Relevant to Health Professionals 20 2. Statements from International Professional Bodies 20 3. National Codes of Medical Ethics 21 C. Principles Common to all Codes of Health Care Ethics 21 1. Duty to Provide Compassionate Care 21 2. Informed Consent 22 3. Confidentiality 23 D. Health Professionals with Dual Obligations 23 1. Principles Guiding All Doctors with Dual Obligations 24 2. Dilemmas Arising from Dual Obligations 24 IV. LEGAL INVESTIGATIONS OF TORTURE 26 A. Introduction 26 B. Purposes of a Torture Investigation 26 C. Principles on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment 27 D. Procedures of a Torture Investigation 28 1. Determination of Appropriate Investigative Body 28 2. Interviewing the Alleged Victim and Other Witnesses 29 2a) Informed consent and other protections for the alleged victim 29 2b) Selection of the investigator 29 2c) Context of investigation 30 2d) Safety of witnesses 31 2e) Use of interpreters 31 2f) Information to be obtained from the person alleged to have been tortured 31 2g) Statement from the person who is alleging torture 32 2h) Alleged perpetrator’s statement 32 3. Securing and Obtaining Physical Evidence 32 4. Medical Evidence 34 5. Photography 34 E. Commission of Inquiry 34 1. Defining the Scope of the Inquiry 34 2. Power of the Commission 35 2 3. Membership Applications 35 4. Number of Commissioners 35 5. Choosing a Commission Counsel 35 6. Choosing Expert Advisors 35 7. Choosing Investigators 36 8. Protection of Witnesses 36 9. Proceedings 36 10. Notice of Inquiry 36 11. Receipt of Evidence 36 12. Rights of Parties 36 13. Evaluation of Evidence 37 14. The Report of the Commission 37 15. Response of the State 37 V. GENERAL INTERVIEW CONSIDERATIONS 38 A. Introduction 38 B. Purpose of Inquiry, Examination and Documentation 38 C. Procedural Safeguards with Respect to Detainees 38 D. Official Visits to Detention Centres 40 E. Techniques of Questioning 41 F. Taking the History 41 1. Psychosocial History, Pre-arrest 41 2. Summary of Detention(s) and Abuse 41 3. Circumstances of Detention(s) 42 4. Prison/Detention Place Conditions 42 5. Methods of Torture and Ill Treatment 42 G. Assessment of the History 43 H. Review of Torture Methods 43 I. Risk of Retraumatisation of the Interviewee 44 J. Use of Interpreters 45 K. Gender Issues 46 L. Indications for Referral 46 M. Interpretation of Findings and Conclusions 46 VI. PHYSICAL EVIDENCE OF TORTURE 48 A. Introduction 48 B. Interview Structure 48 C. Medical History 49 1. Acute Symptoms 49 2. Chronic Symptoms 49 3. Summary of Interview 50 D. Physical Examination 50 1. Skin 50 2. The face 50 2a) Eyes 51 2b) Ears 51 2c) The nose 51 2d) Jaw, oropharynx and neck 51 2e) Oral cavity and teeth 51 3. Chest and Abdomen 51 4. Musculoskeletal System 52 5. Genitourinary System 52 6. Central/Peripheral Nervous System 52 E. Examinations and Evaluations Following Specific Forms of Torture 52 1. Beatings and Other Forms of Blunt Trauma 53 1a) Skin damage 53 1b) Fractures 54 1c) Head trauma 55 1d) Chest and abdominal trauma 55 2. Beatings of the Feet (Falanga, Falaka, Bastinado) 55 3. Suspension 57 3 4. Other Positional Torture 58 5. Electric Shock Torture 58 6. Dental Torture 59 7. Asphyxiation 59 8. Sexual Torture Including Rape 59 8a) Review of symptoms 60 8b) Examination following a recent assault 60 8c) Examination after the immediate phase 61 8d) Follow-up 62 8e) Genital examination of females 62 8f) Genital examination of males 63 8g) Examination of the anal region 63 F. Specialised Diagnostic Tests 64 VII. PSYCHOLOGICAL EVIDENCE OF TORTURE 65 A. General Considerations 65 1. Central Role of the Psychological Evaluation 65 2. Context of the Psychological Evaluation 66 B. Psychological Consequences of Torture 66 1. Cautionary Remarks 66 2. Common Psychological Responses and Symptoms 66 2a) Re-experiencing the trauma 66 2b) Avoidance and emotional numbing 67 2c) Hyperarousal 67 2d) Symptoms of depression 67 2e) Damaged self-concept and foreshortened future 68 2f) Dissociation, depersonalisation and atypical behavior 68 2g) Somatic complaints 68 2h) Sexual dysfunction 68 2i) Psychosis 68 2j) Substance abuse 69 2k) Neuropsychiatric impairment 69 3. Diagnostic Classifications 69 3a) Depressive disorders 69 3b) Posttraumatic stress disorder 70 3c) Enduring personality change 70 3d) Substance abuse 71 3e) Other diagnoses 71 C. The Psychological/Psychiatric Evaluation 72 1. Ethical and Clinical Considerations 72 2. Interview Process 72 3. Components of the Psychological/Psychiatric Evaluation 75 3a) Introduction 75 3b) History of torture and ill treatment 75 3c) Current psychological complaints 76 3d) Post-torture history and description of current circumstances 76 3e) Pre-torture history 76 3f) Medical history 77 3g) Past psychiatric history 77 3h) Substance use and abuse 77 3i) Mental status exam 77 3j) Assessment of social function 77 3k) Psychological testing and the use of checklists and questionnaires 78 3l) Clinical impression 78 3m) Recommendations 79 4. Neuropsychological Assessment 79 4a) Limitations of neuropsychological assessment 79 4b) Indications for neuropsychological assessment 80 4c) Conclusion 83 5. Children and Torture 83 5a) Introduction 83 4 5b) Developmental considerations 83 5c) Clinical considerations 84 5d) Role of the family 84 APPENDIX I: Principles on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment 85 APPENDIX II: Diagnostic Tests 87 1. Radiologic imaging 87 2. Biopsy of electric shock injury 88 APPENDIX III: Anatomical Drawings for the Documentation of Torture 91 APPENDIX IV: Guidelines for Medical Evaluations of Torture and Ill Treatment 99 5 I. INTRODUCTION Torture is defined in this Manual according to the United Nations Convention Against Torture, 1984: Torture means 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 information or a confession, punishing him for an act he or a third person has committed or is suspected of havi ng committed, or intimidating or coercing him or a third person for any reason based on discrimination of any kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity. It does not include pain or suffering arising only from, inherent in

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