a) Cigarette burns - Circular or ovoid; 0.6-1.2 cm diameter. Often but not always pale centre, hyper-pigmented edge.
b) Lacerations: Signs of infection (e.g. wide, irregular scarring). Were they sutured? (Are other lesions sutured?) E.g. does absence of stitch marks suggest they were inflicted in circumstances (such as detention) where medical assistance unavailable.
c) Head injury: Scalp scars? History of unconsciousness. Persisting neurological damage (esp grand mal and partial seizures, common after blunt head injury). How does this intersect with psychiatric issues?
d) Maxillo-facial: Missing teeth, zygomatic fractures, infraorbital nerve (Vb) impairment, TM joint damage.
e) Falaka: typical history of swelling up to 3+/52, residual patchy hyper-pigmentation of sole of foot, tender over MT heads or heel, possible pain on weight-bearing or walking limitations (similar to claudication), collapse of plantar arch, lymphoedema
f) Gun shot and shrapnel: entry and exit wounds/ high and low velocity injuries.
g) Rape: Late disclosure is common. Only ~5% of cases have vaginal or other persisting genital injury. Human bites / stab wounds to thighs etc more common. Anal rape commonly creates persisting fissure. See Bögner et al 2007 ; Cohen 2001 ; Peel, 2004 .
h) FGM: varying grades; sometimes not disclosed.
i) Post-inflammatory hyper-pigmentation. Common in dark skinned people. Follows blunt trauma without break in epithelium; ? due to over-stimulation of melanocytes by products of resorbing haematoma. See Peel, 2003 .
j) Electrocution: rarely leaves signs, esp. on genitals; occasionally tiny burns, but may also have scars from crocodile clips.
k) Ears and eyes: Barotrauma can → perforated eardrums. Photo-trauma can → epiphora in bright light. See Polat, 2010 .
l) Suspension: (Palestinian hanging) rotator cuff > brachial plexus injuries
m) Restraint injuries: (old or new) partial annular abrasions, hyperpigmentation or scars, Tinnel’s sign, cervical pain and nerve signs.
Some points to consider:
1) Clinical assessment
You should relate the history to the examination findings, describing both with as much precision as is possible and giving an opinion about each lesion. For example:
History: “she states she was beaten by armed police wielding truncheons at a demonstration, and sustained a severe bruise to the right thigh before being arrested”
i. Does the history of recovery (such as swelling of the feet after falaka for days or weeks) support the statement that torture occurred?
ii. A plausible description of treatment of serious injuries may support claim, as may contemporaneous medical notes (rare) or subsequent investigations.
Examination: ”there is an area of dark pigmentation measuring 1.5x4 cm over the outer aspect of the middle of the right thigh.”
i. If unsure about lesions, take digital photos (see DSO 11/2007 ) including the face in at least one for ID purposes and get written permission to share them.
Opinion: “the area of hyper-pigmentation over the right thigh is consistent with a contusion with a truncheon as described by her”
i. If appropriate, give prognosis and make recommendations for referral or treatment.
ii. The Istanbul Protocol gives confidence levels for attribution of causation as used in opinions. The terminology is worth using and citing.
iii. The standard of proof in most immigration cases is “a reasonable likelihood.” The more lesions of independent causation found on examination, the LESS likely it is that the person was NOT tortured.
Example Opinion: to be updated “Lesion E2 is typical of a cigarette burn.” “Lesion E3 is highly consistent with a stab wound inflicted by a bayonet; the fact that it displays no evidence of surgical repair supports the contention that it was inflicted under conditions such as detention, where medical assistance as not available.” “My overall assessment is that - from the evidence available to me - there is a reasonable likelihood that this person has suffered torture.”
2) Previous assessments
i. If the person is in detention, check the notes. Was the “torture question” asked during the long admission clerking? Is the correct box ticked? Was any effort made to examine the patient? Was a report sent to BIA?
ii. If the person is in detention, if is very likely that an immigration officer (fast track) and/or an immigration judge (at end of process) has discredited their statement about torture. The legal documents are worth reading because they show what would need to be challenged in this area.
iii. Read the “reasons for refusal” from IO or “determination and reasons” by IJ. Have they made unwarranted medical assumptions?
iv. Where there may be useful information in GP or hospital notes, or a discussion with previous clinicians is indicated, get written detainee permission to obtain them and fax this to the relevant doctor. You may also need written authorisation to reveal otherwise confidential information, e.g. to the BIA, especially if there is no lawyer.
3) Writing your report
i. Cite references (see over) and if necessary attach the whole document.
ii. Do NOT overstate; never write anything you would not be prepared to defend in court. A lesion the person does not attribute to torture may support their credibility, but don’t use that word - judges claim they are the sole arbiters of credibility.
iii. Do not worry about being challenged by another doctor employed by the Home Office; the IO or IJ will be likely to seek ways to discredit your evidence. These findings are often bizarre and worth contesting.
4) After your visit
Keep a record of outcomes through continuing contact with the patient, the case coordinator of their lawyer. (Was the patient released, given leave to remain, successful in a civil claim?) Learn from this, but remember: you have not failed if the person does not get leave to remain or is removed.
Psychological Consequences of Torture
Assaults on removal and handcuff injuries
Istanbul Protocol: The Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment.
“186)…(b) Consistent with: the lesion could have been caused by the trauma described, but it is non-specific and there are many other possible causes;
(c) Highly consistent: the lesion could have been caused by the trauma described, and there are few other possible causes;
(d) Typical of: this is an appearance that is usually found with this type of trauma, but there are other possible causes;
(e) Diagnostic of: this appearance could not have been caused in any way other than that described…..
187. Ultimately, it is the overall evaluation of all lesions and not the consistency of each lesion with a particular form of torture that is important in assessing the torture story.” nb PTSD is an independent lesion.
Arnold F. The wounds and scars of torture. Bulletin of the European Tissue Repair Society
2007; 14/3:51 www.etrs.org
Bögner D, Herlihy J and Brewin CR Impact of sexual violence on disclosure during Home Office interviews. British Journal of Psychiatry 191, 75-81: 2007
Cohen J. Errors of Recall and Credibility: Can Omissions and Discrepancies in Successive Statements Reasonably be Said to Undermine Credibility of Testimony? Medico- Legal Journal, 69 (1): 25-34, 2001
Peel M (ed). Rape as a form of Torture
Medical Foundation for the care of Victims of Torture. London, 2004.
Peel M et al. Postinflammatory hyperpigmentation following torture.
Journal of Clinical Forensic Medicine 2003; 10: 193-6.
Peel M, Lacopino V,. The medical documentation of torture. Greenwich medical media. London 2002 .
Polat J, Feinberg E, Crosby SS, 2010, Ocular manifestations of torture: solar retinopathy as a result of forced solar gazing, British Journal of Ophthalmology, 94:1406-1407 doi:10.1136/bjo.2009.171595 http://bjo.bmj.com/content/94/10/1406.extract
Last Updated on Wednesday, 12 January 2011 22:41