MODULE 4 Prevention through Documentation Project

1. MODULE 4Prevention through Documentation Project Torture Methods and Medical Consequences 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 Türkcan Baykal MD, Human Rights Foundation of Turkey Caroline Schlar, PhD, Human Rights Foundation of Turkey, Emre Kapnın, Human Rights Foundation of Turkey Kathleen Allden, MD, Indochinese Psychiatric Clinic PtD Project (IRCT, HRFT, REDRESS, PHR)

2. Module 4 Outline • Subjective element of suffering • Torture methods • Psychological consequences of torture PtD Project (IRCT, HRFT, REDRESS, PHR)

3. The Subjective Element of Suffering • Take into consideration individual factors: • Gender • Religion • Physical and psychological condition • Age • Meaning of experiences affects degree of suffering PtD Project (IRCT, HRFT, REDRESS, PHR)

4. Beating • Most common method of physical torture • Practiced with or without instruments • Impacts may cause • Abrasions • Lacerations • Contusions • Hematoma • Internal bleeding • Perpetrators may: • wait for signs to resolve prior to remanding to judicial custody • Attempt to limit evidence using barriers (ie blanket) PtD Project (IRCT, HRFT, REDRESS, PHR)

5. Beatings PtD Project (IRCT, HRFT, REDRESS, PHR)

6. A prisoner is being hit with a sandbag hanging in a rope PtD Project (IRCT, HRFT, REDRESS, PHR)

7. Beating Beating using a metal cable in South Africa PtD Project (IRCT, HRFT, REDRESS, PHR) [Courtesy of Physicians for Human Rights.]

8. Falanga [Courtesy of the Human Rights Foundation of Turkey.] PtD Project (IRCT, HRFT, REDRESS, PHR)

9. Falanga Falanga [Amnesty International] This photo was taken one week after falanga PtD Project (IRCT, HRFT, REDRESS, PHR)

10. Acute Symptoms and Signs PtD Project (IRCT, HRFT, REDRESS, PHR) The immediate effect of falanga is bleeding and oedema in the soft tissues of the feet, as well as severe pain changes are confined to the soft tissues: Swelling of the feet, discoloration of the soles due to haematoma formation and various degrees of skin lesions are typical and diagnostic findings

11. PtD Project (IRCT, HRFT, REDRESS, PHR) Extensive ulcerations and gangrene of toes due to ischaemia have been described, but are not common Fractures of tarsals, metatarsals and phalanxes are described as occurring occasionally. The acute changes disappear spontaneously within weeks, as the oedema and extravasation of blood resolve, but the induced soft tissue lesions may be permanent

12. Symptoms and Signs in the Chronic Phase PtD Project (IRCT, HRFT, REDRESS, PHR) The majority of torture victims submitted to falanga complain of pain and impaired walking The cardinal symptom is pain in the feet and calves, and two types of pain are usually present:

13. PtD Project (IRCT, HRFT, REDRESS, PHR) 1. A deep, dull cramping pain in the feet, which intensifies with weight bearing and muscle activity spreading up the lower legs A superficial burning, stinging pain in the soles, often accompanied by sensory disturbances and frequently also a tendency for the feet to alternate between being hot and cold, suggestive of autonomic instability

14. PtD Project (IRCT, HRFT, REDRESS, PHR) 2. Because of the pain, walking is impaired in most falanga victims Walking speed and walking distance are reduced Typically, the torture victim is only able to walk a limited distance, during which the pain will increase and make continued muscle activity impossible At rest, the pain subsides and the victim can resume walking.

15. Ear Trauma Bleeding associated rupture of the tympanic membrane following blunt trauma to the ear. [Courtesy of the Human Rights Foundation of Turkey.] PtD Project (IRCT, HRFT, REDRESS, PHR)

16. PtD Project (IRCT, HRFT, REDRESS, PHR) Trauma to the ears, especially rupture of the tympanic membrane (eardurm), is a frequent consequence of harsh beatings The ear canals and tympanic membranes should be examined with an otoscope and injuries described A common form of torture, known in Latin America as telefono, is a hard slap of the palm to one or both ears, rapidly increasing pressure in the ear canal, thus rupturing the drum

17. PtD Project (IRCT, HRFT, REDRESS, PHR) There is often tinnitus for a while Attacks of otitis media may supervene Deafness usually gradually improves as the drum repairs itself Very occasionally there is dislocation of the ossicles which will cause permanent loss of hearing

18. PtD Project (IRCT, HRFT, REDRESS, PHR) Even more rarely, a perilymph fistula my lead to vertigo Few of the long-term signs are specific to torture, but a careful history may make the differentiation from disease possible and an expert may be able to differentiate a perforation resulting from trauma from one caused by infection

19. PtD Project (IRCT, HRFT, REDRESS, PHR) Prompt examination is necessary to detect tympanic membrane ruptures less than 2 millimetres in diameter, which may heal within 10 days Fluid may be observed in the middle or external ear. If otorrhea (leaking middle ear fluid) is confirmed by laboratory analysis, MRI or CT should be performed to determine the fracture site

20. PtD Project (IRCT, HRFT, REDRESS, PHR) The presence of hearing loss should be investigated, using simple screening methods If necessary, audiometric tests should be conducted by a qualified audiometric technician The radiographic examination of fractures of the temporal bone or disruption of the ossicular chain is best determined by CT, then hypocycloidal tomography and, lastly, linear tomography.

21. Eye Trauma Blunt trauma to the right orbit showing a periorbital contusion and conjunctival haemorrhage. [Courtesy of the Human Rights Foundation of Turkey.] PtD Project (IRCT, HRFT, REDRESS, PHR)

22. PtD Project (IRCT, HRFT, REDRESS, PHR) Direct trauma to the eye is very common, either incidental to general beating about the head or else intentionally aimed There may be conjunctival or retinal haemorrhage, dislocation of the lens or detachment of the retina Torturers may force their victims to look at the sun or bright lights for long periods.

23. PtD Project (IRCT, HRFT, REDRESS, PHR) Conversely, detainees may be kept for months or years in total darkness Survivors often complain long afterwards of lachrimation (tearing) and photophobia (light sensitivity) However, such cases do not show any detectable physical abnormality and treatment is purely symptomatic

24. Positional torture An illustration of “Shabeh” PtD Project (IRCT, HRFT, REDRESS, PHR) [From the B’TSELEM Human Rights Report, 1998.]

25. Shabehis a combination of interrogation methods including tying detainees to a small slanted chair, placing an often filthy sack over their heads, exposing them to loud music and sometimes to extremes of temperature, and prevention of sleep PtD Project (IRCT, HRFT, REDRESS, PHR)

26. In shabeh the victim is shackled for hours to a low chair whose front legs have been shortened so that the detainee must constantly struggle to avoid sliding off • Shabeh is usually combined with methods of abuse, i.e. placing an often filthy sack over the victim’s head, exposing him or her to loud music and sometimes to temperature extremes and sleep deprivation PtD Project (IRCT, HRFT, REDRESS, PHR)

27. Restraint, Shackling and Positional Torture • Characteristically, these forms of torture leave fewexternal marks or radiological findings, despite subsequent chronic disability. • Handcuffs, wrist or ankle ties leave no mark if applied properly • The use ofleg irons is widespread in police stations and prisons • Many forms of positional torture, all of which tie or restrain the victim in contorted, hyperextended or other unnatural positions PtD Project (IRCT, HRFT, REDRESS, PHR)

28. PtD Project (IRCT, HRFT, REDRESS, PHR) Some degree of restraint is clearly necessary and legitimate at the time of arrest or during transfer in order to prevent a detainee from escaping However, once detention has been secured, there can be no legitimate need for artificial restraint

29. PtD Project (IRCT, HRFT, REDRESS, PHR) Cramped or distorted postures or prolonged standing are used routinely in many countries. An example is Israel, where 'moderate physical pressure' is permitted by law. Several techniques have been devised by the General Security Service (Shin Bet) and routinely used to put detainees under undue stress.

30. The tortoise cage Victims is held in cramped confinement; fed with salty food and denied water. PtD Project (IRCT, HRFT, REDRESS, PHR)

31. The Motorcycle The victim is seated on a chair, wrists handcuffed behind the back of the chair. The legs are brought around to the sides, the hips and knees flexed as tightly as possible. Then the legs are raised and put on chairs set on each side of the victim, causing intense pain in the knees. PtD Project (IRCT, HRFT, REDRESS, PHR)

32. The Motorcycle .Further pain is induced by pressing the calves against the thighs. The victim is made to wear a helmet which was hit repeatedly, producing a deafening noise inside. PtD Project (IRCT, HRFT, REDRESS, PHR)

33. In Abu Ghraib Prison PtD Project (IRCT, HRFT, REDRESS, PHR)

34. Fixation to chair, naked and blindfolded. PtD Project (IRCT, HRFT, REDRESS, PHR)

35. Al-shabah The detainee’s hands are tied behind and over the head. In most centres, the bound hands are also tied to pipes or bars, embedded in the wall. The hands are usually fixed so high, that the individual finds it very difficult to stand on his legs, which are also bound. May last from 6-12 hours. The victim is hooded PtD Project (IRCT, HRFT, REDRESS, PHR)

36. Tied in forced position PtD Project (IRCT, HRFT, REDRESS, PHR)

37. Tied in forced position PtD Project (IRCT, HRFT, REDRESS, PHR)

38. Torture Instrument: Thumb cuffs Ref: Amnesty International, 1996 PtD Project (IRCT, HRFT, REDRESS, PHR)

39. Suspension • Common form of torture • produces extreme pain • leaves littlevisible evidence of injury • Examples: • Cross suspension or “crusifixion” • Butchery suspension • Reverse butchery suspension • “Palestinian” suspension • “Parrot perch” suspension PtD Project (IRCT, HRFT, REDRESS, PHR)

40. crusifixion • applied by • spreading • the arms • and tying • them to a • horizontal bar PtD Project (IRCT, HRFT, REDRESS, PHR)

41. Butchery suspension Applied by fixation of hands upwards, either together or one by one PtD Project (IRCT, HRFT, REDRESS, PHR)

42. Reverse butchery suspension Applied by fixation of feet upward and the head downward PtD Project (IRCT, HRFT, REDRESS, PHR)

43. “Palestinian" Hanging Applied by suspending the victim with the wrists or forearms bound together behind the back and tied to a horizontal bar or rope PtD Project (IRCT, HRFT, REDRESS, PHR)

44. “Palestinian” suspension may produce permanent brachial plexus injury in a short period. There is such an unnatural strain on all the muscles and ligaments of the shoulder girdle that one or both shoulders may dislocate. Victims complain for several days afterwards of inability to raise the arms above the head and sometimes of numbness and weakness of the fingers. For years afterwards they may experience pain on raising the arms, lifting weights or combing the hair. On examination there is usually tenderness in the muscles around the shoulders and scapulae and severe pain on passive movements, especially extension and internal rotation of the shoulders PtD Project (IRCT, HRFT, REDRESS, PHR)

45. Winged Scapula “winged” scapula in a torture victim subsequent to prolonged suspension PtD Project (IRCT, HRFT, REDRESS, PHR)

46. PtD Project (IRCT, HRFT, REDRESS, PHR) “Palestinian” suspensionoccasionally causes winging of the scapulae (prominent vertebral border of the scapula) caused by traction on the long thoracic nerve, easily missed unless specially looked for by asking the subject to press against a wall with outstretched arms, and there may be permanent deficit of the lower roots of the brachial plexus, as shown by sensory deficit in an ulnar distribution

47. The Bar or “parrot perch” It has been commonly used in many Latin American countries but is also seen in Africa. The wrists are bound together in front of the body, the arms passed over the knees and a pole thrust behind the knees. PtD Project (IRCT, HRFT, REDRESS, PHR)

48. The result may be rupture of the cruciate ligaments of the knees or sensory or vascular damage below the knees. Victims will often be beaten while suspended or otherwise abused. In the chronic phase, it is usual for pain and tenderness around the shoulder joints to persist, as the lifting of weight and rotation, especially internal, will cause severe pain many years later PtD Project (IRCT, HRFT, REDRESS, PHR)

49. Crushing and Stretch Injuries PtD Project (IRCT, HRFT, REDRESS, PHR)

50. “Cheera” PtD Project (IRCT, HRFT, REDRESS, PHR) is the Punjabi word for tearing. It is the nickname given to a technique common in the North-West of the Indian subcontinent. The victim is seated on the floor, often with an officer behind him with a knee in his back and pulling the head back by the hair. The legs are stretched apart, either suddenly or gradually, until they reach as much as 180 degrees