Identifying and reporting ill-treatment Principles of the Istanbul Protocol

1. Identifying and reporting ill-treatmentPrinciples of the Istanbul Protocol Hans Draminsky Petersen, MD, Member of the SPT & the IMAP

2. The Istanbul Protocol, 2004Manual on the Effective Investigation and Documentation of Torture & CIDT • International and regional legal standards, instruments and bodies • Ethical codes, incl. medical: • Compassionate care, moral independence, respect dignity, • Informed consent, • Confidentiality • Dual obligations: Best interest of the patient vs. duty to society /justice: • Legal fundament, no contravention of medical norms, do no harm, • Inform the person! Keep record! • Seek advise and support, e.g. with the Medical Association • Legal investigation of torture • State responsibility and obligation • Independent, prompt and effective, incl. expert health professionals

3. The Istanbul Protocol, 2004Manual on the Effective Investigation and Documentation of Torture & CIDT • The interview in private: • History of social background and pre-detention health • Detention and abuse • Circumstances of detention, place and conditions • Methods of torture and ill-treatment • Immediate reactions and acute symptoms • Sub-acute and chronic symptoms • The physical examination • The psychological assessment

4. The description of the individual lesion • Description: • Localisation and orientation • Single or in groups • Size • Shape • Border • Colour • Surface • Classification: • Bruises, lacerations, incisions /stabs, abrasions,

5. Para-clinical investigations: • Ultrasound, MR, CT, bone scintigraphy • Biopsy of the skin: • Experimental • invasive procedure, requires injection of local anaesthesia, leaves marks • What to do with a negative result • Muscular enzymes, • even without visible lesions and • with forced physical exercise

6. Assessment of the individual lesionas to age and origin • Colour (yellow* /red**), crust, pigmentation, etc • Region of the body, shape, surface, etc • “Not consistent” = not caused by the trauma described • “Consistent with” = non-specific, may have been caused as stated • “Highly consistent” = may have been caused as stated, and there are few other possible causes • “Typical of” = appearance usually found with this type of trauma, but there are other possible causes • “Diagnostic for” = could not have been caused in other way than stated • Could be commented, e.g. • Localised in body regions often exposed to everyday traumas • Remarkable shapes of lesions, evt multiplicity and in groups • *If yellow colour is present: the age of the lesion is at least 18 hours • **If red only: age not more than 48 hours

7. Psychological consequences of torture • Re-experiences of the traumatic event, awake and at sleep • Avoidance of thoughts and activities – incl. talking about torture • Hyper-arousal: • Sleep disturbances • Irritability and outburst of anger, startled responses • Impaired concentration and memory • Depression • Anxiety • Damaged self-concept and foreshortened future • Sexual dysfunction and somatic symptoms • Substance abuse

8. The psychological assessment • Social background • Medical and psychiatric history, incl. substance use and abuse • History of detention, torture and ill-treatment • Current psychological complaints • Current medication and substance abuse • Post-torture history, social situation and functioning, stress factors • Assessment of mental status • Scales and questionnaires?

9. Questions for the psychological assessmentThe Istanbul Protocol • Are psychological findings consistent with alleged torture? • Are psychological findings expected and typical for extreme stress in the given context? • Given the fluctuating course of trauma related mental disorders, what is the time frame in relation to the torture event? • Where is the individual in the course of recovery?* • What are the coexisting stressors impinging on the individual (ongoing persecution, migration, exile? • What impact do these issues have on the individual?** • Which physical conditions contribute to the clinical picture? Head injuries? • Does the clinical picture suggest false allegations? ***

10. Some reservations /caveats • The torture situation is extremely complex and designed to cause more fear and confusion. Observations may be perceived wrongly. • Impaired concentration and memory are common with survivors * • The detainee may have lost consciousness** • Individual elements of the event may be overridden by others • The survivor may not want to talk about all details***: • It may be too painful • It may cause harm to others • may think that seemingly absurd details shall be inferred as fabrications • May fear that torture / rape shall cause stigmatisation or ostracism • + • May explain some discrepancies in statements given to different interviewers

11. Photos • Identical scarification of nails in two individuals, one alleging torture as origin, the other refusing torture

12. The overall conclusion of the expert examination • The degree of consistency between the: • History of torture /ill-treatment - Knowledge of local practices /HR record • The physical symptoms, immediate, intermediate and chronic • The observed physical evidence (or lack of evidence) • The psychological symptoms and signs • (diagnostic tests) • Suggestion for classification: • Beyond any reasonable doubt • High, no reservations and significant corroborative clinical findings • Moderate, some reservations / no or few unspecific corroborative clinical findings • Low, many reservations and no corroborative clinical findings

13. Substantiation of the overall conclusion • Is the history of torture may be qualified as e.g. being detailed and complex and consistent with the general pattern (in the region /country /institution in question) known from other sources (named) • Acute, intermediate and chronic physical and psychological symptoms may be qualified as commonly seen /typical after torture as alleged • The specificity of findings should be mentioned: “Typical”, “diagnostic” • If inconsistencies are deemed insignificant, the reasons should be given • The absence of torture related scars does not contradict the consistency of torture considering the reported methods of torture • Do not be too cocksure, neither in assessment of lesions, nor in rejection of allegations

14. The assessment of the generalist, the doctor in the detention centre, a gatekeepers • Informed consent 1-2 • Brief history of ill-treatment • Physical and psychological symptoms • Physical signs and psychological observations • Opinion as to consistency • Identification of health needs, • Start treatment /refer for further examination /treatment, if appropr • Informed consent 3 • Report to higher authority, incl. the director, who must • protect the complainant against reprisals and • prevent recurrence • Refer to expert examination

15. The assessment of the generalist • A preliminary medical assessment • The basis for referral to expert examination • Often done shortly after ill-treatment, i.e. lesions are still present • While the expert examination may be delayed considerably • The document of the doctor should be part of the case file • Requires high quality, often great space for improvement

16. Study groups

17. Allegations of ill-treatment

18. Allegations of ill-treatmentNumber of documents = examinations

19. Lacking information

20. Quality of conclusions on age and origin of lesions

21. Obligation to report torture and ill-treatment • With informed consent and considering the risk of reprisals • Report to • The director of the institution • Ministry, register • Refer to independent expert examination • Inform detainee about the possibility to address a complaint body or the Ombudsman • Directors obligation: • Initiate inquiry by independent body or General Prosecutor

22. Hierarchy of responsibility

23. Referral to expert examination in accordance with the Istanbul Protocol • The doctor in the detention centre • The doctor in the prison • The personal doctor of the person • The judge • The (doctor of the) NPM • The Ombudsman • + • Informed consent

24. A prompt and impartial investigation • .. competent authorities shall proceed a prompt and impartial investigation to whenever there is reasonable ground to believe that an act of torture has taken place (CAT § 12) • Medical /expert documentation of torture must amount to “reasonable ground”

25. Counter-reactive use of the result of the expert examination • In case that the examiners do not positively document torture the complainant shall be prosecuted for defaming the police (e.g. Mexico, Spain) • (Many) vulnerable persons who have been subjected to TCIDT would hardly run the risk of • another confrontation with the body that committed the torture • A sentence • Which level of consistency in the medical assessment should be the critical cut-off point? If allegations are not convincingly documented to be fabricated* such an approach amounts to judicial reprisals

26. A central register on allegations of tortureRecommended by the UN General assembly, November 11th, 2011 • All cases of alleged torture or ill-treatment, whether documented or not • Cases of multi traumatisation ? Cases where the doctor for other reasons – e.g., presence of multiple symptoms indicating possible exposure to torture?

27. The central register of the ministryFighting impunity and preventing torture • A tool to ensure that allegations of torture are investigated • A tool to give a overview of allegations of torture with a view to identify risk institutions and risk situations - with the aim to remedy risks • Knowing that information, documents have to be read and inferred before filing them would encourage doctors and other local actors to comply with standards set by the ministry • The NPM and the Ombudsman should have access to the register. • No access for police authorities

28. The central register of the ministry • Hour, date and place for alleged torture • Security body implicated, if possible ID of implicated officers • Place of apprehension and detention • Nature of the allegations, forms of torture and reasons for its use • Relevant findings and conclusions of the doctor in the police station. • Most important findings and conclusions of the expert examination • Details of the body that did the criminal /disciplinary inquiry, • The result of the inquiry and any prosecution • The implementation of sanctions

29. Principles for the effective investigation and documentation of TCIDT • Clarification of facts and establishment of individual and state responsibility • Means to prevent recurrence • Facilitation of prosecution and indication of needs for redress and health care • Experts health professionals are part of the investigation team • State responsibilities • investigation is prompt, independent and competent; that resources and powers of investigative body are appropriate • Victims and witnesses are protected • Victims have access to all information and can present other evidence • Agents possibly implicated in TCIDT removed from position of power • Respond to the written report and indicate steps to be taken • With some additional tools and practices the implementation of the Istanbul Protocol will be useful in the prevention of torture

30. Thank you for your attention ?