Decisions to refer clients for medico-legal reports frequently require quasi-clinical judgements by lawyers. Even the most experienced lawyers can sometimes find this problematic. See:
Wilson-Shaw L, Pistrang N, Herlihy J. Non-clinicians’ judgments about asylum seekers’ mental health. European Journal of Psychotraumatology 2012, 3: 18406
Istanbul Protocol Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment UNITED NATIONS New York and Geneva, 2004
Some Potential Clinical Indicators of Torture
It is important to recognise that not all forms of torture and ill-treatment leave physical evidence:
“… the absence of … physical evidence should not be construed to suggest that torture did not occur, since such acts of violence against persons frequently leave no marks or permanent scars.” Paragraph 161, Istanbul Protocol.
“It is important to recognize that not everyone who has been tortured develops a diagnosable mental illness. However, many victims experience profound emotional reactions and psychological symptoms. The main psychiatric disorders associated with torture are PTSD and major depression. While these disorders are present in the general population, their prevalence is much higher among traumatized populations. “ Paragraph 236, Istanbul Protocol.
“Under [certain] circumstances, the inability to recall precise details supports, rather than discounts, the credibility of the survivor’s story.” Paragraph 253, Istanbul Protocol
“Psychological evaluations can provide critical evidence of abuse among torture victims for several reasons: torture often causes devastating psychological symptoms, torture methods are often designed to leave no physical lesions and physical methods of torture may result in physical findings that either resolve or lack specificity.” Paragraph 260, Istanbul Protocol
Psychological Indicators of Torture:
- Depressed mood, anhedonia, fatigue, difficulty paying attention, poor concentration
- Sleep disturbance (insufficient/interrupted);
- Flashbacks (like watching a movie, visual, tactile, and olfactory)
- Other memory disturbance such as intrusive memories, nightmares, and the inability to recall important aspects of the trauma
- Witnessed absences
- Panic attacks (palpitations, chest pain, breathing problems, tremor, sweating…..)
Physical Indicators of Torture
- Scars, wounds, fractures, deformities and other lesions may strongly agree with given history of relevant injury.
Non-scarring physical injuries and their medical consequences may also be indicators of torture. Examples: falaka,.handcuff injury, post-concussion syndromes (significant blunt head trauma – may interact with PTSD)
Pre-existing medical notes (GP, IRC, hospital) may hold crucial information, as may descriptions of medical care (if any in the days and weeks after injury