Torture survivors: What to ask, how to document
These immigrants are as numerous as patients with Parkinson’s disease, but they are unlikely to be forthcoming about their past. Here’s how to proceed.
If a patient answers Yes to a screening question, your responsibility is 2-fold. First, begin compiling a medical record that accurately reflects the patient’s description of torture and the medical findings relevant to those statements. Accurate documentation is important because medical records are used as evidence in hearings to rule on petitions for asylum. Second, refer the patient for proper treatment that can reduce disability, pain, and psychiatric distress.
Assess physical morbidity
Torture survivors’ physical symptoms and signs are as varied16-18 as the methods by which they have been abused.19-21 Let a patient’s complaints and report of the techniques used guide your examination.9,14,15,22,23
Concussive trauma is nearly universally reported. This includes beatings with fists, clubs, and batons. Caning causes horizontal lesions typically on the buttocks and back or sometimes on the backs of the legs. Whipping is typically applied to the back, where it produces downsloping lesions that curl laterally off the trunk.18 Torturers sometimes place layers of cloth over the skin before beatings to minimize incriminating cuts and scars. In men, genital beatings are so common that researchers include them with general beatings rather than categorizing them as sexual torture.24 A third to half of survivors report beatings on the feet, a technique that produces chronic neuralgias and disability from fascial injuries, which can be evaluated by MRI.25-27 Prolonged pain and disability from foot beatings is associated with PTSD. Concussive trauma to ears can produce hearing loss. Deformities or healed fractures may be signs of blunt force trauma. Gunfire into joints leaves bony injuries and metallic fragments.
Suspension, hyperflexion. Many survivors report being suspended by an extremity or digit or forced into positions of extreme hyperflexion, hyperextension, or rotation. A variant of suspension is the use of stress positions such as confinement in a tight box. These techniques often tear ligaments, tendons, nerves, neural plexi, or other soft tissues, or cause subluxations, dislocations (eg, reverse rotation of the shoulder), fractures, or even amputating avulsions.16,28 Careful examination and imaging of joints can detect such bone and soft tissue injuries.
Ligatures, binding, and compression to extremities or genitalia are used to restrain or to cause pain or injury. The long-term sequelae include scars, neuropathies, ligamentous injuries, muscle trauma, and ischemic injuries. Thumbscrews—small vises clamped on fingers, thumbs, or toes—produce destructive compressive fractures and deformities in the distal bones and joints of the fingers or toes.16
Burns, electrical shock, and mutilation by cutting are widely inflicted. Shock is applied to the skin, genitalia, or within body cavities with wires, cattle prods, or electrified grids such as bedsprings. Muscle spasms caused by intra-oral cattle prods can cause jaw dislocations. Intense shocks on the back can cause muscle spasms that result in vertebral compression fractures.16 Although nontherapeutic, biopsies of electrical scars have evidentiary value.18 Teeth are often extracted as a form of mutilation.
Sexual torture is substantially under-reported. Five percent to 15% of male torture survivors report being sexually abused.24,29 Of these, 50% report threats of castration or rape, 33% are raped or forced to perform sex on, or in view of, others, and 10% report genital shocks or mutilation.24,29 Although fewer women than men are tortured, about half of women survivors report sexual torture, usually rape, sometimes in front of family members.30,31 Given the prevalence of rape among female torture survivors, case finding during or before prenatal care may enable a practitioner to desensitize or sedate a woman before using gynecological instruments or techniques like paracervical injections that can trigger PTSD arousal reactions.
Injurious environments. Nearly all torture survivors report being subjected to extremes of heat or cold, a lack of water or food or sanitation or medical care, or crowding, filth, and extreme noise. Some survivors report asphyxia with a dry or wet cloth over the face or by being immersed in water. A few report being given substances that cause dystonia, diarrhea, or loss of consciousness.
Assess psychological morbidity
The distinction between physical and psychological torture is imperfect. Fear of physical violence is a psychological stressor. Psychological torture has physical sequelae such as sexual dysfunction. Psychological torture uses various methods to humiliate, degrade, or cause extreme fear (sham executions, being forced to watch torture), or to isolate or disorient (blindfolding, sleep deprivation) a prisoner.9,15,21 The combination of physical and psychological torture causes severe, chronic psychological morbidity.7 The nature and severity of this morbidity is shaped by the nature of the torture, personal resilience, social supports, stressors in life after torture, and therapy.
