Introduction

Working with migrants and refugees clearly demonstrates that extreme life experiences clustered around war and different forms of persecution are frequently found in many of the groups encountered. Torture, an act forbidden by numerous international declarations and conventions, such as the United Nations Convention against Torture,^1,2 remains a frequent and destructive form of persecution despite ratification of the Convention by a large number of countries. It has been documented that even children are submitted to torture in many countries.³ Although common, torture cannot be seen as a simple phenomenon, and the sequelae represent a complex challenge for treatment.

Definitions of Torture and Ethics Guidelines for Physicians

Conceptions of torture vary among cultures, legal systems, and organizations. Nevertheless, the essential elements of torture include the following: it is purposeful and systematic; it occurs in captivity, usually face-to-face; and it intends to destroy the victim’s personality through the infliction of psychological or physical suffering.

The UN Convention Against Torture defines in Article 1: ‘For the purposes of this Convention, torture means any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity.’¹ The World Medical Association (WMA) in its declaration of Tokyo offers a similar definition: ‘For the purpose of this Declaration, torture is defined as the deliberate, systematic or wanton infliction of physical or mental suffering by one or more persons acting alone or on the orders of any authority, to force another person to yield information, to make a confession, or for any other reason. The declaration of Tokyo as well as a later WMA declaration underline the duty of physicians not to participate in any such act, but to take an active stance in the fight against torture.’⁴

The importance of an active and responsible role of physicians against torture – prohibited without any exceptions – has been underlined in a recent WMA document.⁵ The same document, referring also to regional documents such as the American Convention on Human Rights in paragraph 19, specifically recommends that ‘National Medical Associations support the adoption in their country of ethical rules and legislative provisions:

19.1 aimed at affirming the ethical obligation of physicians to report or denounce acts of torture or cruel, inhuman or degrading treatment of which they are aware;

19.2 establishing, to that effect, an ethical and legislative exception to professional confidentiality that allows the physician to report abuses, where possible with the subject’s consent, but in certain circumstances where the victim is unable to express him/herself freely, without explicit consent.

19.3 cautioning physicians to avoid putting individuals in danger by reporting on a named basis a victim who is deprived of freedom, subjected to constraint or threat or in a compromised psychological situation.

20. Disseminate to physicians the Istanbul Protocol.

21. Promote their training on the identification of different modes of torture and their sequelae.

22. Place at their disposal all useful information on reporting procedures, particularly to the national authorities, nongovernmental organisations and the International Criminal Court.’⁵

These ethics guidelines support the increasing criticism about attempts of some governments, and physicians in those countries, to justify exceptions. The guidelines also refer to the Istanbul Protocol as the recommended UN standard for documentation of torture: ‘In some cases, two ethical obligations are in conflict. International codes and ethical principles require the reporting of information concerning torture or maltreatment to a responsible body. In some jurisdictions, this is also a legal requirement. In some cases, however, patients may refuse to give consent to being examined for such purposes or to having the information gained from examination disclosed to others. They may be fearful of the risks of reprisals for themselves or their families. In such situations, health professionals have dual responsibilities: to the patient and to society at large, which has an interest in ensuring that justice is done and perpetrators of abuse are brought to justice. The fundamental principle of avoiding harm must feature prominently in consideration of such dilemmas. Health professionals should seek solutions that promote justice without breaking the individual’s right to confidentiality. Advice should be sought from reliable agencies; in some cases this may be the national medical association or non-governmental agencies. Alternatively, with supportive encouragement, some reluctant patients may agree to disclosure within agreed parameters (Istanbul Protocol, paragraph 68).⁶

While the political discussion might at times lead to a blurring of standards,⁷ clear definitions of torture are a key precondition to prevention and legal guidelines, and partly overlapping concepts such as that of organized violence^7,8 can be applied in situations such as the development of treatment programs.

Freedom from torture in this context should be seen as a major factor in healthcare and at the same time as a contribution to a civil society.

It might be noted that trends in perpetrator research – an issue of importance for, among other reasons, prevention – indicate that, especially in mass violence or systematic torture, many torturers are literally the neighbor next door. They may have been mistreated, tortured themselves, or exposed to psychological manipulation, convincing them of the need to torture to protect society or as a moral obligation.⁹

Aims of Torture

Reasons for the use of torture vary. There may be individual motives such as greed, personal cruelty, or monetary gain. In cases of more systematic torture, political aims take precedence, including creating terror, stigmatizing, and damaging the assertiveness of opponents or non-consenting minorities. Sometimes the victims are mistaken for someone else. Situations where torture occurs are not restricted to premises where one is deprived of liberty, such as prisons, police stations, and prison camps, but also to the public sphere, the streets, or even the homes of victims. Especially in these latter situations, friends or family members might witness torture and suffer psychological stress or traumatization without having been directly tortured themselves. Being forced to witness the torture of family members was a common method of indirect torture in the war-torn countries of Central America during the 1980s.

Prevalence of Torture

Every year, Amnesty International lists countries that practice torture and usually the list exceeds 120 countries. Table 50.1 displays selected studies documenting the prevalence of torture survivors among community samples of refugees. Estimates vary due to methodological issues and differences in the use of torture in those countries. In the 1990s, there were approximately 14 million refugees living in Western Europe and North America, of whom 5% to 35% (700 000 to 4.9 million) were believed to have been tortured.¹⁰ If this 5–35% figure is applied to more recent calculations of 23 million refugees, then up to 8 million tortured refugees exist worldwide. At the primary care practice level, a study of three urban medical clinics in Los Angeles, California, found that 7% of all foreign-born Latino patients had experienced political torture.¹¹ None of the patients recalled their primary care provider ever inquiring about their exposure to political violence or torture. It seems safe to say, therefore, that primary care physicians may be treating persons who survived political torture without knowing this and consequently may not fully meet their patients’ needs. Studies in primary care populations from a mixture of countries find similar estimates of prevalence in primary care.¹²

Table 50.1 Empirical studies including torture prevalence estimates in selected population samples

Methods of Torture

While beatings are the most common form of torture, more specific techniques can be observed in many countries. Examples are shown in Table 50.2 but a listing of torture methods can never be complete because torturers are constantly inventing and varying methods.

Table 50.2 Overview of torture methods

Regional variation occurs in the specific forms of torture – often characterized by special names – such as ‘telefono’ (beatings to both ears with subsequent injuries to the outer and inner ear) and ‘falanga’ (beatings to the soles of the feet, leading to swelling, extreme and often chronic pain) (Fig. 50.1). Mutilating injuries consisting of, for example, amputation of limbs or other body parts are common in some regions, such as Rwanda or Iraq, and are, as is usually the case with torture, intended to punish or to create impairment and stigma.

Figure 50.1 A victim of ‘falanga.’

(We are grateful for Dr. Maria Piniou-Kalli of MRCT in Athens for supplying this photograph.)

In the realm of psychological torture methods, regional variations occur with cultural and social differences in what is considered shameful, un-healthy, or dangerous, or as a function of cultural and religious taboos. For instance, one of the authors (DE) interviewed and examined Tibetan nuns tortured by Chinese authorities. They reported that their torture included discarding their supplies used during menstruation in manners inconsistent with their Tibetan Buddhist beliefs about discarding such bodily fluids. This led to imbalances in their spirit that were believed to cause their chronic symptoms similar to fatigue and depression. Hindu authorities in India cut the hair of Sikh men, another example of psychological torture that is regionally specific.

Though the physical aspects of torture might be more obvious, psychological techniques and psychological aspects of physical torture are nearly always present and strongly interact with the physical symptoms. Because psychological torture is so easy to hide and deny, it is often used instead of physical torture. As evidenced by recent debates in the United States and Europe, there is little agreement on what constitutes psychological torture, making it easier for it to be denied and called other things. Still, torture survivors have often told us that it was the psychological methods, such as mock execution or being forced to witness the torture of a friend, that caused them the most lasting harm.

Overall Health Effects

Torture may have both immediate and long-lasting physical and psychological consequences. As clinicians in countries receiving refugees, we rarely encounter the most immediate phases, and those coming for treatment may have undergone torture years prior to accessing care. The survivor may have been fleeing, lack money to pay for treatment, suffer stigma, or experience a refusal for treatment by the healthcare system. Injuries encountered, therefore, might be complicated by lack of timely treatment.

For many survivors, a visit to the primary healthcare clinic may be their only contact with healthcare services.²⁰ Help-seeking²¹ and the pattern of reporting of symptoms might be determined by interrelated factors such as gender, culture, and trauma-related factors such as shame or avoi-dance.^21,22 Impairment can be caused by combinations of both physical and psychological factors.

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