Forensic Psychiatric Evaluation of Torture Victims

Legal Terminology

Article 5 of the Universal Declaration of Human Rights, which was accepted at the 183rd session of the United Nations (UN) General Assembly held in Paris on 10 December 1948 and signed by the Republic of Turkey on 6 April 1949, states, “No one shall be subjected to torture or cruelty. Shall not be subjected to inhuman or degrading punishment or treatment.” it is called [1, 2]. Article 3 of the European Convention on Human Rights, signed in Rome on 4 November 1950 and ratified by the Republic of Turkey on 18 May 1954, states, “No one shall be subjected to torture or to inhuman or degrading treatment or punishment.” is called [3]. The definition of torture in the United Nations Convention Against Torture, which was adopted by the UN General Assembly on December 10, 1984 and signed in Turkey on January 25, 1988, the obligations that the parties must comply with, the method of election of the Committee against Torture to be established, the task and its functioning are mentioned [4].

Article 17 of the Constitution of the Republic of Turkey states: “No one can be tortured or tortured; No one shall be subjected to punishment or treatment incompatible with human dignity.” it is called [5]. Article 94 of the Turkish Penal Code states: “Any public official who commits acts that are incompatible with human dignity and that will cause him to suffer bodily or spiritually, affect his perception or will power, and humiliate him, is sentenced to imprisonment from three years to twelve years. If the crime is committed against a woman, the lower limit of the sentence cannot be less than five years.” It is said, in the second paragraph, “Crime; If it is committed against a child, a person who cannot defend himself physically or mentally, or against a pregnant woman, a lawyer or other public official due to his duty, he is sentenced to imprisonment from eight years to fifteen years.”, in the third paragraph “If the act occurs as sexual harassment In

case of a crime, he shall be sentenced to imprisonment from ten to fifteen years.”, in the fourth paragraph, “Other persons participating in the commission of this crime will also be punished like a public official.”, in the fifth paragraph “In case this crime is committed with negligence, the penalty to be imposed will not be reduced for this reason.” , and in the sixth paragraph, “The statute of limitations does not apply for this crime.” is called. In Article 95, torture that is aggravated due to its consequences is mentioned [6].

After the meeting titled “Human Rights and Medical Profession” organized by the Turkish Medical Association (TTB) in March 1996 in Adana, torture in living things, approved by the UN and used by member countries, at the working group meetings held in Çukurova University Faculty of Medicine, Department of Forensic Medicine. The idea of preparing a torture examination protocol was put forward to detect traces of torture. It was decided that the final meeting would be held in Istanbul and that the name of the torture examination protocol for living creatures would be the “Istanbul Protocol”, just like the “Minnesota Protocol”, which is in a sense referred to as the protocol for the examination of torture in the dead. The draft version of the report as a result of intensive studies. At the end of the 3-day studies hosted by Istanbul University Faculty of Medicine, Department of Forensic Medicine, the editors were selected and the outline of the protocol was determined and the editors were authorized to complete the text. Additional changes were made in the prepared text in line with the recommendations made during the Geneva meeting, and the Istanbul Protocol was presented to the UN by the UN Special Rapporteur on Torture, Sir Nigel Rodley, on November 4, 1999, and officially became a UN document [7].

Interview Environment

First of all, the physical and mental evaluations should be in a comfortable environment suitable for privacy, where the physician considers the conditions to be the most suitable, where the person can feel comfortable and safe. The room should be arranged in such a way that the person does not feel himself being questioned, water, toilet, handkerchief etc. needs must be met. A seating plan designed in a way that does not evoke a hierarchical order, allowing eye contact with the person, should be applied. If these conditions cannot be met within the limits of possibilities, the deficiencies should be recorded in the report [10].

Meeting

The physician should introduce himself, inform the person to be examined in terms of his/her responsibilities and limits, the purposes of this interview and examination, all limitations and possible consequences of the obligation to keep confidentiality, and obtain the informed consent of the person. Closed-ended questions should not be asked in the interview, the subject should proceed in parallel with the establishment of a trust relationship from general to specific. When the interview is completed, the person should be asked if there is anything else they want to add [9, 10]. The physician should tell the patient that he/she can pause the interview and skip the question he/she does not want to answer. The physician should be able to design the interview according to the patient’s needs, general condition and the conditions of the environment [10]. It should be ensured that police or other law enforcement officials are not present in the examination room. The handcuffs, if any, must be released. Upon the physician’s need and necessity, the identity information of the people in the room should be stated in the report [9, 10].

If the physical examination supports the allegations of torture, the detainee should not be sent back to the place of detention, and the Public Prosecutor should be contacted quickly. The story of the event should be reproduced in the report with the person’s own words. The chronological order of the event should be checked. A careful questioning of the person’s family history and background will make it easier to understand the findings that are incompatible with the torture claim.

General Body Examination

General body examination cannot be done while dressed. After the necessary information is given to the patient and his consent is obtained, a detailed examination is performed by ensuring that all of the clothes are removed piece by piece, not at the same time. In the meantime, if it is necessary to take photographs, photographs are made with a scaled ruler, with the consent of the person. The findings that can be encountered frequently in these examinations are summarized in (Table 1).

Table1: Common Torture Findings.

Psychiatric Evidence of Torture

After traumatic experiences such as torture and persecution, various changes may develop in the behaviors and emotions of the victims. In this case, four stages are mentioned in the literature (Table 2). Even if these four stages are completed, victims may not forget the events they experienced [11].

All forms of torture may not lead to the same findings and results. Likewise, it is known that detention and torture do not affect adults and children in the same way. One of the main purposes of torture is to cause the person to deteriorate and dissolve by causing him extreme helplessness and discomfort. In addition, it should be known that not all torture victims may develop a diagnosable mental illness [9].

After the victimization, the victims often develop reactions such as shock, anger, sadness, helplessness and mourning. According to cross-cultural studies, it is recommended that psychiatric disorders should be evaluated most rationally by phenomenological or descriptive methods. A condition that is considered a disorder in one culture may not be considered pathological in another culture. The physician or psychologist making the assessment should evaluate mental suffering in the context of the person’s cultural norms. Considering the severity and consequences of torture, it should not be rushed to make a diagnosis, and an attitude open to learning should be developed [9].

• Acute Stress Disorder: It is a mental disorder that manifests itself with anxiety symptoms, dissociative symptoms, re-experiencing and avoidance symptoms that cause intense fear, helplessness and horror, observed in the individual within a month after severe traumatic experiences such as torture, death threats, severe injury, and sexual assault [12, 13].
• Depression: It is a mood disorder in which feelings of sadness, worthlessness and guilt intensify in the victim and cause problems in functioning. It can manifest itself with feelings of exhaustion, decrease in self-esteem, malaise, reluctance, loss of hope for the future, and thoughts of death [14].
• Post Traumatic Stress Disorder (PTSD): It is a mental disorder that manifests itself as anxiety, re-experiencing, feelings of helplessness, and avoidance according to DSM-5 criteria, compulsive ideas, cognitive variability, and hyperarousal state observed for longer than one month after a traumatic experience [13, 15].
• Dissociative Disorders: It is called the disruption of the integrity of functions such as memory, perception, identity and environmental sensations that work as a whole in the individual. According to DSM-5, dissociative identity disorder is classified as dissociative amnesia, depersonalization, derealization and unspecified dissociative disorders [13].

Increase in alcohol and substance use, some psychotic reactions, and psychophysiological disturbances may also be seen in the victim due to the severe trauma experienced [16]. Psychotic symptoms may develop while the victim is in detention and torture, or they may develop later. Common psychotic findings: delusions, hallucinations, illusions of perception, paranoia and persecution delusions. With or without objective findings, symptoms such as pain, headache and other physical complaints are also common in torture survivors. These bodily findings may be seen as a direct physical consequence of torture, or as a result of psychiatric origin, or both.

Sexual dysfunction is common in people who have been subjected to sexual torture, abuse, and rape, although not every torture. Again, torture may include physical trauma involving the brain at different levels, and these traumas may lead to long-term neuropsychological problems that cannot be easily detected on examination [9].

Reviews

• Radiological Imaging: According to the victim’s history and examination findings, the existing pathologies in soft tissue and bone structures can be made visible and recorded with direct X-ray, CT, MRI, USG, Scintigraphy.
• EMG Examination: It becomes a valuable diagnostic method when neuropathies and musculopathies are suspected in the victim’s history or examination [17].
• Blood Tests: It may be useful in demonstrating blood loss, if any, and rhabdomyolysis in common blunt traumas. Hematocrit, Hemoglobin, CK, LDH and other biochemical tests will be helpful.
• Pee: if there is muscle destruction due to widespread blunt trauma, it will be able to reveal it.