PTSD with secondary psychotic features among trauma-affected refugees: The role of torture and depression.

This cross-sectional study examined the prevalence of PTSD with secondary psychotic symptoms (PTSD-SP), its comorbidities, and its association with torture and depression in treatment-seeking refugees. Data were pooled from the Danish Database on Refugees with Trauma (DART). The sample represents approximately 90% of trauma-affected refugee-patients (N = 627) attending a Danish psychiatric outpatient clinic from 2008 to 2013. PTSD, secondary psychotic symptoms, and comorbidities were assessed with structured and routine clinical interviews. The association of PTSD-SP with torture and depression was investigated using hierarchical logistic regression. The prevalence of PTSD-SP in treatment-seeking refugees with PTSD was 30%. Among these, 44% fulfilled the criteria for Enduring Personality Change After Catastrophic Experience (EPCACE). Psychotic symptoms comprised hallucinations and persecutory delusions, often reflecting trauma-related themes. Comorbidity with depression was high (79%). Neither torture, nor other war-trauma (ex-combatant, imprisonment, civilian war trauma) predicted PTSD-SP, but comorbid depression did. Depression only explained a small amount of the total PTSD-SP variance. Results indicate that PTSD-SP is common in treatment-seeking refugees. However, its etiology is poorly understood. This highlights the need for further research to improve diagnosis and treatment for this patient group.

Evaluation of medical examination of forensic medicine specialists during / after detention within the scope of Istanbul Protocol.

INTRODUCTION: The Istanbul Protocol is a document prepared by many scientists from different countries and accepted by the United Nations thematising the medical reporting of torture. Normally, forensic specialists are responsible for medical examinations of torture victims, but this study looks at forensic specialists who were themselves subject to torture and mistreatment. It aims to analyze and evaluate, especially with regard to the Istanbul Protocol, the medical examinations performed on them while they were in detention. MATERIAL/METHOD: This study includes experts in forensic science who were detained during and after the state of emergency that was declared in 2016 in Turkey. Participants were asked questions regarding the examination steps specified in the Istanbul protocol. The Google Forms system (Google Inc., CA/USA) was used for the surveys, sent to the participants via text message. RESULTS: Twenty-two forensic scientists who were detained during and after the state of emergency in Turkey participated in this study. 45.5% of the participants were not asked for identification before their medical examination in detention. 36.4% of the participants stated that police were present in the examination room. Only 13.6% of participants found the privacy conditions during the examination appropriate. 90.9% stated that the time allocated for the examination was insufficient. The medical examinations lasted from 10 s to 10 min. Most participants were examined in less than 5 min. When asked if they were abused, 22.7% stated that they were not tortured, and 77.3% stated that they were subjected to torture or mistreatment practices, such as beatings, inappropriate use of handcuffs, being forced to wait or being rushed unnecessarily, being abandoned in isolating or hostile environments. In addition, the questions required to assess the psychological indications of torture and maltreatment were never asked in 40.9% of the cases. DISCUSSION AND CONCLUSION: Although torture is prohibited by international and humanitarian law, it has not completely disappeared. Medical personnel play an important role in torture assesment and prevention. The testimony of the forensic experts, who were fired and detained, revealed that the medical examinations during and after the State of Emergency in Turkey did not comply with the Istanbul Protocol and ethical rules. Medical examinations not carried out in accordance with the Istanbul Protocol lead to the denial of many rights and health problems. A worldwide awareness and sensitivity is needed to solve this problem.

Development of interdisciplinary protocols on medico-legal documentation of torture: Sleep deprivation.

BACKGROUND: The use of psychological torture or torture methods that leave no visible marks (stealth torture) is on the increase in various contexts. However, the difficulties in the documentation of such methods should be recognized by lawyers and health professionals who may benefit from using research-based interdisciplinary instruments to improve their documentation for legal processes - in addition to the United Nations Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (1999) (Istanbul Protocol). OBJECTIVE: With the aim to develop additional instruments for the documentation of various psychological torture methods, this article explains the recommended methodology for such research-based interdisciplinary instruments and the process of developing the first example of this approach relating to sleep deprivation. Development and pilot testing of the Sleep Deprivation Protocol: The pilot-testing of the Protocol by lawyers in the Public Committee Against Torture in Israel (PCATI) has already yielded positive results. CONCLUSION: Further advanced documentation instruments, using medical evidence in non-torture contexts and legal research, should be developed to effectively identify and record other psychological torture methods.

Protocol on Medico-Legal Documentation of Sleep Deprivation.

This Protocol originates from a joint project regarding documentation of psychological torture initiated by the Public Committee against Torture in Israel (PCATI), REDRESS and DIGNITY - Danish Institute Against Torture (DIGNITY) in 2015 after the Copenhagen Conference on Psychological Torture. The project is a vehicle to establish a common understanding between health and legal professions as to how to best ensure the most accurate documentation of torture. Historically, sleep deprivation has been used for different objectives but, primarily, to cause stress and duress for the purpose of extracting information and confessions. Detention centers with poor conditions is another context in which sleep deprivation, as a consequence of sleep disruption, takes place. This is often due to overcrowding, insufficient or no mattresses, and poor conditions of transportation between the courts and detention facilities. The aim of the Protocol is to improve documentation of sleep deprivation used in such settings (most often during interrogation) and therefore to clarify the facts of the case so that stronger legal claims can subsequently be submitted to local and international complaints mechanisms. The Protocol has been developed based on a methodology involving: compilation and review of legal and health knowledge on sleep deprivation, also in non-torture contexts; drafting by first author; discussion in the group of international experts; pilot- testing by PCATI; and evaluation by the three organizations and the group of experts. Despite generic elements of sleep deprivation, the context in a specific country will determine many aspects of the factual situation. Each context differs and as such this Protocol could serve as a guideline or a checklist of elements to be considered in a specific context. We hope that this Protocol will assist in the discussions between the various stakeholders and provide guidance on what can be documented and how to document sleep deprivation.

Voices of torture survivors in Tanzania: A qualitative study.

This paper outlines the narratives of a female and male survivor of sexual violence. It draws attention to the benefits of assisting survivors break their silence as a strategy to overcome the sequelae of shame that accompanies these acts. The two cases illustrate that both men and women experience sexual violation as de-humanising and assisting them to access and make meaning of their memories can be empowering. The need to develop a screening tool to assist survivors access treatment in a timely manner and further develop appropriate strategies incorporating both individual and group sessions is highlighted.

Torture and torture practices in Tanzania: Knowledge, attitudes and practice among medical professionals.

INTRODUCTION: Medical professionals have a key role in addressing torture and need an awareness and knowledge of torture in relation to rehabilitation approaches, prevention and international standards. This study was undertaken with the aim of assessing the current knowledge, attitudes and practices of medical professionals in Tanzania, creating a baseline for possible future interventions. METHODS: Both quantitative and qualitative data were collected. A cross-sectional survey was carried out using an interviewer-administrated structured questionnaire with 31 questions. Five focus group discussions were held. 386 medical professionals participated in the study representing primary, secondary and tertiary levels of health care in five regions of mainland Tanzania: Arusha, Dar es Salaam, Kigoma, Mara and Mbeya. RESULTS: Around 95% of all professionals acknowledged the existence of torture in Tanzania, but only 7% could correctly identify six different acts as being actual acts of torture according to the definition of the UN Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. Less than 15% were aware of relevant international standards like the Istanbul Protocol and the Mandela Rules. Up to 57% perceived that torture could be acceptable under certain circumstances. About 68% of all professionals reported to have encountered torture victims. The majority (82.9%) saw themselves as competent in the management of torture victims, but only 22% had received training specifically focusing on torture and its consequences. Most were interested in learning more on the subject. CONCLUSION: While medical professionals may be aware of the existence of torture in the country and report encountering torture victims in their daily work, both the professionals' skills and attitudes with regards to torture require development to intensify the work against torture in Tanzania. Intervention strategies should target training in medical schools and in-service training for medical profesionals at all levels within the health care system.

A problematic Israeli High Court dismissal of a torture complaint. A commentary by Hans Draminsky Petersen, MD.

It is not for the documenting medical experts (Shir, 2019), but for the court to decide whether the level of pain and suffering inflicted reaches the threshold of torture [while disregarding ill-treatment], i.e., the court upholds the prerogative to apply its own interpretation of the definition of torture, no matter existing medical evidence and disregarding the Istanbul Protocol. The criteria used to determine the level of FT's pain and suffering does not appear in the ruling. The ruling states that the burden of proof that the "means" were not reasonable [constituting torture] falls upon the petitioner (para 36). In the light of the above (1, a-h) this is in practice impossible for the petitioner to establish. This aligns with Shir's statement that no ISA interrogator has been indicted in 1200 torture complaints.

A gay Nigerian man's journey to asylum in the USA.

We report the case of an individual from Nigeria seeking asylum in the USA on the basis of persecution for being gay, who was physically and sexually assaulted in Nigeria and detained upon arrival to the USA. We present physical examination findings and the results of a brief mental health evaluation performed at Elizabeth Detention Center in New Jersey for his asylum evaluation. Individuals are able to seek asylum as members of a "particular social group", in this case, being gay. They seek asylum in the USA as they will continue to be at risk for harm if they stay in their home countries. However, the detention of asylum seekers often violates US human rights obligations and can occur without formal oversight. We explore the unique complications and experiences of lesbian, gay, bisexual, transgender and queer asylum seekers throughout the asylum process, from Nigeria to a detention centre in the USA.

The importance of positive need fulfillment: Evidence from a sample of war-affected Sri Lankans.

There has been growing interest in understanding the psychological and social-environmental factors that facilitate adaptive functioning in populations affected by ethnopolitical warfare. In the current study, we tested the hypothesis that a brief measure incorporating local idioms of positive need fulfilment would predict functioning in a war-affected Sri Lankan population above and beyond psychopathology when controlling for demographic variables and current life stressors. A brief measure of positive need fulfillment was derived from qualitative data and administered to a sample of 163 Sri Lankans affected by the civil war. Positive need fulfillment was found to uniquely predict functioning after controlling for age, war-related life problems, and psychopathology as assessed by the Penn-RESIST-Peradeniya War Problems Questionnaire. These findings highlight the importance of both basic need support and the fostering of agency in addition to addressing mental health needs. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Boys who work on the streets of Iraq are exposed to more traumatic events such as torture than schoolboys of the same age.

AIM: Information is scarce about the issues faced by street working. This study examined traumatic events experienced by boys working on the streets of Iraq compared to schoolboys. METHODS: We compared 100 street working boys aged 8-16 years who were attending a drop-in centre for street working children in Duhok City, Kurdistan, Iraq, in 2004/2005 with 100 age-matched schoolboys randomly selected from six local schools. The instruments that were used included the Harvard-Uppsala Trauma Questionnaire for Children. RESULTS: Most of the street working boys were involved in activities such as selling goods or shoe shining, and some were stealing or begging. None were involved in drugs or prostitution. The street working boys showed a significantly higher rate of traumatic events than the control group (96% versus 64%, p < 0.001) and higher rates of moderate to severe trauma levels (78% versus 25%, p < 0.001). A varying degree of association was found for reporting different traumatic events. The largest effect size was found for torture, with an odds ratio of 28.4, and the smallest for maltreatment or assault (2.7). CONCLUSION: Street working boys in Iraq faced a higher risk of exposure to traumatic events than age-matched schoolboys.

Determining Physical and Mental Health Conditions Present in Older Adult Refugees: A Mini-Review.

In 2017, there were over 65 million displaced persons at the global level, with approximately 23 million of these people living as refugees around the world. In this same year, the US resettled 53,716 refugees, with the State of Utah receiving 954 of those refugees. Refugees, in general, often face health-related challenges upon resettlement. Since the health of aging refugee men and women is of growing concern, host communities face significant challenges in accommodating the health needs of a diverse refugee population. This study, a review of physical and mental health data from the Utah Department of Health, was undertaken in an effort to ascertain the prevalence of health conditions among refugee men and women 60 years and older arriving in Utah. Findings include information on diseases correlated with increasing age, such as hypertension, decreases in vision, arthritis, and low back pain, which are common among this population of refugees aged 60 years and older. Overall, most of the health conditions assessed affect women and men with a similar prevalence. Some notable exceptions are a history of torture and violence, and a propensity for tobacco use. When dealing with refugee men older than 60 years, providers should consider the psychological ramifications of having endured such atrocities, as well as introduction to evidence-based tobacco cessation programs. When working with refugee women of the same age, an increase in the prevalence of musculoskeletal pain and urinary tract infections should be considered.

Deliberate Rumination and Positive Reappraisal as Serial Mediators Between Life Impact and Posttraumatic Growth in Victims of State Terrorism in Chile (1973-1990).

This study examines the role of coping strategies related to positive reappraisal versus other cognitive strategies (deliberate rumination) as mediators between life impact and posttraumatic growth in survivors of the military dictatorship in Chile between 1973 and 1990 (tortured political prisoners and family members of political prisoners executed and missing). Survey data from 251 political violence survivors were analyzed using the SPSS PROCESS macro for bootstrapping indirect effects (Hayes, 2013). Results indicated that positive reappraisal (or reframing) coping mediated the relationship between life impact and posttraumatic growth. A serial multiple mediation model indicates that in the life impact to growth moderation process, rumination must be followed by positive reappraisal to drive this growth. These findings suggest that positive reappraisal of the traumatic experience is essential to achieve growth reports. Implications of these more complex relations are discussed for both counseling interventions and further research.

Violence against African migrant women living in Turin: clinical and forensic evaluation.

The phenomenon of migration is often related to violence and exploitation. Data collection in conflict-affected countries is hard and complicated by the lack of literature, especially on the health of migrant female victims of violence. The aim of our study has been to realise a clinical and forensic evaluation on African female migrant's global health through their admissions to the Rape Centre "Soccorso Violenza Sessuale" at Sant'Anna Hospital in Turin. In our sample, we considered several aspects such as place where the violence occurred, number and the identity of the perpetrators, use of physical restraint instruments and/or substances, kidnapping, prostitution under duress, abuses, pregnancies and outcomes, injuries and complained symptoms, female genital mutilation, and sexually transmitted diseases. The sample consisted of 143 women, of which 136 were victims of violence. In 72.8% of the episodes, the perpetrator of violence was an unknown subject. Of the women, 58.8% reported being abused in Libya, 92.6% were victims of sexual violence, and 30.2% became pregnant after sexual abuse. The physical examination of the sample showed that 34.6% of women had at least a scar and that 12.5% reported a female genital mutilation. This is the first database on health of African female migrants in Turin area collecting data on migration, violence, and physical and psychological effects of abuse.

Intentional burn injury: Assessment of allegations of self-infliction.

This study investigates the question of whether there is evidence that suggests the possibility of self-infliction, or self-infliction by proxy, of burn injury among a group of asylum claimants in the UK who have attributed such injuries to torture, and how such evidence might be assessed. The question arose from the observations of doctors at the UK-based charity Freedom from Torture that increasing numbers of individuals from Sri Lanka who described a history of torture had suffered severe and disfiguring burn injuries from heated metal objects, and the suggestion from asylum decision-makers that in some cases such injuries could have been acquired deliberately by self-infliction or self-infliction by proxy rather than by torture as claimed. This suggestion has not been confined to Sri Lankan cases, but due to the large numbers of Sri Lankan asylum claimants referred to Freedom from Torture in recent years, including many with this type of injury, the case set for this study was drawn from this population. As many of these injuries are found to be on the back, where self-infliction would be extremely difficult, the possibility of self-infliction by proxy was specifically investigated. An observational data set was examined in detail, comprising medico-legal reports for Sri Lankans with heated metal object burn injuries documented in 2011-14 by the Medico-Legal Reports Service at Freedom from Torture. All had described detention in Sri Lanka since the end of the civil war in 2009. The study reviewed the documented evidence of these injuries alongside other physical and psychological evidence attributed to torture and relevant contextual factors documented in each case. Findings were compared with previous research on torture in Sri Lanka and patterns of injury identified in forensic medicine for both self-infliction and self-infliction by proxy. Thorough examination of the evidence found no indication in this data set to suggest the possibility of self-infliction or self-infliction by proxy and supported the view that, as indicated in the Istanbul Protocol, the overall conclusion on likelihood of torture should be made on evaluation of all the physical and psychological evidence over and above the scrutiny of an individual lesion.

Recognition and treatment of law enforcement violence against detainees and prisoners: A survey among Israeli physicians and medical students.

INTRODUCTION: Physicians regularly encounter victims of violence. Although some at-risk groups are increasingly recognized as such, the risks faced by prisoners and detainees are often overlooked. The scope of violence against them is unknown and their treatment is often hampered by unique social and institutional impediments. This article reviews the need for improved recognition and protection of such patients and the associated obstacles, while presenting information on the experience, knowledge and attitudes of physicians in Israel regarding the maltreatment of prisoners and detainees. METHODS: We sent a questionnaire to physicians and medical students in Israel to enquire about their knowledge concerning examination and treatment of persons under police custody who appear to be victims of violence as well as their attitude concerning torture. RESULTS: We received answers from 443 physicians and 114 medical students. Most physicians would correctly examine and document the injuries, but only 59% would report their suspicions of violence to the Ministry of Health. Though 60% of physicians objected in principle to the use of torture, a majority endorsed the use of physical and psychological pressure during interrogation. Moreover, 29% of physicians thought it is permissible for physicians to examine detainees and verify their health so that torture can begin or continue. DISCUSSION: Our study shows that there is a need for development and implementation of treatment and reporting protocols as well as educational programs concerning the ethical and legal requirements of physicians towards detainees and prisoners in Israel. Limitations of our study are discussed.

Asylum seekers alleging torture in their countries: Evaluation of a French center.

MATERIALS AND METHODS: Over a 6-year period, 570 survivors gave consent to this study and were examined by forensic medical doctors in academic French hospital. They evaluated with the aim of cataloguing the physical evidence of torture. Sociological data, declared violence (single physical altercation, repeated physical violence less than one year or more than one year, incarceration not more than one week or more than 1 week), and method of violence (blows by blunt object, crushing, burns, electrical shocks, attempted drowning, smothering, incision, or gunshot) were studied. An association between victims' statements and physical evidence of torture was determined. RESULTS: 70% were male with an average age of 31.9 years and ages between 1 and 70 years old. Dagestan, Guinea-Conakry and Guinea-Bissau were the countries most represented among asylum seekers. Beatings were reported by 27.89%, confinement was reported by 40.22%, and repeated violence by 30.16% of refugees. The average time interval between the first assault and forensic evaluation was 53 months. Forms of torture reported included: blunt force trauma (82.51%) truncheon blows (27.50%), arm incision (30%), and burns (16.3%). Statistically, truncheon blows were experienced more often by males in confinement due to political conflict. The use of crushing methods and electrical shocks also were experienced more often by males during confinement. Victims who had received incision wounds were significantly younger. Gunshots were statistically associated with male survivors of political conflict. Men experienced drowning and electrical shocks while in confinement in the Balkans, Asia, and Russia. Electrical shocks were reported by males during confinement and in northern Caucasus countries. The association was significant between assertions of burns and the presence of cutaneous scars (p = 0.0105); similarly, assertions of incision wounds were significantly corroborated by evidence of scars (p = 0.0009). DISCUSSION: Asylum seekers assessed were usually young men. Beatings with blunt objects were the most often reported form of torture used during episodes of repeated violence and during confinement. Assertions of burns were not associated with any particular circumstances. Electrical shocks were reported during confinement and most often in countries of the northern Caucasus. Attempted drowning, smothering, and shocking were noted, but these methods typically do not leave physical evidence. Wounds resulting from burns and incisions usually leave scars that corroborate refugee statements. Torture by crushing and gunshot were reported by asylum seekers for the first time. CONCLUSION: Investigation of the types of torture and circumstances under which torture occurs is critical for efficient forensic evaluation of claims of torture experienced by asylum seekers.

Measurement Invariance of the Brief Symptom Inventory in Survivors of Torture and Trauma.

The United States accepts more refugees than any other industrialized nation. As refugee populations grow, mental health professionals must implement culturally and ethnically appropriate strategies to assess and treat individuals from diverse backgrounds. Culture can exert a powerful and often misunderstood influence on psychological assessment, and few structured measures have been demonstrated to have adequate cross-cultural validity for use with diverse and vulnerable populations such as survivors of torture. This study examined the factor structure and equivalency of underlying construct(s) of psychological distress as measured by the Brief Symptom Inventory (BSI) in three samples who had survived torture and other severe trauma from Tibet, West Africa and the Punjab region of India. Confirmatory factor analyses provided support for configural invariance of a two-factor model across the three samples, suggesting that the two latent factors of Complex Dysphoria and Somatic Distress were present in each subgroup. The data provide additional support for the strict invariance model in the West African-Tibetan dyad suggesting that scores are comparable across those two groups. Implications for research and treatment are discussed.