Attitudes and experiences of health professionals towards clinical evaluations of torture and ill-treatment.

Torture and ill-treatment are crimes practiced systematically in many countries around the world. Little is known about the attitudes and experiences of health professionals who evaluate the victims of these crimes. This study was conducted to assess the attitudes and experiences of health professionals who conduct clinical evaluations of alleged torture and ill-treatment and identify common needs and challenges. Two surveys were administered to health professionals who attended a series of Istanbul Protocol (IP) trainings in various countries of Central Asia, Middle East/North Africa and Latin-America. The findings indicate that participants documented a significant number of torture and ill-treatment cases during a three-year period preceding the survey and that they were interested in conducting evaluations in accordance with the IP, but expressed concern about the impact of such evaluations on their workload and the effects of secondary trauma. Participants indicated support for a wide range of professional development and self-regulatory measures. The study also indicates the need for additional training and other measures to ensure effective documentation practices as 13% of participants failed to understand one of the most basic IP concepts - that the absence of physical and/or psychological evidence does not rule out the possibility that torture and/or ill-treatment occurred.

Effectiveness of a simulation-based training for health professionals conducting evaluations of alleged torture and ill-treatment.

Simulation has been used as an effective pedagogical tool for complex, high risk industries, including aviation, merchant marine, military, nuclear energy, and healthcare. Forensic science has also employed a variety of simulation training formats, such as virtual reality simulators, cadaver farms, objective structured clinical exercises, and mock trials. An evaluation of an alleged torture and ill-treatment victim is one of the most challenging types of evaluations forensic experts may conduct given the complex nature of the abuse and its physical and psychological effect, the status of perpetrators being State Officials, and the critical importance of judicial outcomes for alleged victims. The study presents a simulation-based training curriculum on the effective evaluation of alleged torture and ill treatment according to United Nations standards contained in the Istanbul Protocol and its effectiveness as measured by the participants' perceived gains in knowledge and skills. Of 262 participants, 176 pre-training surveys and 150 post-training surveys were collected for a response rate of 67% and 57%, respectively. Of the 899 end of day course evaluations distributed to the participants, 594 were returned for a response rate of 66%. Participants reported that the course increased their confidence to perform all aspects of the medico-legal evaluation of an alleged victim torture and ill-treatment. Participants' median score for the course content, instructors and course material was 5 using a 5-point Likert scale. The findings of this study demonstrate that a simulation-based course significantly improved the cognitive and technical skills necessary to conduct medico-legal evaluations of alleged victims of torture and ill-treatment in accordance with Istanbul Protocol standards.

Evaluations of alleged torture and ill treatment in Thailand: A collection of forensic medical evidence by non-medical evaluators.

Forensic medical evidence plays a critical role in the investigation and documentation of torture and ill treatment, as well as in civil reparation cases and in state monitoring mechanisms, especially if conducted on a timely basis by qualified, impartial experts. Detainees in many countries, such as Thailand, face significant barriers to access medical personnel while in custody or independent, non-governmental or impartial forensic experts. This study summarizes an effective method of collecting forensic medical evidence of torture and ill treatment by non-medical evaluators under conditions of limited access to detainees. The aim of the study was to determine the feasibility to render an expert opinion based on such documentation. We reviewed 49 non-medical forensic evaluations of alleged torture and ill treatment conducted by 11 attorneys or legal representatives in Southern Thailand between March and October 2011. Forty-four non-medical evaluations (90%) had sufficient information for the authors to formulate an opinion between the alleged abuse and the documented findings and to make a statement as to the level of consistency between them. Of these 44 evaluations, the authors determined that in 28 (70%) cases, the documented findings were highly consistent with the alleged abuse and in 13 (30%) cases, the documented findings were consistent with the alleged abuse. The study shows that non-medical evaluations conducted by attorneys and legal advocates can be a resource when individuals are denied access to forensic medical expertise. The results of a non-medical evaluation interpreted by an expert can have great evidentiary value when courts are reluctant to entertain writs of protection, such as a habeas corpus, or when states are reluctant to meet their obligations to pursue formal forensic evaluations.

Statement of the Independent Forensic Expert Group on Conversion Therapy.

Conversion therapy is a set of practices that aim to change or alter an individual's sexual orientation or gender identity. It is premised on a belief that an individual's sexual orientation or gender identity can be changed and that doing so is a desirable outcome for the individual, family, or community. Other terms used to describe this practice include sexual orientation change effort (SOCE), reparative therapy, reintegrative therapy, reorientation therapy, ex-gay therapy, and gay cure. Conversion therapy is practiced in every region of the world. We have identified sources confirming or indicating that conversion therapy is performed in over 60 countries. In those countries where it is performed, a wide and variable range of practices are believed to create change in an individual's sexual orientation or gender identity. Some examples of these include: talk therapy or psychotherapy (e.g., exploring life events to identify the cause); group therapy; medication (including anti-psychotics, anti- depressants, anti-anxiety, and psychoactive drugs, and hormone injections); Eye Movement Desensitization and Reprocessing (where an individual focuses on a traumatic memory while simultaneously experiencing bilateral stimulation); electroshock or electroconvulsive therapy (ECT) (where electrodes are attached to the head and electric current is passed between them to induce seizure); aversive treatments (including electric shock to the hands and/or genitals or nausea-inducing medication administered with presentation of homoerotic stimuli); exorcism or ritual cleansing (e.g., beating the individual with a broomstick while reading holy verses or burning the individual's head, back, and palms); force-feeding or food deprivation; forced nudity; behavioural conditioning (e.g., being forced to dress or walk in a particular way); isolation (sometimes for long periods of time, which may include solitary confinement or being kept from interacting with the outside world); verbal abuse; humiliation; hypnosis; hospital confinement; beatings; and "corrective" rape. Conversion therapy appears to be performed widely by health professionals, including medical doctors, psychiatrists, psychologists, sexologists, and therapists. It is also conducted by spiritual leaders, religious practitioners, traditional healers, and community or family members. Conversion therapy is undertaken both in contexts under state control, e.g., hospitals, schools, and juvenile detention facilities, as well as in private settings like homes, religious institutions, or youth camps and retreats. In some countries, conversion therapy is imposed by the order or instructions of public officials, judges, or the police. The practice is undertaken with both adults and minors who may be lesbian, gay, bisexual, trans, or gender diverse. Parents are also known to send their children back to their country of origin to receive it. The practice supports the belief that non-heterosexual orientations are deviations from the norm, reflecting a disease, disorder, or sin. The practitioner conveys the message that heterosexuality is the normal and healthy sexual orientation and gender identity. The purpose of this medico-legal statement is to provide legal experts, adjudicators, health care professionals, and policy makers, among others, with an understanding of: 1) the lack of medical and scientific validity of conversion therapy; 2) the likely physical and psychological consequences of undergoing conversion therapy; and 3) whether, based on these effects, conversion therapy constitutes cruel, inhuman, or degrading treatment or torture when individuals are subjected to it forcibly2 or without their consent. This medico-legal statement also addresses the responsibility of states in regulating this practice, the ethical implications of offering or performing it, and the role that health professionals and medical and mental health organisations should play with regards to this practice. Definitions of conversion therapy vary. Some include any attempt to change, suppress, or divert an individual's sexual orientation, gender identity, or gender expression. This medico-legal statement only addresses those practices that practitioners believe can effect a genuine change in an individual's sexual orientation or gender identity. Acts of physical and psychological violence or discrimination that aim solely to inflict pain and suffering or punish individuals due to their sexual orientation or gender identity, are not addressed, but are wholly condemned. This medico-legal statement follows along the lines of our previous publications on Anal Examinations in Cases of Alleged Homosexuality1 and on Forced Virginity Testing.2 In those statements, we opposed attempts to minimise the severity of physical and psychological pain and suffering caused by these examinations by qualifying them as medical in nature. There is no medical justification for inflicting on individuals torture or other cruel, inhuman, or degrading treatment or punishment. In addition, these statements reaffirmed that health professionals should take no role in attempting to control sexuality and knowingly or unknowingly supporting state-sponsored policing and punishing of individuals based on their sexual orientation or gender identity.

Istanbul Protocol implementation in Central Asia: Bending the arc of the moral universe.

In countries emerging from authoritarian rule, a major challenge is ending often widespread and systematic torture and ill-treatment practices. Between 2011 and 2019, Physicians for Human Rights (PHR), in collaboration with the Open Society Foundation (OSF), the Open Society Justice Initiative (OSJI) and regional and local partners, worked to establish effective torture investigation and documentation practices in the Central Asian countries of Kyrgyzstan, Tajikistan, and Kazakhstan. Our approach consisted of activities in three sequential phases - (1) assessment, (2) capacity building, and (3) policy reform. In this paper, we briefly describe activities during each phase and identify key lessons learned from these experiences and resulting policy and program reforms as a model for future efforts in other settings.

The Istanbul Protocol: A global stakeholder survey on past experiences, current practices and additional norm setting.

INTRODUCTION: The Istanbul Protocol (IP) principles and guidelines have served as international norms for the effective investigation and documentation of torture and ill-treatment since 1999. Given the widespread use of the IP and recent calls to update or enhance its norms, we conducted a large-scale study among stakeholders to understand current practices as well as opinions on additional IP norm setting. METHODS: Between February 20, 2017 and April 7, 2017, we conducted an online survey of IP users using a combination of criterion and chain sampling. The survey instrument included the following domains of inquiry: 1) respondent characteristics (demographics, anti-torture work, country conditions, and IP training); 2) IP use, importance and practices, and; 3) opinions on additional IP norm setting. RESULTS: The survey was distributed to 177 individuals and 250 organizational representatives with response rates of 78% and 47% respectively. The respondents came from a variety of clinical, legal, academic, and advocacy disciplines from around the world. The respondents indicated that they use the IP for a wide range of anti-torture activities: investigation and documentation, advocacy, training and capacity building, policy reform, prevention, and treatment and rehabilitation of torture survivors. The vast majority (94% of individual respondents and 84% of organizations) reported that the IP is important to their anti-torture work. A majority of individual (60%) and organizational (59%) respondents reported that updating or adding clarifications to the IP would help to address the challenges they face and provided specific suggestions. However, 41% of individuals and 21% of organizational respondents also reported concerns that additional IP norm setting could have negative consequences. DISCUSSION: The IP provides critical guidance for a wide range of torture prevention, accountability, and redress activities and can be enhanced through the development of additional updates and clarifications to respond to the current needs of torture survivors and stakeholders.

Death, injury and disability from kinetic impact projectiles in crowd-control settings: a systematic review.

OBJECTIVE: We conducted a systematic review of the available literature on deaths, injuries and permanent disability from rubber and plastic bullets, as well as from bean bag rounds, shot pellets and other projectiles used in arrests, protests and other contexts from 1 January 1990 until 1 June 2017. DATA SOURCES: PubMed, Scopus, JSTOR and grey literature. DATA SYNTHESIS: We report on descriptive statistics as well as data on injury severity, permanent disability and death. We analysed potential risk factors for injury severity, including the site of impact, firing distance and access to medical care. RESULTS: Of 3228 identified articles, 26 articles met inclusion criteria. These articles included injury data on 1984 people, 53 of whom died as a result of their injuries. 300 people suffered permanent disability. Deaths and permanent disability often resulted from strikes to the head and neck (49.1% of deaths and 82.6% of permanent disabilities). Of the 2135 injuries in those who survived their injuries, 71% were severe, injuries to the skin and to the extremities were most frequent. Anatomical site of impact, firing distance and timely access to medical care were correlated with injury severity and risk of disability. CONCLUSIONS: Kinetic impact projectiles (KIPs), often called rubber or plastic bullets, are used commonly in crowd-control settings. We find that these projectiles have caused significant morbidity and mortality during the past 27 years, much of it from penetrative injuries and head, neck and torso trauma. Given their inherent inaccuracy, potential for misuse and associated health consequences of severe injury, disability and death, KIPs do not appear to be appropriate weapons for use in crowd-control settings. There is an urgent need to establish international guidelines on the use of crowd-control weapons to prevent unnecessary injuries and deaths.

Health impacts of chemical irritants used for crowd control: a systematic review of the injuries and deaths caused by tear gas and pepper spray.

BACKGROUND: Chemical irritants used in crowd control, such as tear gases and pepper sprays, are generally considered to be safe and to cause only transient pain and lacrimation. However, there are numerous reports that use and misuse of these chemicals may cause serious injuries. We aimed to review documented injuries from chemical irritants to better understand the morbidity and mortality associated with these weapons. METHODS: We conducted a systematic review using PRISMA guidelines to identify injuries, permanent disabilities, and deaths from chemical irritants worldwide between January 1, 1990 and March 15, 2015. We reviewed injuries to different body systems, injury severity, and potential risk factors for injury severity. We also assessed region, context and quality of each included article. RESULTS: We identified 31 studies from 11 countries. These reported on 5131 people who suffered injuries, two of whom died and 58 of whom suffered permanent disabilities. Out of 9261 total injuries, 8.7% were severe and required professional medical management, while 17% were moderate and 74.3% were minor. Severe injuries occurred to all body systems, with the majority of injuries impacting the skin and eyes. Projectile munition trauma caused 231 projectile injuries, with 63 (27%) severe injuries, including major head injury and vision loss. Potentiating factors for more severe injury included environmental conditions, prolonged exposure time, and higher quantities of chemical agent in enclosed spaces. CONCLUSIONS: Although chemical weapons may have a limited role in crowd control, our findings demonstrate that they have significant potential for misuse, leading to unnecessary morbidity and mortality. A nuanced understanding of the health impacts of chemical weapons and mitigating factors is imperative to avoiding indiscriminate use of chemical weapons and associated health consequences.

Health and Human Rights in Karen State, Eastern Myanmar.

BACKGROUND: Decades of conflict in eastern Myanmar have resulted in high prevalence of human rights violations and poor health outcomes. While recent ceasefire agreements have reduced conflict in this area, it is unknown whether this has resulted in concomitant reductions in human rights violations. METHODS AND FINDINGS: We conducted a two-stage cluster survey of 686 households in eastern Myanmar to assess health status, access to healthcare, food security, exposure to human rights violations and identification of alleged perpetrators over the 12 months prior to January 2012, a period of near-absence of conflict in this region. Household hunger (FANTA-2 scale) was moderate/high in 91 (13.2%) households, while the proportion of households reporting food shortages in each month of 2011 ranged from 19.9% in December to 47.0% in September, with food insecurity peaking just prior to the harvest. Diarrhea prevalence in children was 14.2% and in everyone it was 5.8%. Forced labor was the most common human rights violation (185 households, 24.9%), and 210 households (30.6%) reported experiencing one or more human rights violations in 2011. Multiple logistic regression analysis identified associations between human rights violations and poor health outcomes. CONCLUSION: Human rights violations and their health consequences persist despite reduced intensity of conflict in eastern Myanmar. Ceasefire agreements should include language that protects human rights, and reconciliation efforts should address the health consequences of decades of human rights violations.

Implementing Istanbul Protocol standards for forensic evidence of torture in Kyrgyzstan.

The Kyrgyz government declared a policy of "zero tolerance" for torture and began reforms to stop such practice, a regular occurrence in the country's daily life. This study presents the results of 10 forensic evaluations of individuals alleging torture; they represent 35% of all criminal investigations into torture for the January 2011-July 2012 period. All individuals evaluated were male with an average age of 34 years. Police officers were implicated as perpetrators in all cases. All individuals reported being subjected to threats and blunt force trauma from punches, kicks, and blows with objects such as police batons. The most common conditions documented during the evaluations were traumatic brain injury and chronic seizures. Psychological sequelae included post-traumatic stress disorder and major depressive disorder, which was diagnosed in seven individuals. In all cases, the physical and psychological evidence was highly consistent with individual allegations of abuse. These forensic evaluations, which represent the first ever to be conducted in Kyrgyzstan in accordance with Istanbul Protocol standards, provide critical insight into torture practices in the country. The evaluations indicate a pattern of brutal torture practices and inadequate governmental and nongovernmental forensic evaluations.

Medical evidence of human rights violations against non-Arabic-speaking civilians in Darfur: a cross-sectional study.

BACKGROUND: Ongoing conflict in the Darfur region of Sudan has resulted in a severe humanitarian crisis. We sought to characterize the nature and geographic scope of allegations of human rights violations perpetrated against civilians in Darfur and to evaluate their consistency with medical examinations documented in patients' medical records. METHODS AND FINDINGS: This was a retrospective review and analysis of medical records from all 325 patients seen for treatment from September 28, 2004, through December 31, 2006, at the Nyala-based Amel Centre for Treatment and Rehabilitation of Victims of Torture, the only dedicated local provider of free clinical and legal services to civilian victims of torture and other human rights violations in Darfur during this time period. Among 325 medical records identified and examined, 292 (89.8%) patients from 12 different non-Arabic-speaking tribes disclosed in the medical notes that they had been attacked by Government of Sudan (GoS) and/or Janjaweed forces. Attacks were reported in 23 different rural council areas throughout Darfur. Nearly all attacks (321 [98.8%]) were described as having occurred in the absence of active armed conflict between Janjaweed/GoS forces and rebel groups. The most common alleged abuses were beatings (161 [49.5%]), gunshot wounds (140 [43.1%]), destruction or theft of property (121 [37.2%]), involuntary detainment (97 [29.9%]), and being bound (64 [19.7%]). Approximately one-half (36 [49.3%]) of all women disclosed that they had been sexually assaulted, and one-half of sexual assaults were described as having occurred in close proximity to a camp for internally displaced persons. Among the 198 (60.9%) medical records that contained sufficient detail to enable the forensic medical reviewers to render an informed judgment, the signs and symptoms in all of the medical records were assessed to be consistent with, highly consistent with, or virtually diagnostic of the alleged abuses. CONCLUSIONS: Allegations of widespread and sustained torture and other human rights violations by GoS and/or Janjaweed forces against non-Arabic-speaking civilians were corroborated by medical forensic review of medical records of patients seen at a local non-governmental provider of free clinical and legal services in Darfur. Limitations of this study were that patients seen in this clinic may not have been a representative sample of persons alleging abuse by Janjaweed/GoS forces, and that most delayed presenting for care. The quality of documentation was similar to that available in other conflict/post-conflict, resource-limited settings.