Respect for bioethical principles and human rights in prisons: a systematic review on the state of the art.

BACKGROUND: Respect for human rights and bioethical principles in prisons is a crucial aspect of society and is proportional to the well-being of the general population. To date, these ethical principles have been lacking in prisons and prisoners are victims of abuse with strong repercussions on their physical and mental health. METHODS: A systematic review was performed, through a MESH of the following words (bioethics) AND (prison), (ethics) AND (prison), (bioethics) AND (jail), (ethics) AND (jail), (bioethics) AND (penitentiary), (ethics) AND (penitentiary), (prison) AND (human rights). Inclusion and exclusion criteria were defined and after PRISMA, 17 articles were included in the systematic review. RESULTS: Of the 17 articles, most were prevalence studies (n.5) or surveys (n.4), followed by cross-sectional studies (n.3), qualitative studies (n.1), retrospective (n.1) and an explanatory sequential mixed-methods study design (n.1). In most cases, the studies associated bioethics with prisoners' access to treatment for various pathologies such as vaccinations, tuberculosis, hepatitis, HIV, it was also found that bioethics in prisons was related to the mental health of prisoners, disability, ageing, the condition of women, the risk of suicide or with the request for end-of-life by prisoners. The results showed shortcomings in the system of maintaining bioethical principles and respect for human rights. CONCLUSIONS: Prisoners, in fact, find it difficult to access care, and have an increased risk of suicide and disability. Furthermore, they are often used as improper organ donors and have constrained autonomy that also compromises their willingness to have end-of-life treatments. In conclusion, prison staff (doctors, nurses, warders, managers) must undergo continuous refresher courses to ensure compliance with ethical principles and human rights in prisons.

Impact of (forensic) expert opinions according to the Istanbul Protocol in Germany-results and insights of the in:Fo-project.

As part of a third-party funded project, expert opinions according to the Istanbul Protocol (IP) standards were compiled in Germany on a larger scale for the first time. The assessment process was initiated for 130 project participants. Statistical analysis on numerous variables was performed to test the impact of the expert opinions, foremost of the forensic medical expert opinions, on the individuals' asylum proceedings. The variables were drawn from forensic medical expert opinions and reports of findings, questionnaires for the study participants' counsellors in the project and a query on the asylum status of the study participants. Regression analysis and bivariate analysis on two dependent variables-subjective impact on the asylum procedure from the counsellors' point of view and objective change in the asylum status-were performed to test for an influence on asylum procedures. No statistically significant results were obtained for the objective change of the study participants' asylum status. For the subjective dependent variable, a positive prediction was possible when simultaneously controlling for the independent variables introduction of a forensic medical expert opinion and highest IP grade; a negative prediction was possible when simultaneously controlling for the independent variables introduction of a forensic medical expert opinion and use of IP grading. Apart from the statistical analysis, a positive effect of the assessment on the psychosocial well-being of the study participants could be demonstrated. The results differed from other European studies which demonstrated a correlation between the objective outcome of an asylum procedure (asylum status) and, for example, specific types of violence or the number of documented injuries. Differences also occurred in the use of the plausibility grades proposed by the IP, which questions their use in cases in which the reported torture happened a relevant time ago. Therefore, compiling individually worded evaluations instead of using the IP grading system-if possible, by an experienced forensic physician-is recommended in this scenario. Still, the assessment of alleged torture experiences should follow the IP guidelines, since psychological assessments are of especially high importance in cases with healed physical injuries and since the results also demonstrated a positive effect on the psychosocial well-being of the study participants.

The general health status of newly arrived asylum seekers in Denmark.

AIMS: The number of asylum seekers in Europe is increasing and is likely to do so continuously due to conflicts, poverty and climate. Asylum seekers are exposed to many health risk factors related to their migration process and this study aimed to explore their general health status on arrival at an immigration country. METHODS: A retrospective study including 1907 general health assessments (GHAs) of adult asylum seekers arriving in Denmark between 1 September 2017 and 31 December 2019 was undertaken. The GHA is offered to all adult asylum seekers as part of the health-care reception programme. Only asylum seekers who attended the GHA within 1 month of their arrival in Denmark were included. Data comprised sociodemographic factors, health outcomes, and indication of exposure to trauma and torture. Data were described by absolute and relative frequencies, means and through regression analyses. RESULTS: The majority of asylum seekers were male (58.6%) of Middle Eastern origin with a mean age of 33.6 years (SD = 12.1). More than half (60.1%) of the participants had one or more physical health complaints, whereas mental health complaints were less frequent (25.0%). Asylum seekers, who had been exposed to trauma were more likely to have physical health complaints (OR 1.52, 95% CI 1.22;1.89) and to have symptoms of mental health problems (OR 12.71, 95% CI 8.76;18.45). These complaints were substantially elevated for survivors of torture. CONCLUSIONS: This relatively high prevalence of health complaints, both physical and mental, emphasises the necessity of providing appropriate and timely health care from the very beginning of the asylum process.

Psychiatry and the UN Convention Against Torture.

OBJECTIVE: To expand on psychiatry's duties under the United Nations (UN) Convention Against Torture. CONCLUSIONS: As it is currently practised in Australia, psychiatry is in breach of a number of major international conventions. Full compliance with treaty obligations will entail substantial changes in current practice.

The Impact of Parent Torture and Family Functioning on Youth Adjustment in War-Affected Families: A Path Analysis Describing Intergenerational Trauma and the Family System.

The direct exposure to physical or psychological trauma from torture or war leads to well-documented individual health consequences. Less understood are the inclusive and intergenerational effects of war trauma on family systems and youth adjustment. The purpose was to examine mechanisms in war-affected families that explained the significant emotional and behavioral consequences of intergenerational trauma in youth through the use of multiple methods. Quantitative assessments of maternal and paternal caregivers and youth characterized associations between parent torture, parent mental health distress, parent physical health problems, family functioning, and youth adjustment. Narrative statements further contextualized processes through which the trauma of a parent impacted youth and family systems. The research was conducted in partnership with local, refugee-serving community-based organizations. The study sample included parents and youth in 96 Karen families, originating from Burma in Southeast Asia, who had been resettled to the United States through the U.S. Refugee Admissions Program. Path analysis results indicated that parent torture (ß = -0.173) had statistically significant negative direct effects on youth adjustment. Parent torture had a negative indirect effect on youth adjustment through the mental health (ß = -0.345) and physical health problems of parents (ß = -0.305), and youth gender (ß = 0.126) and trauma exposure of youth (ß = -0.048). Family functioning type demonstrated a positive direct effect on youth adjustment (ß = 0.449). Family type had an indirect effect on youth adjustment through youth gender (ß = 0.142), youth trauma exposure (ß = -0.165), parent physical health problems (ß = -0.202), and parent mental health (ß = 0.509). The current study developed and tested the first model of intergenerational trauma's effects on the adjustment of Karen refugee youth. Results emphasize that individual recovery from torture must be accompanied by adjunct interventions focused on family systems and youth adjustment, to holistically address intergenerational sequala of trauma.

Assessing signs of torture: A review of clinical forensic dermatology.

BACKGROUND: It is important for dermatologists and other physicians in refugee-receiving countries to acquire knowledge of forensic dermatology to identify lesions from torture. OBJECTIVE: Review forensic dermatology in cases of torture. RESULTS: In provision of medical assessment and care to refugees and migrants, chronic skin lesions will be the most readily identifiable signs of torture. Beatings are common, with blunt force trauma resulting in postinflammatory hyperpigmentation. Torture burns can be thermal, chemical, or electrothermal, causing distinct lesions determined by the method, duration, and intensity of exposure, and area of skin affected. Sharp instruments inflict a wide range of lesions arising from stabbing/perforation or cuts from knives. Wound healing without medical attention and in unsanitary conditions will affect the scarring process. Lesions from suspension and ligatures may occur alongside scars from other forms of torture. Differential diagnoses include self-inflicted wounds, ethnic scarification, and scars from traditional healing practices. CONCLUSION: Physicians who may encounter survivors of torture in community or specialist practice would benefit from basic training in forensic dermatology, whereas knowledge of common forms of torture and cultural practices in refugees' countries of origin is important when considering differential diagnoses of skin lesions.

The Syrian regime's apparatus for systemic torture: A qualitative narrative study of testimonies from survivors.

BACKGROUND: Despite broad interest of the Syrian refugee plight in the academic and media circles, there are still limited studies analyzing the lived experiences of torture survivors under the Syrian regime. This qualitative study interviewed torture survivors to examine the form and function of the Syrian regime's security apparatus, and the personal aftermath of survivors. METHODS: Thirteen in-depth interviews were conducted in Arabic with Syrian refugees who endured torture. Study participants were at least 19 years of age, resided as refugees in Jordan, and voluntarily agreed to participate in the study. Participation was anonymous and no incentives were provided. Only oral consent was required. Audio-recorded interviews were transcribed and translated to English, and then analyzed for repetitive themes utilizing the narrative approach. RESULTS: Major themes were observed across three experience-phases: pre-captivity, during captivity, and post-captivity. The pre-captivity phase included two sub-themes: the Syrian regime's initial detection and arrest system, and the intelligence system. The captivity phase was also divided into two sub-themes: environmental conditions in detention facilities, and torture methods including physical and psychological torture. Some of the environmental conditions in detention facilities included lack of sanitation, crowding, starvation, and withholding of medical care. Torture methods encompassed beatings, electric shocks, nail-pulling, hanging, drowning, suffocation, rape, and the witnessing of killing, sexual assault, or torture of others. The post-captivity phase included their release from captivity, escaping Syria, and post-displacement conditions and activism. CONCLUSIONS: The Syrian regime employs a vast security apparatus to track, detain, interrogate, torture, and subjugate its civilian population. A systematic mechanism commences even before captivity and continues for years after release, with negative implications on the well-being of survivors, their families, and the Syrian people as a collective community. The Syrian war saw a shift toward mass detention, torture as a form of social punishment, subjugation, and indeterminate imprisonment. Intervention agencies, host countries, and policymakers must be informed of survivors' experiences to better address their needs. Moreover, the international community must advocate for a firm stance against torture, demand justice, and prosecute all parties engaged in perpetuating such extreme forms of suffering and trauma.

Seeing the person before the teeth: A realist evaluation of a dental anxiety service in Norway.

Patients with a trauma history, whether sexual abuse or torture, or dental phobia, tend to avoid dental services due to severe dental anxiety. Subsequently, they experience poor oral health, lower quality of life, and poorer general health. In Norway, a specific service (torture, abuse, and dental anxiety [TADA]) targets these patients' dental anxiety through cognitive behavioural therapy (CBT) prior to dental restoration. By exploring patients' experiences with TADA services using a realist evaluation approach, this paper aims to increase our understanding of how this type of service addresses patients' dental anxiety in terms of its mechanisms and contextual factors. Interviews with TADA patients (n = 15) were analysed through a template analysis driven by context-mechanism-outcome heuristics. The analysis revealed that patients value a dental practitioner who provides a calm and holistic approach, positive judgements and predictability elements that lean towards a person-centred care approach. Provided this, patients felt understood and cared for, their shame was reduced, self-esteem emerged, and control was gained, which led to alleviation of dental anxiety. Therefore, our findings suggest that combining CBT with a person-centred care approach helps alleviate patients' dental anxiety. This provides insights into how dental services could be executed for these patients.

Is the international regulation of medical complicity with torture largely window dressing? The case of Israel and the lessons of a 12-year medical ethical appeal.

This is the account of an ongoing appeal initiated in 2009 by 725 doctors from 43 countries concerning medical complicity with torture in Israel. It has been underpinned by a voluminous and still accumulating evidence base from reputable international and regional human rights organisations, quoted below, and has spanned the terms of office of four World Medical Association (WMA) presidencies and two UN special rapporteurs on torture. This campaign has been a litmus test of whether international medical codes regarding doctors and torture actually matter, and are applied rigorously and even-handededly, particularly when compelling evidence incriminates a WMA member association. Our findings in the case of Israel suggest that this is not true, and that impunity largely operates. The WMA seems in partisan violation of its mandate to be the official international watchdog on the ethical behaviour of doctors. And as the IMA case demonstrates, by their inaction national medical associations or other regulatory bodies appear to function at base as buttresses and shields of the state.

Exploring the contexts, mechanisms and outcomes of a torture, abuse and dental anxiety service in Norway: a realist evaluation.

BACKGROUND: Torture, abuse and dental anxiety (TADA) are often precursors to developing a pathological relationship with dental care due to elevated anxiety. Consequently, patients who suffer from one or more of these tend to avoid dental services. This could leave them with severe tooth decay, which could affect their general and psychosocial health. Norwegian dental services have implemented the TADA service to specifically alleviate dental anxiety and restore oral health for the TADA patient group. However, the service has not been evaluated, and there is a need to understand how and why this service works, for whom, under what circumstances. Therefore, this study aimed to develop theories on how the service's structure alleviates dental anxiety and restores these patients' oral health. Although developed in a Norwegian context, these theories may be applicable to other national and international contexts. METHODS: This realist evaluation comprised multiple sequential methods of service and policy documents (n = 13), followed by interviews with service developers (n = 12). RESULTS: The analysis suggests that, by subsidising the TADA service, the Norwegian state has removed financial barriers for patients. This has improved their access to the service and, hence, their service uptake. National guidelines on service delivery are perceived as open to interpretation, and can hereby meet the needs of a heterogeneous patient group. The services have become tailored according to the available regional resources and heterogeneous needs of the patient population. A perceived lack of explicit national leadership and cooperative practices has resulted in regional service teams becoming self-reliant and insular. While this has led to cohesion within each regional service, it is not conducive to interservice collaborations. Lastly, the complexity of migration processes and poor dissemination practices is presumed to be the cause of the lack of recruitment of torture survivors to the service. CONCLUSIONS: Policy documents and service developers described the TADA service as a hybrid bottom-up/top-down service that allows teams to practise discretion and tailor their approach to meet individual needs. Being free of charge has improved access to the service by vulnerable groups, but the service still struggles to reach torture survivors.

Edgework, institutions and enhanced interrogation.

The Enhanced Interrogation programme was a medicalised interrogation programme that was designed by the United States in the wake of 9/11. It is now widely recognized that the Enhanced Interrogation programme engaged in some activities that were, at the least, tantamount to torture. The programme was designed by Psychologists and overseen by other professionals, including medical professionals. This article argues that the Enhanced Interrogation programme displayed many of the features of what Sociologists refer to as Edgework. It demonstrated voluntary risk-taking by health and other professionals; this risk-taking pressed up against catastrophic outcomes across multiple dimensions; risks were taken for the purposes of escaping a death-saturated macrosocial context; and the health professionals in the programme were highly skilled. The article argues that a new form of Edgework can be detected by studying the programme, which the article refers to as 'Institutional Edgework'.

An Evaluation within the Context of the Istanbul Protocol of the Medico-Legal Examinations of Turkish Detainees during the Recent State of Emergency in Turkey.

The present study evaluates the reported medical examination procedures in Turkish detention facilities of Turkish detainees who sought asylum in Germany after their detention in Turkey and the present process of medico-legal reporting, to evaluate compliance with the principles of the Istanbul Protocol and to discuss the issue in the context of the literature. Fifty-one participants were asked questions related to the examination steps specified in the Istanbul Protocol. 61% of participants were examined in an inappropriate place according to Istanbul Protocol. 42 participants (82.3%) claimed they had been mistreated through beatings, improper application of handcuffs, being forced to stand up for a long time, lying on bare concrete floors, staying in confined spaces without fresh air, and psychological torture. The answers given by the participants revealed that not all medical examinations conducted by the Turkish authorities during the detention were carried out in accordance with the Istanbul Protocol.

An unusual suicide by self-waterboarding: forensic pathological issues.

The authors present the first case, to the best of our knowledge, of a preplanned suicide by self-waterboarding. Waterboarding (WB) is a military method of torture in which water is poured into the nostrils and the mouth of a victim, to evoke the sensation of asphyxiation by drowning. The victim was a 22-year-old male student, who was found dead and naked in the bathtub. His head was covered by a soaked canvas bag, and his hands were tied with two nylon ropes and a padlock. The water jet of the showerhead was specifically directed at the victim's head, so that the canvas bag could be soaked with water. The cause of death was defined as the combination of asphyxiation by drowning with the direct suffocation provoked by the soaked canvas bag in the context of the waterboarding practice. Finally, the authors discuss the differential diagnosis regarding the modality (suicide versus homicide) through which this case of waterboarding was performed. The case is intended to be used as source data for similar forensic cases, where a multidisciplinary approach is advisable in such complex cases.

Forensic evaluation of alleged wrist restraint/handcuff injuries in survivors of torture utilizing the Istanbul Protocol.

Despite being a common form of abuse, there is a paucity of literature describing shackling and wrist restraint injuries among survivors of torture. Forensic evaluation of alleged wrist restraint/handcuff injuries in survivors of torture presents challenges to the evaluator, especially if the injuries are remote and do not leave lasting marks nor neurologic deficits. Thorough history-taking and physical examination are critical to effective forensic documentation. Guidance is provided in The Manual on Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (Istanbul Protocol), the gold standard for the medicolegal documentation of torture. This guidance relies primarily on physical findings, with less direction provided on how to interpret historical evidence or when historical evidence provided by the patient can be interpreted as highly consistent with alleged injury in the absence of current physical findings. Through a case-based review, we present diagnostic strategies for the evaluation of alleged abuse involving wrist restraints/handcuffs, focusing on skin, neurologic, and osseous injuries. We highlight key findings from both the history and physical examination that will allow the evaluator to improve the accuracy of their expert medical opinion on the degree to which medical findings correlate with the patient's allegations of wrist restraint injuries.

Tortures alleged by migrants in Italy: compatibility and other medicolegal challenges.

BACKGROUND: Illegal immigration to Europe is a well-known phenomenon whose numbers are being steadily increasing in recent years. Most of the immigrants in Italy come from war zones, and many of them submit an asylum application supported by the complaint to have been victims of persecutory acts in their home countries. MATERIAL AND METHODS: One hundred ninety-six medicolegal reports are analyzed considering the different country of origin, the type of the lesions claimed, tools used, evidenced effects, location of the perpetration of the physical abuses, and the possible motivation of the alleged torture. RESULTS: Greater than 80% of the assessed asylum seekers are over 18-year males coming from African countries. Fifty-eight percent of migrants were tortured or abused in countries of transit, 95% in Libya. Economic, familial, politic, and ethnic reasons prevail in some countries of origin, while tortures or abuses perpetrated in transit countries are mainly linked to forced labor and detention. In the 42.2% of cases, no physical evidence of tortures was detected. The Istanbul Protocol resulted to have been only partly applicable and about 40% of the medicolegal reports are "inconclusive" about the compatibility of physical evidence with the alleged tortures. CONCLUSIONS: The medicolegal and forensic experts involved in torture and ill-treatment cases should seek specific education and training to lower the risks of underestimation and the rate of inconclusive reports. More extensive implementation of the Istanbul Protocol in daily practice should be pursued by the authorities in charge of asylum or protection releasement.

Physical activity, post-traumatic stress disorder, and exposure to torture among asylum seekers in Sweden: a cross-sectional study.

BACKGROUND: Forced migrant populations have high rates of trauma-related ill health, including post-traumatic stress disorder (PTSD). Physical activity (PA) is well-established as an effective stress reliever, while insufficient PA is associated with adverse effects on both mental and physical health. The aim of this study was to examine the prevalence of different levels of PA and its association with PTSD symptom severity, controlled for exposure to torture, among asylum seekers in Sweden. METHODS: A cross-sectional survey study, with data from 455 asylum seekers, originating from Afghanistan, Eritrea, Iraq, Somalia, and Syria, residing at large housing facilities across Sweden. Level of PA was assessed by the Exercise Vital Sign and categorized as; Inactive, Insufficient PA, and Sufficient PA. Prevalence estimates for proportions of different levels of PA were calculated. Analysis of variance were conducted to determine the association between levels of PA and PTSD symptom severity, measured by the Harvard Trauma Questionnaire. Multivariable logistic regression analysis was performed to determine the contribution of PA on PTSD beyond sex, age, and exposure to torture. RESULTS: About half of the participants (53.3, 95% CI: 48.6-58.1) met the recommendations for Sufficient PA. One third of the participants (33.3, 95% CI: 28.7-37.8) were insufficiently engaged in PA, and 13.4% (95% CI: 10.1-16.7) were inactive. There was a significant difference in PTSD symptom severity between groups of asylum seekers with different levels of PA (F(2, 316) = 23.15, p < .001). When controlling for sex, age, and exposure to torture, Sufficient PA was found to be associated with less PTSD symptom severity compared to both Insufficient PA (B = 0.297, SE = 0.086, p < .001) and Inactive (B = 0.789, SE = 0.104, p < .001). CONCLUSIONS: Insufficient PA was common among the asylum seekers and our findings suggest that more PA is highly associated with lower PTSD symptom severity. An increased focus on assessment and promotion of PA is justified and discussed as particularly pertinent considering the much extended time of asylum-seeking processes. The results support previous evidence of PA as a potentially important factor in the context of PTSD and forced migrants' health.

More than just a dental practitioner: A realist evaluation of a dental anxiety service in Norway.

Patients with dental phobia or a history of trauma tend to avoid dental services, which may, over time, lead to poor oral health. In Norway, a specific service targets these patients by providing exposure therapy to treat their fear of attendance and subsequently enable oral restoration. Dental practitioners deliver the exposure therapy, which requires a role change that deviates from their traditional practice. This paper explores how - and under what circumstances - dental practitioners manage this new role of alleviating dental anxiety for patients with a history of trauma or dental phobia. Using a realist evaluation approach, this paper develops theory describing which contexts promote mechanisms that allow practitioners to alleviate dental anxiety for patients with trauma or dental phobia. A multi-method approach, comprising service documents (n = 13) and stakeholder interviews (n = 12), was applied. The data were then analysed through a content analysis and context-mechanism-outcome heuristic tool. Our findings reveal that dental practitioners must adopt roles that enable trust, a safe space, and gradual desensitisation of the patient to their fear triggers. Adopting these roles requires time and resources to develop practitioners' skills - enabling them to adopt an appropriate communication style and exposure pace for each patient.

"I just need to be with my family": resettlement experiences of asylum seeker and refugee survivors of torture.

A global migration of individuals fleeing persecution, violence and armed conflict reached almost 60 million world-wide in 2015. This world-wide crisis of displacement reflects people seeking safety across borders and oceans; dangerous journeys that compound the trauma endured by these women, men and children. Refugees/asylum seekers face barriers upon entry to the U.S. The Western New York Center for Survivors (WNYCST) provides care coordination/trauma-informed care to mitigate these challenges. The objective of this study was to explore the resettlement experiences of survivors of torture living in Western New York, who had received services from the WNYCST; identifying challenges, unmet needs, and services that were helpful. Secondarily, we describe the experiences of asylum seekers and legally resettled refugees, who due to their differing legal status, might be expected to have different experiences. Data were collected using semi-structured qualitative interviews. RESULTS: Three themes emerged: mental health challenges, relating to their experiences in their home country and their separation from family; unmet needs, including lack of a sense of purpose and meaning, difficulty navigating services, and missing connections to community; and coping strategies, including WNYCST assistance with connecting with sources of social support in their new community. WNYCST services were helpful, particularly the assistance and connection with care coordinators and local support groups. This care and outreach helped to mitigate feelings of separation and apartness from their home countries and families. CONCLUSIONS: Some refugees/asylum seekers continue to struggle with unmet needs, issues of loss and isolation. If care providers recognize signs of stress early, appropriate interventions can be implemented. Care connections and trauma informed treatment with an emphasis on recreating ties with communities, may be one important factor in ensuring successful integration.

Beyond torture checklists: an exploratory study of the reliability and construct validity of the Torturing Environment Scale (TES).

BACKGROUND: Torture methods have traditionally been quantified using checklists. However, checklists fail to capture accurately both the almost infinite range of available methods of torture and the victims' subjective experience. The Torturing Environment Scale (TES) was designed as a multidimensional alternative that groups torture methods according to the specific human function under attack. This study aims to do an exploratory assessment of the internal consistency reliability and discriminatory validity of the TES as part of a construct validity assessment in a sample of Basque torture survivors. METHODS: We applied the TES to a sample of 201 torture survivors from the Istanbul Protocol Project in the Basque Country Study (IPP-BC) to profile torturing environments in detention. To estimate the internal consistency reliability of the scale, categorical omega values were obtained for each subscale of the TES. To assess its discriminatory validity, the "known groups" method was used comparing mean scorings by gender, state security forces involved in the detention, and decade (the 1980s to the present) when the events took place. RESULTS: Men reported more physical pain, while women reported more attacks on self-identity and sexual integrity. The TES also showed significant differences as regards the security forces involved in the detention: Civil Guard (a militarised police) used more manipulation of the environment, threats, fear, pain and extreme pain, as compared to national and regional corps. Finally, although patterns of torture remained mostly unchanged across decades, more recent detentions included more emphasis on psychological attacks: context manipulation, humiliation linked to sexual identity, and attacks to meaning and identity. For all subscales of the TES, categorical omega values ranged from 0.44 to 0.72. CONCLUSION: The TES may be a useful tool in profiling torturing environments. Its sensitivity to key contextual variables supports the discriminatory validity of the scale. While some of the subscales showed an acceptable degree of internal consistency, others require further analysis to improve reliability. The scale provides unique insights into the profile of contemporary torture. It will allow for future quantitative research on the relationship between different torturing environments and the medical and psychological consequences thereof.

The impact of torture on interpersonal threat and reward neurocircuitry.

OBJECTIVE: Torture adversely influences emotional functioning, but the neurophysiological mechanisms underpinning its impact are unknown. This study examined how torture exposure affects the neural substrates of interpersonal threat and reward processing. METHODS: Male refugees with (N = 31) and without (N = 27) torture exposure completed a clinical interview and functional magnetic resonance imaging scan where they viewed fear, happy and neutral faces. Between-group activations and neural coupling were examined as moderated by posttraumatic stress disorder symptom severity and cumulative trauma load. RESULTS: Posttraumatic stress disorder symptom severity and trauma load significantly moderated group differences in brain activation and connectivity patterns. Torture survivors deactivated the ventral striatum during happy processing compared to non-torture survivor controls as a function of increased posttraumatic stress disorder symptom severity - particularly avoidance symptoms. The ventral striatum was more strongly coupled with the inferior frontal gyrus in torture survivors. Torture survivors also showed left hippocampal deactivation to both fear and happy faces, moderated by trauma load, compared to controls. Stronger coupling between the hippocampus and frontal, temporoparietal and subcortical regions during fear processing was observed, with pathways being predicted by avoidance and hyperarousal symptoms. CONCLUSION: Torture exposure was associated with distinct brain activity and connectivity patterns during threat and reward processing, dependent on trauma exposure and posttraumatic stress disorder symptom severity. Torture appears to affect emotional brain functioning, and findings have the potential to guide more targeted interventions for torture survivors.