Torture is the deliberate infliction of severe pain or suffering, physical or mental. When perpetrated by someone who is working as or with the approval of an agent of a state, torture is a violation of international human rights law. Allegations of torture must be investigated by the state and, if they are found to have substance, prosecuted. States that fail to prevent, investigate or prosecute torture may be breaching various universal human rights conventions and, for many countries, also regional international agreements. The United Nations has several mechanisms that investigate widespread allegations of torture, and national and international NGOs are encouraged to gather information and pass it on (see The Torture Reporting Handbook see section 8.2 for further details).

Torture can be prevented in part by the regular inspection of detention facilities by independent bodies. Different countries do this in different ways, and there are also independent international organisations with considerable experience in visiting places of detention, including the International Committee of the Red Cross (ICRC) and the Committee for the Prevention of Torture (CPT) of the Council of Europe. The Optional Protocol of the UN Convention Against Torture requires signatories both to establish national visiting mechanisms and to allow visits by an international body of experts formed under the Protocol.

The documentation of torture is generally a multi-disciplinary task in which doctors and other health professionals (for example nurses and psychologists) have important roles. These range from the treatment of individuals seeking medical help for health problems that are a consequence of being tortured, through working in NGOs that provide services to victims of torture, to participating in official visiting bodies. Health professionals have an ethical duty to treat victims of torture and, with their consent, to make the relevant authorities aware of the torture, providing this does not put the subjects or those close to them at risk.

Documentation can take a range of formats. Well-written clinical notes are indispensable in medico-legal settings, or an NGO may bring together a number of reports to provide an anonymised summary of human rights abuses in a particular place. A health professional can be asked to provide a medico-legal report, which can be a statement of fact and opinion. It is important, however, not to express an opinion without the necessary expertise. With experience and, if available, training, a health professional should be able to produce a high standard of documentation, and if required, a good quality report. The aim of this Handbook is to introduce health professionals to the framework and key elements for providing accurate medical documentation of allegations of ill-treatment.

The first part of any documentation is an account by the individual of the ill-treatment that he or she suffered. A survivor of torture is in a vulnerable situation, and the circumstances of any interview may contribute to this vulnerability (e.g. a history and examination that may have to be conducted on someone in custody of the police or military). Witnesses who may not themselves have been similarly ill-treated might also be vulnerable. The health professional may have limited control over the environment of the interview, but where possible the environment should be as neutral as it can be. The interviewer should avoid leading or closed questions. Some cognitive techniques can be valuable. Photography, drawings or body diagrams, and notes about demeanour are helpful. Consent is essential, and intrusive physical examinations must be avoided. An expert clinical opinion can be sought regarding the physical and psychological findings. The absence of any clinical findings does not necessarily mean that ill-treatment has not occurred.

There are many reasons why accounts may differ from one telling to the next, or may conflict with other evidence. This does not mean that the individual is not telling the truth about what happened. For example, both head injuries and post-traumatic stress disorder can interfere with normal memory function. However, discrepancies should be probed, and explained in any subsequent report. Explanations should be in the clinical sphere, as it is not the health professional who is the ultimate arbiter of fact.

The documentation of torture must take into account often complex histories of repeated arrests and detention, and repeated and varying levels of both mental and physical torments and suffering. By approaching the documentation within the framework given in this Handbook, each element of the complex history can be identified and addressed. While medical documentation cannot by itself definitively prove torture, it often provides a central element in corroborating (or refuting) allegations of torture, be they in instances of asylum claims, complaints and investigations against security forces, or investigations by international bodies or organisations. Physical findings are described using standard technical terms such as ‘abrasion’, ‘bruising’, ‘laceration’, ‘dislocation’ and ‘fracture’. Any report can then assess the consistency, within a clinical context, between these findings and the individual’s account.

The psychological evaluation is equally important in the documentation of torture since both physical and psychological methods produce psychological sequelae. ‘Purely psychological’ forms of torture are not uncommon and need to be explored in as much detail as physical torture because the consequences can be equally severe. Frequent diagnoses are depression and post-traumatic stress disorder, and they may co-exist. Many survivors of torture prefer not to show emotion when describing their experiences and may not be aware of the clinical significance of symptoms such as nightmares. So, the absence of psychological findings does not necessarily mean that the account of ill-treatment is false.

Thus health professionals have an important role in the investigation and documentation of torture. Health professionals have a moral, ethical and legal duty to assist within their capabilities. It is within the capability of most experienced health professionals to document torture and to work with multidisciplinary teams investigating allegations. The skills include of interviewing the patient – taking a history; making a psychological assessment; and documenting both psychological and physical signs of trauma. Report writing involves documenting facts and drawing conclusions within the professional capability of the writer.