Torture and its consequences

 An ICRC viewpoint  

 Hernan Reyes, MD*, is a trained obstetrician/gynaecologist from Geneva University, the author subsequently specialized in the medical aspects of detention. He has been a medical coordinator for the ICRC's detention-related activities since 1984 and is now based in Geneva. His work includes visiting prisoners, together with ICRC teams in the field, and medical coordination at headquarters level, as well as liaising and exchanging experiences with many medical groups around the world.  

 * Medical Division, International Committee of the Red Cross, ICRC, Geneva, Switzerland  

During the Seminar on Torture and Organized Violence held in Moscow by COMPASSION in September 1994, the International Committee of the Red Cross (ICRC) gave an outline of its main activities in the field of visits to prisoners, stressing the work being done in connection with the Nagorny-Karabakh conflict. Since then the conflict in Chechnya has taken on a new dimension. The principles stated at that time for visits to prisoners fro m all sides hold just as true in the more recent conflict as they do for all areas in which the ICRC works.

In writing this summary, the author has deliberately decided to specify certain general principles concerning torture and its consequences, as they are relevant to the work performed by ICRC delegates and physicians in the field.

 ICRC visits to prisoners  

The many activities of the International Committee of the Red Cross in areas of conflict include visits to prisoners all over the world. In 1994, over 99,000 prisoners were visited by its delegates and physicians. The purpose of these visits is to ascertain that people in custody are kept in adequate conditions of detention, and that they are not subjected to any forms of ill-treatment, i.e. that their physical and moral integrity is respected.

ICRC visits and the necessary conditions for them to take place have to be negotiated beforehand with the detaining authorities. There are several sine qua non conditions that have to be accepted by the authorities before the ICRC begins visits. These conditions and what ICRC visits are meant to accomplish have been described in a previous paper published in the International Rehabilitation Council for Torture Victims (IRCT) TORTURE journal [1,2 ] . All health aspects unrelated to the problem of torture are detailed therein and will not be mentioned here.

In situations where prisoners are subjected to cruel, inhuman or degrading forms of treatment, ICRC delegates document the use of torture so as to submit a detailed account of the situation to the authorities, calling on them to put a stop to such practices. ICRC physicians have the additional task of seeing and examining these prisoners so as to assess their state of health.

 The physician's role  

ICRC doctors receive specific training and specialized documentation to enable them to give the most effective help possible to victims of torture whom they see during the visits. The role of the physician in this specific field of work is obviously quite different from that of a doctor " outside " the detention environment. There can be no question of the ICRC doctor " treating " these persons, in the generally accepted sense of the term, whilst they are still held in captivity. Once they are released, moreover, the question of treatment is likewise beyond the scope of the ICRC doctors, but at least those persons in need of treatment can be referred to any readily accessible centre.

What can be achieved within the short period of time allotted to the doctor during the ICRC visit is to give the individual prisoner the opportunity to consult a medical professional who sympathizes with his or her plight. (A medical visit to a prisoner may take between 15 and, rarely, 40 minutes, sometimes even more: ICRC doctors have to explain that there has to be sufficient time for all those who need to see the physician to be able to do so.) The ICRC doctor can offer counsel and guidance after performing an independent medical examination, if the latter is warranted. The prisoner can then count on a medical advocate for any necessary therapy that is in fact available while he or she is still in detention. ICRC physicians endeavour to do all of this: one of their tasks that is often difficult is trying to obtain an outside medical examination (X-ray, laboratory, etc.) for the prisoners they see, or to have someone taken for specific treatment to a referral hospital, where the patient will be followed up by the ICRC doc tor.

The importance of an independent - in this case an ICRC - doctor being able to perform a medical examination should not be minimized. Seeing an independent physician who shows genuine concern for the prisoners'health is all the more important, since in many (or most?) countries where ill-treatment or torture is practised, prisoners have to rely on the services of institutional doctors - outside physicians are not allowed to attend to prisoners. Most often in such situations, prisoners do not trust the " inside " medical personnel. This may be for legitimate reasons in countries where doctors have, for example, actually participated in interrogations. It may also be an understandable feeling of mistrust that any prisoner might have while in detention.

If there is any question of torture, the importance of the doctor being independent is manifest. However genuinely professional a prison doctor is, it is only too understandable that prisoners who have undergone torture will not place their trust in a doctor seen as being part of the custodial - or repressive - system.

So apart from the obvious interest in establishing firsthand documentation of torture, ICRC doctors are thus also in a unique position to bring some medical assistance and comfort to these persons who have been denied comfort and relief during their ordeal.

On the one hand, a professional assessment of the torture situation leads to a report - which, in accordance with the ICRC's proven working methods, is confidential - to the higher authorities, demanding that all such practices cease. On the other hand, at the " field " level (i.e. in the prison), and with immediate and practical benefit for the victims themselves, the ICRC doctor can advise, explain to and reassure persons suffering from the multifarious complaints and after-effects of torture.

Even though what may obviously be the main problem for prisoners - their being deprived of freedom - is an issue which the ICRC cannot and usually does not tackle (apart from exceptional medical cases: requests for releases on medical or humanitarian grounds can then be presented), this unique contact while still in custody can be helpful. Being able to explain symptoms and give advice on what can possibly be done while still in prison, or what is to be expected in the long term, is already a form of therapy in many cases. It can be explained to someone, even behind bars, that the symptoms of torture are the " normal reaction by a normal person to an abnormal situation " (quoted from IRCT's Dr. Inge Genefke) [3 ] . This is, in our view, a service that can help prisoners much more than may seem apparent to the outsider at first sight. (To give just one example, it can be of immense relief for a prisoner to learn from an independent doctor that his body has been battered and abused, but that apparently - after examination - there is no permanent damage to the reproductive system. It must be remembered that the threat of future sterility is often brandished by torturers as part of the ordeal.)

Much of the knowledge acquired from the vast experience of the many rehabilitation centres for torture victims around the world, information that has been duly published, can be used by ICRC doctors in their attempts to bring all possible relief to these prisoners whilst they are still in custody, sometimes serving long sentences and with little hope of release in any foreseeable future.

 On definitions of torture  

The reasons for torture are many. They have been discussed at length in countless publications and papers, and particularly in medical studies and documents by the IRCT in Copenhagen and other such rehabilitation centres. While it is not the purpose o f this paper to reopen this issue, a number of comments based on the author's experience with the ICRC would seem necessary and useful.

" State torture " , as a designated government policy intended to break any or all political opposition and, as such, applied to anyone suspected of being an " enemy " of those in power, is unfortunately still a very real occurrence. Torture of " political prisoners " , and particularly of their leaders, is clearly still going on in various countries. (The term " political prisoner " is used here for the sake of convenience to designate opponents, real or seen as such by the government. Few if any governments admit to having " political prisoners " .) It is this use of torture that best fits the description of " the most efficient weapon against democracy " as used by the Danish IRCT (quoted from Dr. Inge Genefke) [4 ] . Unfortunately, this rather restrictive definition tends to make people forget that torture can be and is used in many other contexts.

There are indeed many other aspects to this issue. The ICRC does not have its own definition of torture and uses, when necessary, those already established - or none at all - as it sees fit in a given situation. Definitions of torture have become more complex, and not necessarily clearer, over the years. (See the Amnesty International and World Medical Association definitions, both formulated in 1975, and the 1984 definition by the United Nations in its Convention against Torture.) The one generally accepted today is that of the UN, which defines torture as being an aggravated form of cruel, inhuman and degrading treatment.

It is interesting to note that definitions of torture have tried to set out the possible intents of those who practise torture. (Earlier definitions, as for example the definition by Professor Chet Scrignar of Tulane University, New Orleans, do not attempt to define the pu rpose of the torturer, but only describe the effect of torture on the victim. Prof. Scrignar defines torture as " An intentional trauma deliberately conceived by vile men to systematically cause pain and suffering to a selected individual, and ultimately ending with the physical and psychological collapse of the victim. " ) The old notion that the main purpose of torture was to make people " talk " (and give information) was rightly countered in the 1970s by the opposite notion, namely that the intent of torture was, in fact, to make the general population keep silent ... It is this targeted type of torture that indeed attempts to curb democracy.

Without getting into a detailed analysis of torture as it stands in the mid-1990s, it must be said, however, that the purpose of torture is not as clear-cut as it was, for instance, in the mid-1970s or early 1980s. In those years, the " torture versus democracy " formula was, if not the rule, arguably the most visible and widespread form of systematic state torture. This was the kind of torture that had been applied to the victims (or " survivors " , as they are called today) who managed to reach the various centres in Europe and North America, where they were received and tended by concerned health professionals and human rights workers. These people were the sources of information for many of the publications on torture.

But as it did even then, the true purpose of torture spans a much broader spectrum of reasons today in the mid-1990s than " merely " the dissuasion of political dissidents. Torture has always been, and still is, used for many other reasons. One of the most perverse forms of torture is its use to elicit compliance and collaboration from people not actually involved in a given conflict, but who are tortured and blackmailed so that they will infiltrate or testify against suspected " enemies " of the government.

Forced collaboration, with all its implications, is arguably one of the most tragic aspects of the use of torture. The victims who have been forced to collaborate are shunned and rejected by all, and are at immense risk of being killed or tortured by their own people.

Torture and other forms of violence perpetrated to induce what is now called " ethnic cleansing " are another case in point. Innocent civilians without any political stance or ideology have been brutally tortured - and many massacred - only to force them to leave their lands. These people are victims of a policy that has little to do with repressing democracy.

A third example of torture that does not fit the " antidemocracy " definition could also be mentioned, namely the incredibly cruel and inhuman beatings and other forms of violence - that cannot be called anything else but torture - inflicted on prisoners in some countries. Those people are common law prisoners, and not dissidents or opponents of any kind, and they are tortured so as to dissuade them from escaping. Prison guards, when told that their already miserable wages will be slashed by 50% if a prisoner escapes, do not hesitate to use incredibly violent forms of repression.

The list could go on. The point being made here is that the fight against torture has to be seen to encompass all these forms of torture, and not just the torture of real or imagined political dissidents. It is in this light that the 1984 UN Convention's definition of torture very rightly states as the bottom line, when defining the possible intents of torture: " ... or for any other purpose".  

The term organized violence itself is perhaps rightly championed by many human rights groups. Such v iolence has been and is used for the same purposes as torture, and in some cases there has been a government policy to implement it. In other cases the motive behind the use of organized violence may be less clear ... The term certainly includes the notion of torture, whatever the definition, and its use may in many cases be preferable to the always controversial term'torture " . (What is meant here by " controversial " is that the purpose of intervening against torture is to have it cease, no to beat around the bush by dissecting definitions. This is one of the reasons why the ICRC does not use any specific definition, but prefers instead to describe what is going on.)

The effects on the victims of torture or organized violence (and what about " unorganized " violence?) are obviously very different depending on the group that is targeted. When subjected to state torture, political activists, who are arguable " prepared " for torture - in some cases even " trained " to expect it - have coping mechanisms that men, women and children who are tortured because they happen to be in the wrong place or belong to the wrong ethnic group, or both but who are not militants in any particular cause, obviously do not have. Civilians caught up in the various forms " ethnic cleansing " in various countries are examples of persons who are in no way " prepared " for the frightful violence perpetrated against them.

It is certainly not the objective here either to comment on the diverging parameters of those professional medical groups who favour what can be summarized as the " torture syndrome " approach, and of those other professionals who believe that the effects of one and the same form of torture will vary immensely according to the inner strength, personality and coping mechanisms of those to whom it is applied.

Suffice it to say that there is still an immense amount of w ork to be done in this field. The main point to be stressed here would be that torture must not only be seen as a form of repression of potential political prisoners, but as a far more extensive evil.

 On the documentation of torture  

The ICRC can be said to have a significant amount of experience in this field, because it has been visiting political prisoners continuously since 1918. Torture has unfortunately very often been an issue during these visits.

Documentation of torture is compiled by ICRC delegates and physicians during their visits to prisoners in their places of detention. (Only rarely are prisoners seen by ICRC physicians after their release.) They do so during the essential stage of the visit which involves direct dialogue and contact with prisoners. These interviews in private are one of the non-negotiable conditions for ICRC visits to take place at all. Only through this personal and direct contact with the prisoner can the ICRC expect to get firsthand information on the various topics it is interested in covering.

The subject of torture and its consequences is obviously one of the main concerns of the ICRC. By interviewing prisoners individually and allowing them to talk about their problems and preoccupations, ICRC delegates and physicians get a general picture of what the situation is. Once the ICRC has a clear idea of it, the main objective is to raise the issue officially with the relevant authorities, calling on them to end such practices.

The doctor's additional specific role has been mentioned above. In some cases, ICRC nurses also assist the delegate and doctors in these tasks.

The actual reports submitted to the authorities have to give a complete and accurate picture of the prisoners situation. By working in a professional way, with trained delegates and physicians, and by carefully cross-checking al information received - from authorities as well as from prisoners - the ICRC can determine what has actually happened. It is stressed to physicians in particular, who actually examine victims of torture and obtain most key information through their privileged doctor-patient relationship, that torture has to be documented in a comprehensive way. The main objective is an assessment of the overall consequences of torture, and not just a listing of the methods used.

This is an important point, with at least two subheadings. First, it must be emphasized that merely " listing methods " , a practice all too often used in the documentation of torture, is not an efficient way of dealing with the issue. Such listings cannot convey the real horror of a situation, and tend to separate " physical methods " from " psychological methods " .

Second, it has to be underlined that visible and apparent lesions are only part of the story, and may indeed not be the worst part at all. ICRC delegates are trained to see beyond the mere scars or marks of torture they may initially see or be shown. " The worst scars are in the mind " (quoted from Dr. Sten W. jakobsson, Stockholm) [5 ] , and it is much easier for torture victim to show the wounds on his back than to the about the wounds on the soul. What could be called the " WYSIWYG " (term meaning " What You See Is What Yo Get " ) approach to documentation should be avoided at a costs. Sequelae of torture have been widely documented elsewhere [6,7 ] . Unfortunately, many health professionals who work with asylum seekers, for example, have to produce " physical evidence " to prove that torture has taken place. Psychological evidence of torture has yet to be accepted in most countries as valid evidence.

Whatever the method of analysis used by professionals in studies and reports on torture, it would seem necessary to say a word for the record on documentation in general. There is a tendency to use " check-lists " and other such tables in field work. The information received from torture victims is often quite varied, and with the ever more frequent use of computers and databased systems, inexperienced health professionals who have to manage this information often present it in tabular form, merely checking off what methods of torture are used and listing them. Worse, the figures and categories in these tables are often fed into a system that calculates " statistics " . These figures may in some cases make a report look professional, but they are often misleading and certainly reductive.

At the ICRC, delegates and physicians are told when in training to avoid this " tabular " mentality. Nothing can replace a professional written report, describing methods and observations in factual sentences, with as many examples as necessary. These examples can be given in a transcription of the victim's own words, or in a summary, whichever is more convenient and practical. Many professional human rights organizations work in this way and do not rely on misleading tabular presentations.

The following intentionally simplistic table (table 1) illustrates the type of documentation that, in the author's opinion, should be avoided. The shortcomings should be particularly obvious in the three-case example given below, but the principle applies to any such tabulation.

 Table 1. Fictitious example of three prisoners who are victims of torture.  

This table is the " graphic " result of a hypothetical visit to a given prison where three prisoners who have been subjected to torture have been interviewed. The resulting table is similar to many such tabular summaries used by well-intentioned persons working with torture victims in their attempt to organize and set down information.

In the case shown, Sacha has been beaten (badly: ++ is worse than +) and subjected to electric shocks. Alyosha has also been badly beaten and has likewise suffered from the application of electric current. He has been hooded, too. Pavel, according to the table, has been subjected to the same treatment as Alyosha, without electric shocks. All three have been subjected to what is euphemistically called " threats and insults " .

What is not specified in the said table, but very well could be in an additional column, are the " statistics " : in this simplified case, there would be 100% beatings, 66% electric shocks, 66% hooding, and all (100%) prisoners subjected to threats and insults while being tortured. (The observation that statistics should never be drawn up on the basis of such a small number of cases is obviously relevant: however, this has been done all too often.)

It is precisely this type of " methodological table " that warrants further scrutiny:

The first prisoner, Sacha, who was subjected to beatings and electric shocks, should seem a straightforward enough case. An apparently " severe beating " was given. But what does this mean? Is the qualifying double " ++ " sign based on the description given by the prisoner? Or is it perhaps because of the physical state in which he was found at the time of the interview? Does " ++ " take into account the differences between receiving a beating when the subject it a strapping, athletic, strong-willed mil itant, or a peasant farmer's wife who happens to belong to the wrong ethnic group or religion and has not the faintest notion of why she is being mistreated?

Electricity was used. But a mere + in the appropriate box gives no idea of the effect electric shocks may actually have had on the person. The + sign reduces the information here to the presence or absence of their use.

" Threats and insults " are all too often dismissed as an inevitable part of torture by inexperienced workers in their summing up. As entered in such a table, they might be considered by the intended reader as something of a common side-effect, as nausea and vomiting are considered frequent side-effects induced by many medicines ... This is obviously not the case, as anyone who has dealt with torture victims will know.

The second prisoner, Alyosha, has been subjected to the same ill-treatment. For argument's sake, let us suppose that the circumstances were outwardly the same (same torturer, same duration, same place ... ). Threats and insults were also a reality of torture for Alyosha.

The fact that he was hooded during the " session " can be most important, a feature that a mere table cannot convey. The additional anguish and pain induced by not knowing from which angle the next kick or bludgeon will come changes the situation entirely. The " same " beating will have a considerably different effect on these two prisoners. Many studies have shown that this apparently superficial detail is a major factor in making torture even more unbearable.

Apart from the mental anguish induced by the inability to see where the next blow will strike, there is an actual physical component as well. The uncertainty makes the body's muscles contract in anticipation, and this makes the blow aIl the more painful - and an electric shock even more so. Muscular spasms induced by electric current in this situation are described as being much worse than when the shocks can be anticipated, and have been known to cause additional lesions.

Is it necessary to repeat that hooding is part and parcel of torture, and not, as always alleged by the torturers, " merely a security precaution " ? Included in a torture session of beatings and electric shocks, it compounds the effects of this torture. This fact can hardly be transcribed in a mere additional column in a table!

In the third case, Pavel, (this example - one of so many is taken from a real case, that of a person interviewed by the author in 1994) the treatment would seem to have been the same as for Alyosha, with the difference that electricity was not used. How can any such table, however, convey what may actually have been the worst part of the ordeal for Pavel. In this case, the prisoner Pavel was arrested at the same time as his 14-year-old son. While being subjected to the same beatings as the preceding case (beatings while hooded), the worst of all in Pavel's case was not knowing whether'they " were going to inflict the same treatment on his son and to be threatened with the use of electricity on him. Torture of his son may have been implied directly (and set down dutifully in the table's aseptic column " threats and insults " , or merely imagined by the father. The threat to the son may have been real, or it may have been merely used by the torturers as yet another form of torment. The result is that for this third prisoner, the fear he felt for his son completely screened off all physical suffering. (In the real-life case, the prisoner said he hardly remembered the pain caused by the (brutal) beating, he was worried for his son.) The mental anguish, however, continued well beyond the actual " session " , until he was finally able to find out what had happened to his son.

This psychological factor ( " the worst scars are in the mind " ) is impossible to incorporate into such a table! The  point here is that the psychological effect torture has on people is  impossible to translate into tabular form.  A proper description of the effects the different methods of torture have on people, in a properly drafted text, cannot be replaced. It should be obvious from this intentionally simplistic example that describing torture situations is a complex matter, and that the real picture cannot be conveyed by tables and charts. The false sense of " scientific evaluation " given by drawing up such tables and their " statistics " can in fact be counter-productive. This is one of the main pitfalls drawn to the attention of ICRC delegates and doctors who are sent into the field to visit prisoners.

What is needed to convey the real situation to an authority responsible for such matters, with any hope of convincing it that torture has to stop, is a comprehensive report with an indisputable description not only of the methods used, but also of the after-effects of the torture on the victims. Medical descriptions, if warranted, should give the overall picture and not merely a forensic description of scars or other sequelae. The psychological aspects should be integrated into the physical aspects, so that there is no false dichotomy in what is in fact a single, indivisible entity.

Another consideration that is all too often overlooked or minimized, namely the degrading and humiliating aspects that play such a fundamental part in the world of torture, should also be spelt out and underlined. These aspects were omitted in the example above (table) so as to simplify the message, but likewise clearly cannot be transcribed in any additional column.

To summarize, an a ctual " clinical picture " of the situation should leave no doubt in anyone's mind that the victims were indeed subjected to something that can only be called torture. In this way one can begin to discuss how to stop the procedure, instead of haggling over definitions, methods, or percentages.

 Conclusions  

To draw definitive conclusions on such a difficult topic as the one formulated in the heading would be presumptuous. Let it simply be said here that the ICRC endeavours in its work to bring relief and assistance to all prisoners it visits in a conflict situation, and to ensure their physical and moral integrity. This applies to all parties and to all sides.

Emphasis has been placed on the necessity of having neutral, and particularly medical, intermediaries. This necessity is particularly great when torture is involved. By obtaining its information directly from all sources and through firsthand assessments by its own personnel, including medical staff, the ICRC is able to draw up comprehensive reports which it transmits to all authorities concerned. By ensuring that all reports are as professional as possible, appropriate requests can be made at all levels for a stop to all use of torture.

To this effect, ICRC delegates and physicians must constantly strive to maintain a professional approach in making their assessment. In reporting cases of torture to the authorities, they must avoid the pitfalls inherent in categorizations and database simplifications. Use of tabulations and statistics is better left to physicians and medical groups who do research in adequate settings, using proper scientific methodology. The two approaches are complementary but most often not interchangeable.

 References  

1. Reyes H. Comments by Hernán Reyes, MD, on the 1993 WMA Statement on Body Searches of Prisoners. Torture 1994; vol.4, no 2, 1994, pages 54-55.

2. Reyes H., Visits to prisoners, Torture, vol.3, no2, 1993, page 58.

3. Genefke I. The purpose of torture, torture methods and sequelae. Copenhagen: International Seminar 1986.

4. Presentation by Dr. Inge Genefke at the IV International Symposium on Torture and the Medical Profession, Budapest, Hungary (Oct. 24-26 1991).

5. Presentation by Dr. Sten W. jakobsson (CTD: Centrum for Tortyr- och Traumaskadede, Karolinska Sjukhuset, Stockholm), at the Vth International Symposium on Torture and the Medical Profession, Istanbul, Turkey (Oct. 22-24 1992).

6. Rasmussen OV. Medical aspects of torture (thesis). Danish Medical Bulletin 1990; 37 Suppl. 1.

7. Basoglu M, editor. Torture and its consequences: current treatment approaches. Cambridge: Cambridge University Press, 1993.