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The Istanbul Protocol- issues and perspectives Prof. Thomas Wenzel, Medical University of Vienna, Austria Medical Director, Wellcome Centre for Torture Survivors, Vienna with: Project ATIP (Advanced and Training for the Istanbul Protocol) Istanbul Protocol The Manual on Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment A. History of the IP Aug. 1999: IP finished by more than 75 experts, representing 40 organisations in 15 countries March 2001: IP published as part of the UN‘s Professional Trainings Series Dec. 2000: IP adopted by UN General Assembly and High Comissioner for Human Rights Istanbul Protocol Supported by international organisations and umbrellas including the • United Nations • World Medical Association • World Psychiatric Association • World Council for Psychotherapy • International Council of Nurses The Istanbul Protocol Is referred to by (for example) • European Court on Human Rights • Interamerican Court on Human Rights The Istanbul protocol is• A comprehensive interdisciplinary framework to guide training (and practice) in documentation and investigation of alleged torture • It is not a standard handbook of all relevant medical knowledge Outline of the IP content I. II. III. IV. V. VI. Relevant international legal standards Relevant ethical codes Legal investigation of torture General considerations for interviews Physical evidence Psychological evidence Annexes: I. Principles, II. Diagnostic tests, III. Anatomical drawings for documentation, IV. Guidelines for medical documentation Examples for application Prisons • Prison visits • Preventive monitoring Asylum procedures Court cases • Protection • Documentation • Monitoring • Civil law • International courts • Criminal law Aspects: Medical/Psychological forensic evaluation Identify and document injuries, preservation of evidence Consistency: between medical findings and narrative, between medical and psychological findings, regional torture practices, culture Expert interpretation, referral and recommendations See also six principles Special challenges • • • • • • • Implementation Mental Health DSM V, changes DSM V and Culture Indirect victims Brain trauma Redress and recompensation Special challenges • „Curative“ justice- therapeutic aspects, prevention of undue distress and retraumatisation • Assessment of impact and needs • Indirect victims • Immaterial reparation, complex social and legal approaches to redress and reparation • Children • Preventive monitoring (Birk, Nowak, et al.) Implementation • • • • • • Translation Local manual Country strategy Reference cases Reference in legal standards and law Reference point in pre-graduate health care education and training • Reference point in post-graduate health care education and training (CME) Implementation • IPIP • FEAT • ARTIP/ATIP Implementation Implementing Istanbul Protocol standards for forensic evidence of torture in Kyrgyzstan Alejandro Moreno a, b, Sondra Crosby a, c, Stephen Xenakis a, Vincent Iacopino a, d, e, * Journal of Forensic and Legal Medicine 30 (2015) 39e42 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 2011eJuly 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. © 2014 Elsevier Ltd and Faculty of Forensic and Legal Medicine. 4. Medical examination Any iindicators of false allegation ? Impact of other stressors (like persecution, flight, displacement) Physical and psychological findings consistent with the report ? Time frame as to mental health impact and recovery ? Physical factors that contribute Six principles in the IP medical part Psychological symptoms to be expected in this cultural and social background ? See also later chapters ! Importance of mental health aspects Interfere with reporting, limit disclosure, cause contradictions Immediate treatment needs and secondary prevention including suicidality Mental health problems– psychological problems, brain trauma Can be consequences and proof/e vidence of torture and IDTt being common, persistant and potentially severe ©:Thomas Wenzel/ WPA, 2010 Inadequate legal and medical procedures lead to additional stress, trauma and injury Importance of mental health aspects Trauma-specific disorders: or symptoms example: PTSD, cultural idioms of distress, ICD 10 F 62.0 (persistant personality change) Unspecific Disordersor symptoms caused by trauma Pre-existing Disorders/symptoms aggrevated by trauma ©:Thomas Wenzel/ WPA, 2010 Complications: Substance abuse Suicidality Sexual dysfunction Impairment “Harmless” medical procedures can trigger memories of violence. Examples: Electrical contacts in an Electrocardiogram (to monitor the heart) Spreading the legs for a gynecological examination triggers memories of rape Gastroscopy triggers memories of oral rape ©:Thomas Wenzel/ WPA, 2010 Moving a leg leads to pain triggering flash-backs (intense unwanted memories) in examination or physiotherapy DSM V changes • PTSD now includes „complex“ symptoms as additional group of symptoms • Extended definition of posttraumatic disorders in children • Emphasis on culture • Cultural Idioms of Distress Culture Culture • The new DSM V framework provides a much improved structured system to describe culture specific reactions. • The IP is based on the DSM III R/IV, ICD 11 is expected for 2017. • DSM V lists especially cultural idioms of distress – highly relevant for assessment of specific, causally related reactive symptoms reflecting traumatisation. Culture • Due to the wide range of observed patterns an exhaustive „handbook“ of idioms is again not realistic. • DSM V provides the „Cultural formulation interview“ (CFI), which is using a structure similar to the McGill University MINI interview and qualitative research. • It could serve as a standard to map idioms and might be used in specific assessment if the time frame permits. DSM V (1) cultural syndromes: “clusters of symptoms and attributions that tend to co-occur among individuals in specific cultural groups, communities, or contexts . . . that are recognized locally as coherent patterns of experience” (p. 758); (2) cultural idioms of distress: “ways of expressing distress that may not involve specific symptoms or syndromes, but that provide collective, shared ways of experiencing and talking about personal or social concerns” (p. 758); and (3) cultural explanations of distress or perceived causes: “labels, attributions, or features of an explanatory model that indicate culturally recognized meaning or etiology for symptoms, illness, or distress” (p. 758) Historical Idiom of distress: „Faint“ World War I: Shell shock, „tremblers“ „Kriegszitterer“ (Conversion disorders) DSM V Cultural Formulation Interview: • 16 questions referring to four domains of assessment: Cultural Definition of the Problem (questions 1-3); Cultural Perceptions of Cause, Context, and Support (questions 4-10); Cultural Factors Affecting Self-Coping and Past Help Seeking (questions 11-13); and Cultural Factors Affecting Current Help Seeking (questions 14-16) Indirect victims • • • • Family members Peers, friends Helpers, therapists Civil society and rule of law Indirect victims Grand Chamber judgment in the case of Cyprus v. Turkey (application no. 25781/94)-reg. Article 41 (just satisfaction): awarded 30,000,000 euros (EUR) in respect of the non-pecuniary damage suffered by the relatives of the missing persons Key points: - Psychological suffering of secondary/ indirect victims - Lack of efficient and prompt investigation Indirect victims Inter-American Court of Human Rights: Miguel Castro Castro Prison v. Peru Key points: - Psychological suffering of secondary/ indirect victims - Role of experts and standards, IP used - Non-pecunary recompensation/reparation Brain Trauma Advanced module Joint project Brain Trauma: ARTIP/ATIP WPA Section of Sport Psychiatry Thomas Wenzel (Austria) David Baron (USA) Brain trauma • Brain trauma (Traumatic Brain Injury, TBI) in its wide range of forms has been frequently underestimated as a source of short and long term symptoms and impairment*. • It is very common in torture survivors. • Assessment of brain trauma is a corner stone in the investigation of torture. Keatley, E., Ashman, T., Im, B., & Rasmussen, A. (2013). Self-Reported Head Injury Among Refugee Survivors of Torture. The Journal of head trauma rehabilitation. Example: Questionnaire (I) A concussion requires a blow to the head. • Strongly Agree • Agree • Disagree • Strongly Disagree A single mild concussion can result in long-term effects, with symptoms that occur in the days and weeks following the injury. • Strongly Agree • Agree • Disagree • Strongly Disagree Although a major concussion is very serious, mild concussion symptoms can be ignored. • Strongly Agree • Agree • Disagree • Strongly Disagree There is no cumulative effect of multiple concussions. • Strongly Agree • Agree • Disagree • Strongly Disagree Brain trauma • (Blunt) Brain trauma due to beatings, fall, asphyxiation or other forms of torture is frequently overlooked, but extremely common. • Repeated brain trauma (also during torture) can lead to different sequels then a single event. • Repeated blunt brain trauma in a short time can lead to immediate death (second impact syndrome). • Symptoms can vary. Brain trauma TBI can be separated in • Immediate sequels (including intracranial bleeding) • Long term sequels • Sequels commonly caused only by repeated events (such as Chronic traumatic encephalopathy (CTE)) Brain trauma • Symptoms can be identical, similar or overlapping with PTSD (and depression) – concentration and memory problems, sleep disorder and irritability are most common shared symptoms. • Suicide risk is increased. • MRI or other radioimaging requires special strategies and might be inconclusive especially after time. Diagnosis must often be based on clinical symptomatology. • Different treatment strategies might be required. Pathophysiology • Dysregulation of ions • Causes strain on ion pumps • Leads to increased energy demand • Hypermetabolic state • Larger than normal amounts of glucose consumed • Reduction of brain blood flow • Combined with hypermetabolic state, results in “energy crisis” Postconcussional syndrome (PCS) ICD 10 F07.81 - A history of TBI (Traumatic Brain Injury) - and the presence of three or more of the following eight symptoms: 1) headache, 2) dizziness, 3) fatigue, 4) irritability, 5) insomnia, 6) concentration or 7) memory difficulty, and 8) intolerance of stress, emotion, or alcohol. Postconcussional syndrome (PCS) ICD 10 F07.81 Besides clinical psychiatric and neurological testing the following methods can be applied: • • • • Nuclear Magnetic Resonance Imaging SPECT, PET (EEG) Neuropsychological testing Cave: Posttraumatic Stress Disorder (PTSD) and PCS • Posttraumatic Stress Disorder (PTSD) and PCS are common results of the same events. • Symptoms are at least in parts similar or overlapping. • Due to the larger range of, mainly unspecific symptoms in PCS, symptom overlap with other disorders is common. • Patients can suffer from both PTSD and PCS, though treatment might have to be adapted. Cave: Posttraumatic Stress Disorder (PTSD) and PCS PTSD • • Somatoform disorders • • Concentraion difficultues Memory impairment Disordered sleep Irritability PCS Headaches Seizures Chronic Traumatic Encephalopathy (CTE) First described in 1928 (“punch drunk syndrome”) Later called “Dementia Pugilistica”, and more recently, “Chronic Traumatic Encephalopathy” Chronic Traumatic Encephalopathy Common presenting symptoms include: • • • • • • • memory loss irritability outbursts of aggressive or violent behavior confusion speech abnormalities cognitive decline/dementia gait abnormalities Up-coming challenges Are partly adressed by recent projects that provide additional matrials and certification*: • IPIP (IRCT) • ARTIP (Awareness raising and training for the IP, EU, lead Wenzel*, interdisciplinary), /ATIP www.istanbulprotocol.info • Training materials online (PHR) (Advanced) • Torture Atlas (HFT) • Torture Atlas (AI Medgroup/J. Oomen) (Especially physical sequels) EU Framework Directive Thomas Wenzel Medical University of Vienna, Austria Wellcome Centre Vienna, Austria EU Framework Directive Directive 2012/29/EU of the European Parliament and of the Council of 25 October 2012 establishing minimum standards on the rights, support and protection of victims of crime, and replacing Council Framework Decision 2001/220/JHA Budapest roadmap “In its resolution of 10 June 2011 on a roadmap for strengthening the rights and protection of victims, in particular in criminal proceedings (6)(‘the Budapest roadmap’), the Council stated that action should be taken at Union level in order to strengthen the rights of, support for, and protection of victims of crime. To that end and in accordance with that resolution, this Directive aims to revise and supplement the principles set out in Framework Decision 2001/220/JHA and to take significant steps forward in the level of protection of victims throughout the Union, in particular within the framework of criminal proceedings.” EU Framework Directive 9. “Crime is a wrong against society as well as a violation of the individual rights of victims. As such, victims of crime should be recognised and treated in a respectful, sensitive and professional manner without discrimination of any kind based on any ground such as race, colour, ethnic or social origin, genetic features, language, religion or belief, political or any other opinion, membership of a national minority, property, birth, disability, age, gender, gender expression, gender identity, sexual orientation, residence status or health EU Framework Directive In all contacts with a competent authority operating within the context of criminal proceedings, and any service coming into contact with victims, such as victim support or restorative justice services, the personal situation and immediate needs, age, gender, possible disability and maturity of victims of crime should be taken into account while fully respecting their physical, mental and moral integrity. Victims of crime should be protected from secondary and repeat victimisation, from intimidation and from retaliation, should receive appropriate support to facilitate their recovery and should be provided with sufficient access to justice.” EU Framework Directive - Application This Directive does not address the conditions of the residence of victims of crime in the territory of the Member States. Member States should take the necessary measures to ensure that the rights set out in this Directive are not made conditional on the victim's residence status in their territory or on the victim's citizenship or nationality. Reporting a crime and participating in criminal proceedings do not create any rights regarding the residence status of the victim. EU Framework Directive- Geographical This Directive applies in relation to criminal offences committed in the Union and to criminal proceedings that take place in the Union. It confers rights on victims of extraterritorial offences only in relation to criminal proceedings that take place in the Union. Complaints made to competent authorities outside the Union, such as embassies, do not trigger the obligations set out in this Directive.