Content uploaded by Said Louahlia
Author content
All content in this area was uploaded by Said Louahlia on Aug 13, 2020
Content may be subject to copyright.
TORTURE
Journal on Rehabilitation of Torture Victims and
Prevention of Torture
1
2020
VOLUME 30, NO 1, 2020, ISSN 1018-8185
TORTURE
Journal on Rehabilitation of Torture Victims
and Prevention of Torture
Published by the International Rehabilitation Council for
Torture Victims (IRCT), Copenhagen, Denmark.
TORTURE is indexed and included in MEDLINE. Citations
from the articles indexed, the indexing terms and the
English abstracts printed in the journal will be included
in the databases.
Volume 30, No 1, 2020
ISBN 1018-8185
The Journal has been published since 1991 as Torture
– Quarterly Journal on Rehabilitation of Torture Victims
and Prevention of Torture, and was relaunched as Torture
from 2004, as an inter national scientific core field journal
on torture.
Editor in Chief
Pau Pérez-Sales, MD, PhD
Editorial Assistant
Chris Dominey, LL.M
Editorial advisory board
Bernard L. Duhaime, B.C.L., LL.B., LL.M.
Gavin Oxsburgh, PhD
Hans Draminsky Petersen, MD
Jens Modvig, MD, PhD
Jim Jaranson, MD, MA, MPH
John W. Schiemann, PhD, MA
José Quiroga, MD
Lenin Raghuvanshi, BAMS
Mariana Castilla, MSc
Nora Sveaass, PhD
S. Megan Berthold, PhD, LCSW
Steven H. Miles, MD
Tania Herbert, DClinPsy
Editorial assistance in this issue
Naila Kosar, Legal Officer at Freedom from Torture
Correspondence to
IRCT
Vesterbrogade 149, building 4, 3rd floor,
1620 Copenhagen V, Denmark
Telephone: +45 44 40 18 30
Email: publications@irct.org
Subscription
http://irct.org/media-and-resources/publications#torture-journal
The Journal is free of charge.
The views expressed herein are those of the authors and
can therefore in no way be taken to reflect the official
opinion of the IRCT.
Front page: Mogens Andersen, Denmark
Layout by Pedro López Andradas
Printed in Lithuania by KOPA.
Content
COVID-19 and Torture
Pau Pérez-Sales3
Editorial
Internet and Communications as elements for CIDT and Torture.
Initial reflections in an unexplored field
Pau Pérez-Sales, Laia Serra5
Scientific Articles
The complex care of a torture survivor in the United States:
The case of “Joshua”
S. Megan Berthold, Peter Polatin, Richard Mollica, Craig Higson-Smith,
Frederick J. Streets, Caitrin M. Kelly, and James Lavelle 23
Short Scientific Articles
“Parrilla urethra”: A sequalae of electric shock torture to genitals in
men. A 40 case series in Kashmir (India).
Abdul Rouf Khawaja, Manzoor Dar, Yasir Dar, Javeed Magray, Tariq
Sheikh, Suhail Zahur.40
Medical examination of detainees in Catalonia, Spain, carried out in the
presence of police officers
Carme Vivancos Sánchez, Iñaki Rivera Beiras49
Book Reviews
Civilizing Torture: An American Tradition, by W. Fitzhugh Brundage
John W. Schiemann 56
Tortura e migrazioni/Torture and Migration, by Fabio Perocco
Iside Gjergi 59
News
Criminalisation of torture and enforced disappearance in Thailand:
Progress on draft legislation 62
Launch of IRCT Report on Conversion Therapy 64
Statements
Statement on Conversion Therapy
Independent Forensic Expert Group66
Letter to the Editor
Evaluation of the Dismissed Forensic Medicine Specialists and Other
Forensic Professionals in Turkey
Alper Keten, MD79
In Memoriam
Johan Lansen 1933 – 2019
Christian Pross81
Psychiatric experience with perpetrators and countertransference
feelings in the therapist.
J. Lansen MD84
Call for Papers 89
TORTURE Volume 30, Number 1, 2020
3
Over the past few weeks, and with the Edi-
torial already at completion, the COVID-19
pandemic has invaded our lives. Its systemic
impact has affected, and continues to affect in
equal measure the provision of rehabilitation
to victims of torture.
Amongst the many areas in which COVID-19
has impacted the field of prevention and reha-
bilitation of torture survivors, at least 8 areas
of concern can be highlighted.
1. Attacks on basic fundamental rights and
unnecessary increase in social control
measures (Human Rights Watch, 2020a)
2. Increases in cases of ill-treatment or torture
linked to the pandemic itself. For instance,
various media sources have reported cases
related to the dissemination of information
in countries where this was considered to
be against the interest of the state (Wang,
2020; Human Rights Watch, 2020b;
Amnesty International, 2020a)
3. Respect for the rights of detainees and
COVID preventive measures in detention
settings that are compliant with human
rights (Council of Europe, 2020; OHCHR,
2020; Council of Europe, 2010) and espe-
cially amnesty processes for political pris-
oners or the use non-custodial measures
(Comninos, 2020; Amnesty International,
2020b).
4. Increases in cases of gender-based violence
(Ford, 2020; UNFPA, 2020; UN Women,
2020) and assaults on homeless popula-
tions (Phasuk, 2020; Hartley, 2019), both
related to fear and isolation.
5. Relapse of symptoms, especially night-
mares, flashbacks and somatic symptoms,
in survivors that were ill-treated or tor-
tured while in custody, due to COVID-
related self-confinement or measures of
medical isolation.
6. The reshaping of society: Will there be a
change in values towards more egalitar-
ian, empathetic and supportive societies?
Or an evolution towards a more fearful
society with an increasing lack of solidar-
ity as fear instils?
7. The use of warlike metaphors (the “war” on
the Coronavirus) as a prelude to restrictions
in freedoms, censorship or authoritarianism
in the name of the collective good (Human
Rights Watch, 2020a).
8. Cutting budget allocations for the most
disadvantaged, vulnerable groups in
general and survivors of torture spe-
cifically, in favour of security policies or
market-based post-COVID decisions
(UNDP, 2020; European Council, 2020).
These are some of the many areas of reflection
on COVID-19 as a global crisis in the field of
human rights and the prevention of torture
and rehabilitation of torture victims.
Torture Journal invites our readers to share
your experiences, reflections, research and
data in the form of a Letter to the Editor,
News or Research Report for inclusion in
future issues of the Journal. This is a global
crisis which may, in turn, foster a shared
learning opportunity for all.
COVID-19 and Torture
Pau Pérez-Sales*
*) Editor-in-Chief.
Correspondence to: pauperez@runbox.com
TORTURE Volume 30, Number 1, 2020
4
References
China: Free Covid-19 Activists, ‘Citizen Journalists’.
(2020b, April 27). Human Rights Watch. https://
www.hrw.org/news/2020/04/27/china-free-covid-
19-activists-citizen-journalists
Coalition Against Torture: Government officials should
be accountable for excessive use of force, ill-treatment
during COVID-19 lockdown. (2020a, April
23). Amnesty International. https://amnesty.
org.in/news-update/coalitionagainst-torture-
government-officials-shouldbe-accountable-for-
excessive-use-of-force-illtreatment-during-covid-
19-lockdown/
Comninos, A. (2020, March 12). COVID-19 in prison.
APT. https://apt.ch/en/blog/covid-19-in-prison/
Council of Europe. (2020, March 20). COVID-19:
Council of Europe anti-torture Committee issues
“Statement of principles relating to the treatment
of persons deprived of their liberty”. https://www.
coe.int/en/web/cpt/-/covid-19-council-of-europe-
anti-torture-committee-issues-statement-of-
principles-relating-to-the-treatment-of-persons-
deprived-of-their-liberty-
Covid-19 and Ending Violence Against Women and Girls.
(2020). UN Women. https://www.unwomen.org/-/
media/headquarters/attachments/sections/library/
publications/2020/issue-brief-covid-19-and-
ending-violence-against-women-and-girls-en.
pdf?la=en&vs=5006
COVID-19: Measures needed to protect people deprived
of liberty, UN torture prevention body says.
(2020, March 30). OCHR. https://www.ohchr.
org/EN/NewsEvents/Pages/ DisplayNews.
aspx?NewsID=25756&LangID=E
Ford, L. (2020, April 28). ‘Calamitous’: domestic
violence set to soar by 20% during global lockdown.
The Guardian. https://www. theguardian.com/
global-development/2020/apr/28/calamitous-
domestic-violence-set-to-soarby-20-during-
global-lockdown-coronavirus
Hartley, L. (2019, January 31). Anger at ‘torture’ of
city homeless man set on re. Coventry Telegraph.
https://www.coventrytelegraph.net/news/
coventrynews/coventry-homeless-man-set-
fire-15748697
Human Rights Dimensions of COVID-19 Response.
(2020a, March 19). Human Rights Watch.
https://www.hrw.org/news/2020/03/19/human-
rightsdimensions-covid-19-response
Millions more cases of violence, child marr iage, female
genital mutilation, unintended pregnancy expected
due to the COVID-19 pandemic. (2020, April 28).
United Nations Population Fund. https://www.
unfpa.org/news/millions-more-cases-violence-
child-marriage-female-genital-mutilation-
unintended-pregnancies
Phasuk, S. (2020, April 24). Covid-19 Curfew Arrests
of Thailand’s Homeless. Human Rights Watch.
https://www.hrw.org/news/2020/04/24/covid-19-
curfewarrests-thailands-homeless
Position Note on the Social and Economic Impacts
of Covid-19 in Asia-Pacic. (2020). UNDP.
https://www.undp.org/content/undp/en/home/
librarypage/crisis-prevention-and-recovery/the-
social-and-economic-impact-of-covid-19-in-asia-
pacific.html
Report on the comprehensive economic policy response
to the COVID-19 pandemic. (2020, April 9).
European Union. https://www.consilium.europa.
eu/en/press/press-releases/2020/04/vvvvv09/
report-on-the-comprehensive-economicpolicy-
response-to-the-covid-19-pandemic/
Syria: Vulnerable prisoners should be released to prevent
spread of COVID-19. (2020b, March 31).
Amnesty International. https://www.amnesty.
org/en/ latest/news/2020/03/syria-vulnerable-
prisonersshould-be-released-to-prevent-spread-
of-covid19/
The prohibition of torture is absolute and no
exceptions allowed, ever. (2010, October
30). Council of Europe. https://www.
coe.int/en/web/commissioner/blog/-/
asset_publisher/xZ32OPEoxOkq/content/
the-prohibition-oftorture-is-absolute-and-no-
exceptions-allowedever?_101_INSTANCE_
xZ32OPEoxOkq_languageId=en_GB
Wang, M. (2020, April 1). China: Fighting COVID-19
With Automated Tyranny. Human Rights Watch.
https://www.hrw.org/news/2020/04/01/china-
fighting-covid-19-automated-tyranny
TORTURE Volume 30, Number 1, 2020
5
EDITORIAL
The internet was once seen as a new and
definitive window to freedom and a world
without torture. There is however, another
less obvious but perhaps more notorious side:
torturous environments can also be created
through the internet; a place where individu-
als may be targeted for discrimination, coer-
cion or control. There is a dearth of academic
research and theoretical developments in this
very new area of knowledge and this Edito-
rial will review and reflect on various aspects,
thereby suggesting possible lines of research.
Searching for definitions
A recent theoretical review in the field of online
violence (Harris & Woodlock, 2019) with its
focus on gender, proposed the use of the term
technology-facilitated coercive control when re-
ferring to abuse using social networks or the
internet. The authors propose that similar
denominations are sought for other kinds of
digital violence and suggest that any denom-
ination of these new phenomena include the
terms perpetrator and purpose. Other expres-
sions found in the literature include digital coer-
cive control (DCC), technology-facilitated violence
(TFV), or technology-related violence (Douglas,
Harris, & Dragiewicz, 2019).
The Council of Europe’s Cybercrime
Convention Committee has recently defined
cyberviolence1 as: “the use of computer systems
to cause, facilitate, or threaten violence against
individuals that results in, or is likely to result in,
physical, sexual, psychological or economic harm
or suffering and may include the exploitation of
the individual’s circumstances, characteristics or
vulnerabilities” (T-CY, 2018), a definition also
adopted by the European Parliament (Van
Der Wilk, 2018).
This definition, however, focuses on the
internet and leaves aside other forms of com-
munication. For the purposes of this editorial,
we will consider a wider perspective and, mir-
roring the conditions of the UNCAT defini-
tion, consider Internet and Communications
Ill-Treatment and Torture (ICIT) as those acts
of violence intentionally committed, instigated or
aggravated, in part or whole, by the use of in-
formation and communication technologies that
cause psychological and emotional pain or suf
-
fering, for such purposes as obtaining informa-
1 https://www.coe.int/en/web/cybercrime/
cyberviolence#{%2250020850%22:[0]}
*) The Editor-in-Chief takes full responsibility
for the content of the Editorial. The opinions
expressed are his own and do not necessarily
reflect the view of the Publisher.
A draft version of this Editorial was used and
mentioned in the UN Special Rapporteur
on Torture Report (2020) A/HRC/43/49 on
Psychological Torture, as entitled “Internet and
Torture”.
**) Editor-in-Chief.
Correspondence to: pauperez@runbox.com
***) Criminal lawyer specialising in gender, digital
violence and freedom of expression.
Correspondence to: laiaserra@icab.cat
Internet and Communications as elements
for CIDT and Torture. Initial reections in
an unexplored eld*
Pau Pérez-Sales**, Laia Serra***
https://doi.org/10.7146/torture.v30i1.120593
International Rehabilitation Council for Torture Victims. All rights reserved.
TORTURE Volume 30, Number 1, 2020
6
EDITORIAL
tion, punishment, intimidation, coercion or for any
reason based on discrimination of any kind when
such pain or suffering is inicted by or at the in-
stigation of or with the consent or acquiescence of
a public official or other person acting in an of-
cial capacity.
This is achieved, among other methods, by
inducing emotional suffering through threats
and fear, breaking bonds of confidence in the
targeted person, inducing shame, embarrass-
ment, humiliation or guilt, promoting and
fostering prejudices and discrimination, dam-
aging reputation, creating conflict with peers,
fellows, relatives or loved ones or breaking com-
munity ties. The ultimate objective, as in clas-
sical torture, would be to change the identity,
attitudes or behaviours of the targeted person
and break their will. These are working defini-
tions that need to mature further, as research
and knowledge develops.
A particular challenge relates to the role of
the state in ICIT. Indeed, a state’s passivity or
lack of due diligence, when acting against re-
curring and known patterns of digital violence,
especially those affecting socially discriminated
groups such as women or social or political-
ly-motivated activists, facilitates ICIT’s align-
ment with the classic definition of torture or
ill-treatment. In her 2018 report, the United
Nations Special Rapporteur on the issue of vi-
olence, its causes and consequences, stated that
the duty of due diligence to prevent, investigate
and punish sexist violence, extends to the digital
world (UN Human Rights Council, 2018).
Medical and Psychological Impacts.
Although there are no studies on the level
of psychological pain that ICIT can entail,
future studies in this new field must consider
at least three sources of suffering: (a) direct
effects: fear, shame, guilt, helplessness or rage,
leading to anxiety, depressive or somatisation
disorders (b) indirect effects: the cognitive
and emotional burden of being forced to
devote time and energy to prevent and coun-
teract such acts (i.e. to defend reputation pub-
licly, assess danger and implement eventual
security measures or to try to circumvent sur-
veillance and control) (c) psychosocial effects:
impact on family, interpersonal relationships,
workplace and social networks (i.e fear, de-
tachment, polarisation, rumour spreading…).
The closest reference in academia is cyber-
bullying2, and digital dating abuse3, although
the severity of threats, danger and degradation
is not comparable to that of ICIT and there is
no consensus on the role of the state. A recent
European Transnational Study with more than
5000 respondents found three profiles of emo-
tional consequences: 5% of teenagers showed
severe emotional damage to cyberbullying in-
cluding suicidal tendencies; for 75% of teenag-
ers, there were moderate symptoms of anxiety
or depression that disappeared with time and
20% cyberbullying had no major impact on
them (Ortega et al., 2012). A review of the
specific relationship between suicide attitudes
and cyberbullying using studies from 1997 to
2018, found that those who experience cyber
victimisation are at two to three times more
risk of committing suicide
4
depending on
personal and social vulnerability factors that
themselves would necessitate further explo-
ration (John et al., 2018). Although these are
2 There is no consensual definition of bullying and
cyberbullying. For a review of definitions see
Gleeson (2014). Bullying is defined as ongoing
harmful behaviour in relationships with power
disparities. Cyberbullying is referred to the use of
communication technologies for bullying.
3 Digital dating abuse is defined as the use of
verbal, physical and sexual aggression by an intimate
partner.
4 OR 2.35 (95% CI 1.65-3.34) times as likely to self-
harm, OR 2.10 (95% CI 1.73-2.55) times as likely
to exhibit suicidal behaviors and OR 2.57 (95% CI
1.69-3.90) times more likely to attempt suicide
TORTURE Volume 30, Number 1, 2020
7
EDITORIAL
indirect data obtained from a population com-
prising different ages and in different contexts,
it highlights the immense mental suffering that
Internet and Communications Ill-treatment
and Torture can entail.
Certain organisations track internet-related
violence specifically as a form of gender-based
violence (Barrera & Rodríguez, 2017; Serra,
2018; Van Der Wilk, 2018). Especially relevant
is the work of Colectivo Luchadoras (“Fight-
ers Collective”) from Mexico (Barrera & Ro-
dríguez, 2017); a feminist group that has
collected and analysed hundreds of internet
incidents and propose 13 categories that could
serve as a good point of departure for the ac-
ademic study of ICIT (table 1).
There is also a similar classification de-
veloped by the Internet Governance Forum
(IGF, 2015).
Summarising table 1, the Internet Gover-
nance Forum and the Council of Europe doc-
uments, we can consider four main situations:
(a) Coercion, threats, and intimidation; (b) Sur-
veillance, monitoring, and control in real-time;
(c) Theft of sensitive information; (d) Defama-
tion and public degradation.
In terms of analysis, and from a psycho-
logical perspective, conditions (a) and (b) are
fear-producing actions, and (c) and (d) target
identity.
Essential elements to understand Internet
and Communications related-violence as
ill-treatment or torture.
We have defined internet related violence.
Now, we turn to the subject that suffers this
violence and to a new phenomen: the difficult
to define new identities.
Internet-based identities.
ICIT has peculiar characteristics that derive
from attacks on new forms of identity created
through the internet, the exact definition of
which is still subject to debate. Digital iden-
tity is defined as that which a person creates
on the internet by constructing a way of pre-
senting him or herself in the virtual commu-
nity (Gonzales & Hancock, 2011). A related
concept is Information Technology (IT) identity,
as the extent to which an individual views IT
as integral of a person’s sense of self -as both
a new type of material identity and an integral
part of the self (Carter & Grover, 2015). There
is however, an even more under-researched
identity: the identity that others (including the
state) create of us. When others (including the
state) create and spread information about us,
inaccuracies blend seamlessly with the truth,
the totality of these elements making up the
image others have of us (our “digital iden-
tity”). Anyone carrying out a web search will be
unable to distinguish true elements from those
that may be defamatory and will likely make
conclusions based on the totality of what is
found. Our digital identity is, as a result, almost
impossible to control. The higher the levels of
exposure, the higher the risks of losing control.
It is not surprising that those growing up in the
era of new technologies, who are much more
conscious of their new digital identity, devote
time to carefully construct their digital self.
Furthermore, amongst consistent users
of social networks (as is the case with many
human rights activists), there is a dialogical
effect: the internet constitutes a distinctive
“looking glass” that modifies one’s identity
(Zhao, 2005) and research shows that the
more it is used, the more vulnerable a person
is to what others say about them (Manago,
2014). Stigma in the form of a permanent
digital footprint is arguably more difficult
than ever to escape. The internet has become
a digital prison (Lageson & Maruna, 2018)
by producing a lasting mark of shame through
messages, comments, videos and/or pictures.
That is very difficult to delete.
TORTURE Volume 30, Number 1, 2020
8
EDITORIAL
Table 1. Mapping Internet and Communications attacks
1. Unauthorised access (tapping) and monitoring access. Password theft, spyware; intervention/
tapping devices; equipment theft; locking user access; phishing1, virus infection; key loggers2.
2. Control and manipulation of personal information. Deleting, changing or falsifying personal
data (photo or video); taking photos or video without consent (not necessarily with sexual content);
controlling accounts on digital platforms.
3. Spoofing and Identity Theft. Creation of false profiles or accounts; usurpation of a personal
website with name or data referring to the individual; impersonating an individual , including using
your account to communicate; theft of identity, money or property.
4. Monitoring and Cyberstalking. Surveillance or hidden cameras, location identification employing
images; geolocation on equipment /cellular or notifications; cyberfollowing; cyberstalking3.
5. Discriminatory statements. Abusive comments; discrimination against various groups, electronic
insults; discriminatory media coverage.
6. Harassment. Stalking; waves of group insults; messages from strangers; repeated messages; sending
unsolicited sexual pictures.
7. Threats. Messages, images or videos with threats of physical or sexual violence
8. Dissemination of personal or intimate information without consent. Sharing private informa-
tion (doxxing4); exposure of sexual identity or preference that generates risk (outing); dissemination
of intimate or sexual content without consent; disclosure of privacy.
9. Blackmail. Sextorsion5.
10. Discrediting. Dissemination of content; smear campaigns; defamation; disqualification.
11. Technology-related sexual abuse and exploitation. Deceiving for purposes of trafficking; sexual
abuse; grooming6.
12. Attacks to channels of expression. Removal of profiles or pages on social networks; DDOS
attacks7; restrictions of use domain; domain theft; blackouts (from the state or company) during a
meeting or protest or from a provider
13. Omissions by actors with regulatory power. Lack of regulation or implementation of protection
measures related to messages, images or videos with threats of physical or sexual violence.
1 A technique that seeks to trick people into infecting and/or stealing information from a digital device.
2 Keylogg: Software or hardware that can intercept and save keystrokes on the keyboard of an infected computer.
3 The use of digital technology devices, or online activity, to monitor a person and to use the information
harvested to harass or intimidate him or her online, to monitor his or her physical movements, or to capture
him or her at a specific geographical location.
4 Doxxing: An abbreviation of the phrase "dropping docs," which refers to the act of sharing someone's
personal details with others online, in particular a physical address or personal identification documents,
such as a form of bullying or harassment.
5 Sextorsion: The use of intimate images or personal information as a form of coercion for sexual exploitation
or blackmail
6 Grooming: The use of social networks to deliberately cultivate an emotional connection with minors for the
purpose of sexual abuse or exploitation
7 DDOS attack: DDoS- Distributed Denial of Service – a malicious attempt to create massive traffic,
resulting in temporarily or indefinitely disrupting service of a host connected to the internet
TORTURE Volume 30, Number 1, 2020
9
EDITORIAL
Internet and Communications Ill-treatment
and Torture aims to provoke silence (Basak et
al., 2019), but psychological and psychosocial
mechanisms that operate between victims and
perpetrators and between both and the wider
digital community is also a field of academic re-
search in its infancy. Anonymity and the search
for popularity play a hitherto mediational role
in these mechanisms. As an example, a recent
study showed that a vast majority of shamers on
Twitter shamed the victim and not the perpe-
trator. Shamers’ follower counts also were seen
to increase faster than that of the non-shamers,
showing that shamers could easily be enticed
to do so if their actions are validated by others
(Basak et al., 2019). The mechanisms operat-
ing in the physical world are not the same that
operate in the digital world. This was seen in a
visionary manner by Guy Debord (1967/1995)
in The Society for Spectacle, a book written before
the digital era but essential to understanding
some of the paradoxical destructive dynamics
of the digital world.
Physical world
Outside of the context of the internet, the chal-
lenges are also vast. We live in what has been
labelled a “post-privacy” world (Busch, 2019).
Human beings are permanently exposed to
scrutiny. Computers record personal inter-
ests, searches, purchases, sexual perversions or
political ideology; gadgets capable of playing
music and informing us of the weather are also
capable of informing others of our preferences
and conversations; phone applications access
our photographs and videos; GPS and cameras
inform on who we are and where we are; surveil-
lance cameras in streets, banks and buildings
can trace our paths and who we talk to or even
what we say; credit cards and shopping apps
record our steps and our tastes, while aerial
cameras and drones allow tracking of individu-
als even in the middle of crowds. No news or
event takes place, even in the most remote of
places that is not recorded on smartphones,
uploaded and viewed worldwide within a few
hours, while Periscope, Instagram or Facebook
also broadcast our lives. This is part of what big
data analytics will provide to governments and
private companies. It can however, also be used
against individuals.
The power of big data analytics for social
control is exemplified by the recent scandal in-
volving the use of millions of Facebook pro-
files by Cambridge Analytica in London, to
create psychological clusters of voters that
were latterly used to further Donald Trump
campaign
1
. Linked to this is the new academic
branch of neuro-politics that studies how to
control and direct voters by studying public
and private brain responses to political stimuli
(Rose & Abi-Rached, 2014; Schreiber, 2017).
Torture and ICIT
From a moral and ethical point of view, torture
is defined relationally. It is grounded in con-
cepts of autonomy, control, and free will. For
philosophers and specialists in ethics, torture
is a relationship between two human beings
characterised by a violation of dignity and un-
derstood as a lack of recognition and respect,
and a violation of autonomy, expressed by the
absolute power, control and imposition of the
will of the perpetrator, and the lack of control,
powerlessness and suppression of the free will
of the victim (Koenig, 2013; Luban, 2009;
Maier, 2011; Parry, 2003; Pollmann, 2011;
Scarry, 1985; Sussman, 2006).
When developing the idea of torture as
related to dignity and humiliation, and the ab-
solute repression of free will, most philosophers
conceive of a one-to-one relationship between
1 https://www.nytimes.com/2018/04/04/us/politics/
cambridge-analytica-scandal-fallout.html
TORTURE Volume 30, Number 1, 2020
10
EDITORIAL
perpetrator and victim. The torturer aims to
break the victim by, among other elements, at-
tacking the victim’s identity through fear and
humiliation, which in turn produces emotional
pain and suffering. In psychiatry however, hu-
miliation is conceptualised as an interpersonal
emotion. Torture survivors often have long-last-
ing feelings of humiliation and can perfectly
recall the event or series of events when this
humiliation was provoked by the perpetrator(s)
and indelibly engraved in their memory.
Internet and communications-related vio-
lence acts exactly on these same two essential
points, but with very particular distinctions.
1. Fear is unspecic. For the psychological
study of fear as an emotion, there are
two very distinct phenomena. Fears that
are related to concrete and visible threats
(i.e. an animal attacking the person) and
fears related to invisible, unpredictable
or unknown threats (i.e being confined
in a dark place). While visible and pre-
dictable threats allow for some sense of
control, invisible and unknown threats
induce helplessness and despair (Hopper
& Hidalgo, 2006; Phillips, 2011). ICIT
is a modality of torture that (a) does not
require the physical presence of a perpe-
trator, and in which (b) the perpetrator is
quite often anonymous or behind a hidden
or false identity2. Furthermore, both ele-
ments make it more difficult to demon-
2 As a side note, according to Douglas, Harris, &
Dragiewicz (2019), to understand the emotional
suffering of internet-related violence, the most
essential variable is Spatiality. In their view
the experiences of, risk and mental health
consequences faced by victim/survivors in
regional, rural and remote locations or where the
perpetrator might physically reach the person are
entirely different from pure on-line threats and
must be studied separately.
strate the link of the perpetrator with state
actors or to make evident the political or
discriminatory purpose of the threat.
2. Shame instead of humiliation. While humil-
iation happens in a private space between
two persons or between a person and a
small group of perpetrators, broadcasting
through social networks means that the
attack on an individual’s identity happens
in the public sphere, and is thus amplified
and prolonged endlessly by the almost
infinite memory of internet search engines
(Hodalska, 2019). It is this condition of
public debasement that makes shame, and
not humiliation, the core emotion. From
a psychological point of view, shame is
more damaging and produces more pain
and suffering than humiliation. While
humiliation drives to action towards the
perpetrator (rage, pursue of justice, some-
times desire of revenge), shame is usually
linked to inhibition, paralysis, powerless-
ness, helplessness, avoidance of exposure
and the desire to hide and disappear
(Leary & Tangney, 2012).
3. Cruelty. Studies in social psychology show
that the two most accurate predictors of
cruelty in perpetrators are anonymity and
impunity (Anderson & Carnegey, 2004).
Experimental models show that when per-
petrators are able to act without revealing
their identity, they choose the most cruel
actions possible. The same occurs when
perpetrators can act with impunity and
where retaliation is impossible. Cruelty
is also further facilitated by the way that
interaction takes place on social media and
by the design and format of communica-
tion, such as limitations to the number of
characters in posts that tends to provoke
brief insulting messages.
4. Mediated interaction. If the purpose of
torture is to control and break will, it is
TORTURE Volume 30, Number 1, 2020
11
EDITORIAL
essential to be able to see the impact of
torture on the victim directly. In ICIT,
quite often, there is an inability to see a vic-
tim’s reaction (i.e. regarding threats to life).
This can either protect the victim or trigger
escalation. But there are also contexts in
which visibility is clear and immediate; the
victim’s reaction is especially visible on the
internet either through the violence that
the victim explicitly shows as a reaction,
or because the Internet community can
perceive that the person attacked reduces
online presence, maintains a “low profile”,
avoids interacting with certain profiles,
loses followers or begins to be targeted by
more and more parties.
5. Permanent stress. In ICIT, the perpetrator
often has 24 hours uninterrupted access
to the victim. The victim may engage
in frequent checking behaviours with
exponential anxiety and feelings of fear.
Furthermore, each time violent or contro-
versial content is reactivated, the trauma
is also reactivated. Not knowing when the
controversy may be revived generates a
great deal of helplessness and a sense of
vulnerability. It may also occur at a time
when the victim is ill, emotionally fragile
or facing other personal challenges, or
equally at a time of professional growth
that may suffer detriment as a result.
6. Multiplicity of aggressors. The impact of
digital violence often does not originate
from a single source. Instead, we witness
either a snowball phenomenon with the
multiplication of an initial violent content,
or an organised collective attack in which
the victim is confronted with the ripple
effect of being violently targeted from dif-
ferent online profiles, at the same time and
for the same reason. These two dynamics
increase the feeling of helplessness, the
inability to activate personal resources and
the loss of self-esteem to the extent that
it may irreversibly damage self-perception
and identity.
These are six very specific and peculiar el-
ements that make ICIT a condition liable to
produce very severe pain or suffering, deserv-
ing specific studies from academia that have,
at the time of writing, not yet been explored.
From theory to practice: ICIT cases
Threats and punishment
A nurse works in the health center of a rural
community or a peripheral neighborhood. She
provides clinical care to everybody in her com-
munity, including injured demonstrators who
are participating in protests against the gov-
ernment. Some of her neighbours whose ide-
ology aligns with the government inform the
authorities, and she is, sometime in the future,
made redundant by her employer. The govern-
ment - like most current governments - has an
agency that specialises in network monitor-
ing and control. They soon find her presence
on Facebook and in WhatsApp groups that
disseminate, among other things, news they
deem to be anti-government. She is thus put
on a blacklist and considered an enemy of the
state. Using false or anonymous IP addresses,
the government agency floods other social
networks connected to her (in particular her
Twitter and Facebook family contacts), and
networks akin to the government with mes-
sages that present her as a terrorist, as an anti-
patriot and a danger to the community. They
also reveal information to the media of an in-
timate or deeply humiliating nature from her
time at university; something she thought that
belonged to the past. The message is widely
distributed and includes photos in which she is
easily recognisable. A photo collage makes her
appear to be holding a small weapon – which
TORTURE Volume 30, Number 1, 2020
12
EDITORIAL
she is not. As a consequence, pro-government
groups begin to harass her, both inside and out
of her new workplace through threats, insults
or paintings on walls reproducing Twitter mes-
sages. She is terrorised, and despite her initial
resistance and her efforts to delete all her social
media accounts, the campaign becomes wide-
spread and all her family and peers circles take
positions on what they understand to be her
ideological and personal viewpoints. She soon
begins to think that there is a risk of direct
physical aggression by organised groups, and
eventual arrest by authorities. She is recognised
by some patients in her new workplace, and in-
ternet messages spread information about the
place where she is now employed. There are
letters of complaint and finally the private insti-
tution where she works, decides to avoid public
image problems and eventual problems with
the government and makes her redundant.
Emotionally exhausted, she does not know
what do, and enters into a depressive state with
a mixture of real and overvalued symptoms of
persecution: it is impossible to distinguish, for
her, true and imaginary danger. Countering the
social media campaign is extremely complex.
She first decides to restrict her movements to a
minimum and stay at home except for essential
trips outside. After some time, she moves to a
different town. Shortly after, when she also re-
ceives death threats through phone messages in
her new location, she takes the painful decision
to go into exile.
This case is not fictitious. She is “H,” a
nurse working in Nicaragua. Many more
cases of a similar nature are reported in other
countries, especially concerning journalists3
and human rights defenders, but quite often
3 https://www.elsalvador.com/eldiariodehoy/
periodistas-instan-a-gobierno-no-ignorar-acoso-
en-redes-sociales/625770/2019/
also normal citizens who are not even involved
in political activities and are simply carrying
out their jobs. H never saw her aggressor and
never knew the true nature of the danger she
faced. She was publicly accused, mocked and
debased and was unable to identify the origin
of the violence. There was effectively no need
even to detain her, to produce severe psycho-
logical pain or suffering and to intimidate and
coerce her.
A recent case study in Indonesia, Colom-
bia, and Kenya (NDI, 2019) identified the
widespread practice of hate speech, embarrass-
ment and reputational risk, physical threats,
and sexualised distortion of content targeting
women activists, as dominant forms of threats
and punishment.
Between December 2016 and March
2018, Amnesty International (AI) con-
ducted qualitative and quantitative research
on women’s experiences of threats, violence,
and abuse on Twitter. Their poll in 8 coun-
tries interviewed women and non-gender
binary individuals (Dhrodia, 2018). The re-
search highlighted the particular experiences
of women of colour, women from ethnic or re-
ligious minorities, lesbian, bisexual or trans-
gender women, non-binary individuals, and
women with disabilities, to demonstrate the
intersectional nature of threats, debasement,
and abuse (Amnesty International, 2018). The
research found that women, more often than
men, were the target of threats of murder,
rape, physical violence and graphic imagery
via email, comment sections of newspapers
and across all social media. As of 16 March
2018, Amnesty International had met with
the Twitter CEO on three separate occasions
to obtain a clear policy from the site, and, at
the time of publishing the report, had not re-
TORTURE Volume 30, Number 1, 2020
13
EDITORIAL
ceiving a satisfactory answer. There has been
some progress since then4.
On 27 January 2017, Ugandan human
rights activist, Dr. Stella Nyanzi, wrote a
post on Facebook in which she dubbed
the Ugandan president ‘a pair of buttocks’
(Rukundo, 2018). The message was widely re-
produced and as a consequence, she was then
subjected to various forms of public internet
threats by state agents that limited her activ-
ity. In spite of that, the threats culminated in
her arrest on 7 April 2017. She was charged
with cyber harassment and offensive commu-
nication contrary to sections 24 and 25 of
the Ugandan Computer Misuse Act (CMA),
which is vague legislation developed to restrict
freedom of expression and political dissidence
in the country. She was sentenced and jailed.
ICIT: Shame
Nelson Julio Alvarez, known as Nexy J. Show,
a Cuban LGBTIQ activist and YouTuber, was
detained by the Cuban Security Services, who
seized his digital devices including his com-
puter and mobile phone. During the weeks
that followed, they replaced his identity on
social networks for the purpose of public
denigration5. Ezequiel Fuentes, another
Cuban LGBTIQ cyber activist on Facebook
was also the target of a widespread defama-
tion campaign in which alleged members
of, or collaborators with, the Ministry of the
Interior publicly revealed private informa-
tion including his relationships, as well as his
health records6. Alvarez was targeted through
4 https://blog.twitter.com/en_us/topics/
company/2019/hatefulconductupdate.html
5 https://www.washingtonblade.com/2019/10/24/
policia-detiene-al-yutuber-cubano-nexy-j-show/
6 https://adncuba.com/noticias-de-cuba-derechos-
humanos/lgbtiq/ciberbullying-contra-comunidad-
lgbtiq-cubana-homofobia.
identity theft and humiliation and Fuentes
through defamation. Both were painfully
forced to reduce their online presence.
In an interview, UK journalist Nosheen
Iqbal, often the target of internet attacks, em-
phasised the role of “followers” in internet vi-
olence; an uncritical mass of people who are
ready to denigrate a person and reproduce the
attitude of very aggressive ideological opinion
makers. After writing opinion pieces, Iqbal ex
-
perienced systematically that after certain in-
dividuals made deeply offensive comments in
the mass media, swaths of others followed in
what seemed to be a well-orchestrated strat-
egy (Mijatovic, 2018).
Threats, shame and post-truth
environments
Freedom on the Net is an international da-
tabase that collates and analyses situations of
manipulation of news fora, opinion groups,
harassment and online attacks on human
rights defenders. Their reports include a long
list of countries that infiltrate so-called trolls7
in discussion forums to manipulate and direct
their content. Venezuela, the Philippines and
Turkey are relevant examples among 30
countries where governments were found to
employ armies of “opinion shapers” to create
hegemony for government-supported view-
points, drive particular agendas, and counter
government critics on social media (Freedom
House, 2017). In Turkey, for instance, the
report describes AK Troller, or White Trolls,
a group pertaining to the ruling Justice and
7 On the Internet a ‘troll’ or ‘hater’ is a user
who intentionally seeks to provoke, offend or
impoverish the conversation within an online
community, such as a blog, forum or social
network profile. See also the discussion on
Corporate, political, and special-interest sponsored
trolls in https://en.wikipedia.org/wiki/Internet_troll
TORTURE Volume 30, Number 1, 2020
14
EDITORIAL
Development Party and which is govern-
ment funded. Some 6,000 people have alleg-
edly been recruited by the party to monitor
and manipulate discussions, drive specific
agendas, and counter government opponents
on social media (Freedom House, 2017).
These organised groups create fake news
that are accepted in an uncontested way by an
often uncritical mass of the population (Lazer et
al., 2018). Such widespread situations of creat-
ing parallel worlds have given rise to a new field
of knowledge in social psychology and sociol-
ogy: post-truth environments or a post-truth society.
These are defined as contexts in which people
are more likely to accept arguments based on
emotions and beliefs rather than those based
on facts (Bunce, 2019; Harsin & Harsin, 2018).
Lies and falsehoods or manipulated statistics
are easily accepted by public opinion in as much
as they support the desired emotions. A person
or an organisation can be the target of a post-
truth emotional environment. Internet follow-
ers can, in the same way, react to emotional
slogans in environments of political polarisa-
tion without further reflection.
On the peripheries of torture: controlling
human beings through the net
Until this point, we have described elements
of the psychological foundations of internet
and communications ill-treatment or torture,
with various examples. The internet is about
empowering individuals by providing access
to information. At the same time however, it
is becoming more and more a place where
both state and private companies alike gather
personal information that can potentially be
used for intimidation and control, including
surveillance of movements, acts and opinions.
This can be linked, as far as the individual is
aware, to the production of emotional suffer-
ing or pain for the purposes suggested by the
Convention against Torture. We will review
some of these additional facets in the second
part of the paper.
Surveillance and control of human right
groups and political activists
The European Court of Human Rights recently
published a Fact Sheet on Mass Surveillance8
with case law from Germany, UK, Russia and
Hungary among other countries (ECtHR,
2019). They were selected relevant cases that
violated Article 8 (right to respect for private
and family life, home and correspondence) of
the European Convention, including the Big
Brother Watch and Others v. the United Kingdom
(nos. 58170/13, 62322/14 and 24960/15) after
the revelations by Edward Snowden regarding
programmes of surveillance and intelligence
sharing between the USA and the United
Kingdom. The case concerned three types of
surveillance conducted by the Government
Communications Headquarters, or GCHQ,
Britain’s signals-intelligence agency: (a) bulk
interception of communications under the
TEMPORA program; (b) intelligence sharing
and receipt in collaboration with the PRISM
and Upstream programs run by the National
Security Agency (NSA) and (c) the obtaining
of communications data from service provid-
ers. It was the first ruling against Britain’s
mass-surveillance programmes since Edward
Snowden’s 2013 revelations9.
Russia is an example of a country where
internet usage is under full control by the
state and surveillance is widespread. All cryp-
tographic systems except those licensed by the
Federal Security Service of the Russian Feder-
ation (FSB) are forbidden. All internet provid-
8 https://www.echr.coe.int/Documents/FS_Mass_
surveillance_ENG.pdf
9 For a full discussion of the hearing see https://
www.lawfareblog.com/summary-big-brother-
watch-and-others-v-united-kingdom
TORTURE Volume 30, Number 1, 2020
15
EDITORIAL
ers must install a software named SORM that
allows filtering and remote control of internet
traffic10. A special unit of the Secret Services
is devoted to surveillance and internet control
(HRW, 2017). In September 2017, WikiLeaks
released “Spy Files Russia,” confirming how
state entities had full access to detailed data
on Russian internet and cellphone users by
its citizens as part of SORM
11
. Amongst
many examples, when the Crimean journalist
Mykola Semena was detained and sentenced
for crimes against the state, the Russian Secret
Service had full control over his computer.12
The British organisation Privacy Interna-
tional maintains a database and updated in-
formation on the systems of surveillance and
control of groups and activists in different coun-
tries of the world13 including persons from the
anti-torture movement. It also maintains a
Surveillance Industry Index14 with detailed in-
formation of hundreds of companies offering
internet monitoring and surveillance services to
governments, armies, military institutions, and
private companies. Many of their activities are
manifestly illegal and target the control of and
threat to citizens, and especially political dissi-
dents and human rights activists.
The United States Federal Bureau of In-
vestigations (FBI) uses control and monitoring
mass surveillance systems. A report by Privacy
International (2018) has documented infiltra-
tion and troll activities in the Facebook an-
ti-torture group Mass Action Against Police
Brutality. Privacy International also revealed
the existence of an FBI document mapping
10 https://en.wikipedia.org/wiki/SORM
11 https://wikileaks.org/spyfiles/russia/
12 https://www.bbg.gov/wp-content/media/2017/02/
Mykola-Semena%E2%80%94Fact-
Sheet-2017.03.16.pdf
13 www.privacyinternational.org
14 https://sii.transparencytoolkit.org/
social networks of peaceful climate change ac-
tivists which includes both names and other
personal data15.
A recently leaked document published
in US newspapers showed the existence of a
secret database shared by different US security
agencies to track activists, lawyers and human
rights defenders travelling to the Mexico-USA
border to help migrants16. Furthermore, Look-
ingGlass Cyber Solutions, a private company
hired by US Homeland Security gathered per-
sonal information on the internet of around 600
persons who had participated in demonstra-
tions against Trump’s migrant family separation
process in 201817, a US practice that is consid-
ered by some scholars as torture (Gray, 2019).
The Israel based company Cellebrite offers
the Universal Forensic Extraction Device
(UFED) designed to retrieve chat logs, texts,
and other data from phones, in some cases by-
passing PIN codes or passwords
18
. A recent
report
19
showed, for instance, its use in ex-
tracting information from Mohammed al-Sin-
gace, a Bahraini political activist who was later
detained and tortured in custody. Cellebrite
offers, among other services to governments,
the tracking of phone cells of asylum seekers
to obtain information, through their GPS
records, regarding which countries they have
visited since leaving their countries of origin
and challenge asylum claims as non-credible
15 https://www.theguardian.com/us-news/2018/
dec/13/fbi-climate-change-protesters-iowa-files-
monitoring-surveillance-
16 https://www.nbcsandiego.com/news/local/Source-
Leaked-Documents-Show-the-US-Government-
Tracking-Journalists-and-Advocates-Through-a-
Secret-Database-506783231.html
17 https://theintercept.com/2019/04/29/family-
separation-protests-surveillance/
18 https://www.cellebrite.com/en/product/
19 https://bahrainwatch.org/amanatech/en/
investigations/cellebrite
TORTURE Volume 30, Number 1, 2020
16
EDITORIAL
based on this data. According to journalist re-
search, many European countries, including
Germany, the UK and Austria use Cellebrite
services as evidence to deport migrants20.
A well-known case of surveillance software
usage is that of Pegasus21, the programme that
came to light when R3D, a Mexican human
rights organisation protecting freedom of ex-
pression discovered its systematic use by the
government to spy on journalists and activists
who were later targeted, some of them suffer-
ing threats, defamation, kidnapping or torture
(R3D, 2017). The software consists of malware
that infects Apple iPhones through a WhatsApp
message or a failed phone call. The attacker
has access to everything in the victim’s device:
email, messaging services, camera, and micro-
phone. The software is manufactured by the
Israeli company, NSO Group. On its website22
the company claims to sell the tool exclusively
to governments on the condition that it is only
used “to combat terrorists” and notes that the
software has saved “thousands of lives.” The
software is sold also to private companies and
contractors through reseller companies such as
Hacking Team. According to R3D, the govern-
ment is billed around 75,000 euros per success-
fully controlled telephone. A report by the Red
en Defensa de los Derechos Digitales (Network
for the Defense of Digital Rights) evidenced
that the software was acquired by the Mexican
Army in 2012 and by the office of the Attorney
General (PGR) in 2014. An impressive series of
studies show how the use of Pegasus has been
an essential element in the murdering of jour-
nalists and for targeting politicians, lawyers and
opponents in Mexico.23
20 https://www.wired.co.uk/article/europe-immigration-
refugees-smartphone-metadata-deportations
21 https://en.wikipedia.org/wiki/Pegasus_(spyware)
22 https://www.nsogroup.com/
23 https://citizenlab.ca/2018/11/mexican-journalists-
A research center, Citizen Lab24 based at
the University of Toronto, produces regular
reports and provides advice against such prac-
tices. It has detected the use of Pegasus in 45
countries and other similar software in almost
all countries25.
Social control of population
Although beyond the scope of this review, we
would also at least mention the three most
well- known methods of social control of
the population amongst those of which civil
society groups are aware.
•
International Mobile Subscriber Identity
(IMSI) Catchers. This is a device that con-
nects to mobile phones in a particular area
and can, among other things, provide the
exact location of the user, build a network
of all the numbers with which the person
makes contact, as well as the successive con-
tacts of those contacts; block or intercept
data; access the content of calls, text mes-
sages and web sites visited or send intimi-
dating anonymous messages to other mobile
phones
26
. As a counter-response effort, there
investigating-cartels-targeted-nso-spyware-
following-assassination-colleague/
24 https://citizenlab.ca/
25 Hacking Team owns another malware, also
allegedly to detect terrorists, that, according
to an exhaustive report by Derechos Digitales
is employed by almost all governments in
Latin America to control political opponents,
journalists and human right defenders (Perez
de Acha, 2016). The report considers that
such software has spread rapidly because
secret services from governments in the region
have cooperation programs and share both
technologies and databases.
26 https://www.eff.org/wp/gotta-catch-em-all-
understanding-how-imsi-catchers-exploit-cell-
networks
TORTURE Volume 30, Number 1, 2020
17
EDITORIAL
are different free mobile apps that allegedly
detect IMSI catchers.
• Facial recognition systems. These capture de-
tailed images of the participants in meetings or
demonstrations with high-resolution cameras
located in very distant places or inside drones.
These are compared by the police with pho-
tographs of citizens and cross-referenced with
databases to identify individuals of concern.
Its use is being questioned by civil society or-
ganisations (Ruhrmann, 2019) and it seems
there are plans for a European Union strict
regulation
27
. In a counter-response effort, the
Center for Human Rights Science at Carn-
egie Mellon University has developed a tool
that can collate video recordings made with
smartphones by demonstrators to produce an
account of police brutality (Aronson, Cole,
Hauptmann, Miller, & Samuels, 2018). Dif-
ferent governments have counter-reacted
with legislation that forbids the use of smart-
phones during demonstrations and imposes
severe fines if police are recorded, including
confiscation of the phone28.
• Social media intelligence - often shortened to
SOCMINT - refers to the massive monitoring
and gathering of information posted on social
media platforms. These are software systems
that are capable of downloading an entire
website, forum or communications within a
group, monitoring a citizen’s social networks
and accumulating evidence against them.
In June 2019, in Egypt, amidthe most
repressive period for decades, the govern-
ment-linked El Watan newspaper published
a leaked Interior Ministry tender document
inviting software companies to contribute to
27 https://euobserver.com/science/145707
28 https://blog.witness.org/2015/07/film-the-police-
not-in-spain/
the development of an open-source intelli-
gence system called the “Social Networks Se-
curity Hazard Monitoring System.” It would
monitor Facebook, Twitter, WhatsApp and
Viber in real-time for usage that might “harm
public security or incite terrorism.” It would also
screen content for “vocabulary which is con-
trary to law and public morality.” According
to Wikithawra29, an independent monitoring
group, at least 76 people have been detained
so far this year in Egypt for offenses related
to “online publishing.”30
Such great interest in controlling users
via the internet is not surprising. For certain
authors, the so-called Arab Spring is an inter-
net-based movement lead by a new young gen-
eration (Cole, 2014). Egypt, Tunisia and Libya
were, amongst others, examples of countries
where new technologies harnessed the inter-
net to organise nationwide protests on desig-
nated days and to delegitimise the regime with
videos of police torture and exposing govern-
ment corruption
31
. The murder of Khaled Said
in Alexandria, after he was beaten to death in
public, by plain-clothes police officers, in front
of witnesses, is a good example. Autopsy pho-
tographs of his badly battered face were circu-
lated immediately on the internet, provoking
both widespread demonstrations and vigils –
many of which were organised and announced
on Facebook and Twitter. The Facebook group
“We are all Khalid Said” later became a hub
for activists and a source of information for
the population32.
29 https://wikithawra.wordpress.com/
30 https://www.csmonitor.com/World/Middle-
East/2014/0630/Citing-terrorism-Egypt-to-step-
up-surveillance-of-social-media
31 http://misrdigital.blogspirit.com/
32 There is there a complex double-sword: internet
can help in the fight for freedom, but it is at
cost of enormous risks for those involved.
Egypt’s 2011 uprising early demonstrations
TORTURE Volume 30, Number 1, 2020
18
EDITORIAL
Broadcasting torture to produce collective
fear and terror
Occupy Paedophilia is the name given to groups
of ultra-nationalist Russian neo-Nazi youths
who have made a name for themselves by
publishing videos in which they torture young
members of the LGBTI community. The
groups use targeted dating apps to organise
meetings with individuals under the pretense
of a “date,” who are then filmed while being
humiliated and beaten. At least in one case,
the torture ended in death. In mid-2013, the
first videos and photos began to appear on
YouTube and the social network VK.com, a
Russian equivalent to Facebook. The members
use VK to create cells. At its highest peak, there
were around 500 cells of 8 to 10 members, dis-
tributed in cities all around Russia. Although
their stated goal is to locate paedophiles, the
videos of the victims are of LGBTI teenagers
or young adults, who are tortured and beaten,
and during which their sexual orientation or
gender identity is revealed to family, friends and
their wider communities. For several years, the
Russian state, which had enacted several laws
against so-called “gay propaganda,” did not
act against them despite having their members
identified and appearing in newspapers and
TV, providing relative impunity for these acts
(Wilkinson, 2014). It was also coincident with
Russia’s actions at the Human Rights Council
in pushing for a wide margin of appreciation
when dealing with “traditional values.” A group
that imitated Occupy Paedophilia was created
in Barcelona in 2013. In December 2019, its
were organized via a Facebook page. All the
organizers were detained just three days later
and all followers were tracked, and many of them
detained or interrogated. Not being part of these
groups means not having access to information
on when and where actions would take place, but
accessing them presented high risk for detention,
interrogation and torture (Tufekci, 2014).
members were convicted of a crime against
moral integrity and disclosure of secrets with
aggravating circumstances of superiority and
homophobia, after they had orchestrated meet-
ings with gay men through dating apps with
pretenses of romance or sexual intentions.
Instead, the group collectively ambushed their
targets in order to humiliate them, record their
actions and spread videos publicly. In 2018,
Sudan’s security services tried to undermine
growing popular protests by apprehending a
group of students in Darfur, torturing them
brutally until some “admitted” to producing
bombs to pursue violent intent in the name of
militia groups in Darfur, and spreading false
confession video-recordings on Facebook and
state television (Carmichael & Pinnell, 2019).
Contrary to what was expected, however, this
attempt to create a post-truth situation lead
to a popular reaction. Facebook comments
disputing the validity of the confessions went
viral and fuelled protests. Social media posts
bearing the hashtag #WeAreAllDarfur were
shared thousands of times (Carmichael &
Pinnell, 2019).
Legal initiatives to prevent and act against
ICIT
In July 2018, the United Nations Human
Rights Council approved a resolution on The
promotion, protection and enjoyment of human
rights on the Internet through which it encour-
aged State Parties to legislate on how to protect
freedom in the net while at the same respond-
ing to global threats33. Two years prior, in 2016,
the European Union institutions succeeded in
forcing internet giants Facebook, YouTube,
Twitter, Microsoft, and more recently Insta-
gram, to adopt internal Codes of Conduct34.
33 A/HRC/38/L.10/Rev.1.
34 https://ec.europa.eu/info/policies/justice-and-
TORTURE Volume 30, Number 1, 2020
19
EDITORIAL
These provide for various commitments, and
require companies to implement clear and ef-
fective procedures for examining complaints
regarding hate speech, so that access to such
content can be withdrawn or disabled within 24
hours. According to the fourth evaluation of the
application of this code in February 2019, its
implementation had succeeded in eliminating
70% of content identified as being hate speech.
Google has allegedly tried to control the ma-
nipulation of forums and the use of hate speech
through Perspective35, an app that detects such
practices and which can also be used by social
organisations. There are not many examples of
case law. Quite noticeably, on 14 January 2020,
in the case of Beizaras and Levickas v. Lithu-
ania, the European Court of Human Rights
ruled against the State on the basis of discrimi-
nation, violation of family and private life, and
lack of access to effective remedies, for failure
to properly act or investigate homophobic hate
speech on Facebook against an LGTBI activist.
Forensic and legal considerations
We have described situations in which a state
causes or does not prevent nor put a stop to
the intentional infliction of severe psychologi-
cal suffering of a citizen to achieve coercion,
humiliation or punishment without the need
to resort to physical violence. How this suffer-
ing is distinct from those of traditional torture
is a largely unexplored field. Medical and psy-
chological research must support legal efforts
to regulate these complex and multifaceted
situations.
Online ill-treatment and torture must be
recognised and acknowledged. The revelations
by Snowden and others of the widespread
fundamental-rights/combatting-discrimination/
racism-and-xenophobia/eu-code-conduct-
countering-illegal-hate-speech-online_en
35 https://www.perspectiveapi.com/#/home
practice of surveillance of citizens led to no
consequences for the authorities implicated
other than scandal for and prosecution of the
whistleblower. According to some scholars,
paradoxically, competition for citizen surveil-
lance has in fact increased (Richards, 2019).
The letters to the governments of the United
States, United Kingdom, Ecuador and Sweden
by Special Rapporteur Nils Meltzer regarding
Julian Assange in 2019, showing forensic ev-
idence of torture, was a landmark document
that opened a path for recognition of ICIT36.
There is a delicate line between freedom
of expression and hate conduct, and public
harassment that needs legal clarification. In-
ternational legislation related to ICIT should
consider protection measures, removal of
harmful content in internet, as well as forms
of restoration, rehabilitation, satisfaction as-
surances of non-recurrence, combining mea-
sures that are symbolic, material, individual
and collective.
There is also a need for international reg-
ulations that force internet intermediary com-
panies to guarantee data security and privacy,
regulate and control companies selling spyware
and hardware and software aimed to infiltra-
tion, surveillance and massive control of pop-
ulation. Similar to support for the control of
international trade of weapons potentially
usable as torture devices, comparable legisla-
tion related to the trade of software and hard-
ware of ICIT-capable devices is also necessary.
There is additionally a need for clear regu-
lations on government access to private infor-
mation, including cloud storage systems and
infiltration of personal devices without a judi-
cial order. Anonymity or encryption is a right
and it should not be suppressed, controlled or
36 https://spcommreports.ohchr.org/TMResultsBase
/DownLoadPublicCommunicationFile?gId=24642
TORTURE Volume 30, Number 1, 2020
20
EDITORIAL
restricted by any state. Humanitarian organisa-
tions must also seek greater understanding of
how data and metadata collected or generated
by their programs for social, political or hu-
manitarian purposes, can be accessed and used
by other parties for social control (Pirlot de
Corbion et al., 2018). Organisations working
with survivors have an ethical duty through
the do-no-harm principle to avoid involun-
tarily putting people at risk of internet and
communications-based torture.
Finally, a complex challenge for the medical
field is how to address the specific needs of re-
habilitation of survivors of ICIT, combining, as
with other situations, therapeutic work in indi-
vidual and collective domains, with a special
focus on symbolic elements.
In this issue
MeganBerthold, Peter Polatin, James Lavelle,
Craig Higson-Smith, Frederick Streets, Caitrin
Kelly and Richard Mollicadevelop a Complex
Care Approach (CCA) for treatment of torture
victims that integrates medical, psychological,
psychosocial and existential elements from a
holistic perspective, and apply it to an hypo-
thetical paradigmatic case. Rouf Khawaja and
collaborators present a series of 40 cases of male
victims of sexual torture in India with severe
urological sequelae in defining the concept
of parrilla torture and showing the interplay
between medical and psychological sequels.
Carme Vivancos and Iñaki Rivera present data
from an early analysis of the safeguards in the
medical examination of people detained in
Catalonia (Spain) in the framework of civic
protests. The analysis serves as a reminder that
the ethical principles of the Istanbul Protocol
must be respected in all circumstances. Their
data evidences a request for more thorough in-
vestigation by the Spanish authorities. Sexual
conversion therapies are still common practice
in many countries around the world as a recent
IRCT report has shown. The Independent Fo-
rensic Expert Grouphas been working over the
past two years on an analysis of these practices
as a form of ill-treatment or torture. The reader
will find a landmark document: the group’s
latest Statement with the conclusions and rec-
ommendations to the international legal and
medical communities.
Johan Lansen, one of the great European
figures of the 20th century in the work with
torture survivors, from his own experience as
a Holocaust survivor, passed away in Novem-
ber 2019.Torture Journal reprints, as a posthu-
mous tribute, the article that he published in the
Journal of Medical Ethics more than 15 years
ago with personal reflections on the ethical di-
lemmas of working with perpetrators. This is a
brief but extraordinary contribution that we are
honoured to rescue.
We are living in times of a global crisis of
unknown magnitude. The world has had much
experience of wars in which humans have
fought against each other. It is the first time
however in the contemporary age in which the
world defends itself from a common enemy,
and when the element that should unite hu-
manity, that difficult to define concept that
we call the human condition, is globally chal-
lenged. From the Journal we are compiling
initiatives or situations to provide perspectives
on the current pandemic and the work with
torture survivors. You can send us contribu-
tions (papers, reflections, reviews or news). In
addition, continuing with the regular work of
the journal throughout this year, three specific
Special Sections are planned: Physiotherapy in
the rehabilitation of torture victims, work with
victims in contexts of active and continuous
violence, and forced disappearance as a form
of torture. The Calls for Papers can be found
on the Journal’s website. We look forward to
your contributions.
TORTURE Volume 30, Number 1, 2020
21
EDITORIAL
References
Amnesty International. (2018). #ToxicTwitter: Violence
and abuse against women online. https://www.
amnestyusa.org/wp-content/uploads/2018/03/
Toxic-Twitter.pdf
Anderson, C., & Carnegey, N. (2004). Violent evil
and the General Agression Model. In A. G.
Miller (Ed.), The social psychology of good and evil.
Guilford. New York.
Aronson, J. D., Cole, M., Hauptmann, A., Miller, D.,
& Samuels, B. (2018). Reconstructing human
rights violations using large eyewitness video
collections: The case of euromaidan protester
deaths. Journal of Human Rights Practice, 10(1),
159–178. https://doi.org/10.1093/jhuman/huy005
Barrera, L., & Rodríguez, C. (2017). La violencia en
línea contra las mujeres en México. Informe para la
Relatora sobre la Violencia contra las Mujeres MS.
Dubravka Simonovic. Internet Es Nuestra. www.
Internetesnuestra.mx
Basak, R., Sural, S., Ganguly, N., & Ghosh, S. K.
(2019). Online Public Shaming on Twitter:
Detection, Analysis, and Mitigation. IEEE
Transactions on Computational Social Systems,
6(2), 208–220. https://doi.org/10.1109/
TCSS.2019.2895734
Bunce, M. (2019). Humanitarian Communication in a
Post-Truth World. Journal of Humanitarian Affairs,
1(1), 49–55. https://doi.org/10.7227/jha.007
Carmichael, F., & Pinnell, O. (2019). How fake news
from Sudan’s regime backfired. BBC News, pp.
1–10.
Cole, J. (2014). The New Arabs: How the Millennial
Generation is Changing the Middle East. Simon &
Schuster.
Debord, G. (1995). The Society of the Spectacle.
Society, p. 154. https://library.brown.edu/
pdfs/1124975246668078.pdf
Dhrodia, A. (2018). Unsocial media: A toxic place for
women. IPPR Progressive Review, 24(4), 380–387.
https://doi.org/10.1111/newe.12078
Douglas, H., Harris, B. A., & Dragiewicz, M. (2019).
Technology-facilitated domestic and family
violence: Women’s experiences. British Journal
of Criminology, 59(3), 551–570. https://doi.
org/10.1093/bjc/azy068
ECHRT. (2019). Mass surveillance (Vol. 8). https://
www.echr.coe.int/Documents/FS_Mass_
surveillance_ENG.pdf
Freedom House. (2017). Manipulating Social Media to
Undermine Democracy. https://doi.org/10.1080/002
24545.1975.9923293
Gleeson, H. (2014). The prevalence and impact of
bullying linked to social media on the mental heath
and suicidal behaviour among young people. Dublin.
https://assets.gov.ie/25088/59fb1e4948fc43028f93
1a6c1e0c8790.pdf
Gonzales, A. L., & Hancock, J. T. (2011). Mirror,
mirror on my Facebook wall: Effects of exposure
to Facebook on self-esteem. Cyberpsychology,
Behavior, and Social Networking, 14(1–2), 79–83.
https://doi.org/10.1089/cyber.2009.0411
Gray, G. (2019). Disappearing refugees inside the
United States. Torture Jour nal, 29(1), 144–146.
https://doi.org/10.7146/torture.v29i1.113206
Harris, B. A., & Woodlock, D. (2019). Digital coercive
control: Insights from two landmark domestic
violence studies. British Journal of Criminology,
59(3), 530–550. https://doi.org/10.1093/bjc/
azy052
Harsin, J., & Harsin, J. (2018). Post-Truth
and Critical Communication Studies.
In Oxford Research Encyclopedia of
Communication. https://doi.org/10.1093/
acrefore/9780190228613.013.757
Hodalska, M. (2019). Cyberbullying, Fear
and Silence: From Bystanders to Cyber-
Samaritans. Perils of the Web: Cyber Secur ity
and Internet Safety, (May). https://doi.
org/10.1163/9781848885011_004
Hopper, E., & Hidalgo, J. (2006). Invisible_Chains:
Psychological coercion of human trafficking
victims. Intercultural Human Rights Law Review,
1, 185/209.
HRC. (2018). Report of the Special Rapporteur on
violence against women, its causes and consequences
on online violence against women and girls from a
human rights perspective - A/HRC/38/47.
HRW. (2017). Online and on All Fronts. Russia’s assault
on freedom of expression. Human Rights Watch.
https://www.hrw.org/sites/default/files/report_pdf/
russiafoe0717_web_2.pdf
IGF. (2015). Best Practice Forum (BPF) on Online
Abuse and Gender-Based Violence Against Women.
Internet Governance Forum.
John, A., Glendenning, A. C., Marchant, A.,
Montgomery, P., Stewart, A., Wood, S.,
… Hawton, K. (2018). Self-harm, suicidal
behaviours, and cyberbullying in children and
young people: Systematic review. Journal of
Medical Internet Research, 20(4). https://doi.
org/10.2196/jmir.9044
Koenig, K. A. (2013). The “Worst”. A Closer Look
at Cruel, Inhuman and Degrading Treatment.
University of California, Berkeley - School of
Law; University of San Francisco. Doctoral
Dissertation.
Lageson, S. E., & Maruna, S. (2018). Digital
degradation: Stigma management in the internet
age. Punishment and Society, 20(1), 113–133.
TORTURE Volume 30, Number 1, 2020
22
EDITORIAL
https://doi.org/10.1177/1462474517737050
Lazer, D. M. J., Baum, M. A., Benkler, Y., Berinsky,
A. J., Greenhill, K. M., Menczer, F., … Zittrain,
J. L. (2018). The science of fake news. Science,
359(6380), 1094–1096. https://doi.org/10.1126/
science.aao2998
Leary, M. R., & Tangney, J. P. (2012). Handbook of
Self and Identity. Guilford Press.
Luban, D. (2009). Human Dignity, Humiliation, and
Torture. Kennedy Institute of Ethics Journal, 19,
211–230. https://doi.org/10.1353/ken.0.0292
Maier, A. (2011). Torture. How Denying Moral
Standing Violates Human Dignity. In E.
Kaufmann, P., Kuch, H., Neuhäuser, C.,
& Webster (Ed.), Humiliation, Degradation,
Dehumanization (pp. 101–118). Springer
Netherlands.
Manago, A. (2014). Identity Development in the Digital
Age: The Case of Social Networking Sites. Oxford
Handbooks On-line.
Mijatovic, D. (2018). New Challenges to Freedom
of Expression: Countering Online Abuse of
Female Journalists. https://www.osce.org/files/f/
documents/c/3/220411.pdf
NDI. (2019). Tweets That Chill : Analyzing Online
Violence Against Women in Politics. www.ndi.org/
tweets-that-chill
Ortega, R., Elipe, P., Mora-Merchán, J. A., Genta,
M. L., Brighi, A., Guarini, A., … Tippett, N.
(2012). The Emotional Impact of Bullying and
Cyberbullying on Victims: A European Cross-
National Study. Aggressive Behavior, 38(5), 342–
356. https://doi.org/10.1002/ab.21440
Parry, J. T. (2003). What Is Torture, Are We Doing
It, and What if We Are. Pitt. Law Review, 64,
237–249.
Perez de Acha, G. (2016). Hacking team malware para
la vigilancia en América Latina. Santiago de Chile.
Phillips, E. M. (2011). Pain, Suffering, and
Humiliation: The Systemization of Violence in
Kidnapping for Ransom. Journal of Aggression,
Maltreatment & Trauma, 20(8), 845–869. https://
doi.org/10.1080/10926771.2011.626512
Pirlot de Corbion, A., Hosein, G., Nyst, C., Fisher,
T., Gerathy, E., Callander, A., & Bouffet,
T. (2018). The Humanitarian Metadata
Problem: ‘Doing No Harm’ in the Digital
Era. (October), 130. Privacy International.
https://privacyinternational.org/sites/default/
files/2018-12/The HumanitarianMetadata
Problem - Doing No Harm in the Digital Era.pdf
Pollmann, A. (2011). Humiliation, Degradation,
Dehumanization (P. Kaufmann, H. Kuch, C.
Neuhaeuser, & E. Webster, Eds.). https://doi.
org/10.1007/978-90-481-9661-6
Privacy International. (2018). Secret Global
Surveillance Networks: Intelligence Sharing Between
Governments and the Need for Safeguards. (April),
173. https://privacyinternational.org/sites/
default/files/2018-04/Secret%20Global%20
Surveillance%20Networks%20report%20
web%20%28200%29.pdf
R3D. (2017). Gobierno espía. Vigilancia sistemática
a periodistas y defensores de derechos humanos en
Mexico. Mexico. https://r3d.mx/2017/06/19/
gobierno-espia/
Richards, J. (2019). Intelligence gathering, issues of
accountability, and Snowden. In Terrorism and
State Surveillance of Communications. (pp. 19–37).
Routledge.
Ruhrmann, H. (2019). Facing the future. Protecting
Human Rights in Policy Strategies for Facial
Recognition Technology in Law Enforcement.
Rukundo, S. (2018). My President is a Pair of
Buttocks’: The limits of online freedom of
expression in Uganda. International Journal of
Law and Information Technology, 26(3), 252–271.
https://doi.org/10.1093/ijlit/eay009
Scarry, E. (1985). The body in Pain. Oxford University
Press.
Serra, L. (2018). On-line gender based violence.
Pikara - Online Magazine., 2(December), 227–
249. Pikara Magazine. http://lab.pikaramagazine.
com/wp-content/uploads/2019/06/
VIOLENCIAS_EN.pdf
Sussman, D. (2006). Defining Torture. Case Western
Reserve Journal of Inter national Law, 37, 225.
T-CY. (2018). Mapping study on cyberviolence. Council
of Europe. www.coe.int/cybercrime
Tufekci, Z. (2014). Social Movements and
Governments in the Digital Age: Evaluating a
Complex Landscape.Journal of Inter national
Affairs,68(1), 1–18. http://blogs.cuit.columbia.
edu/jia/files/2014/12/xvii-18_Tufekci_Article.pdf
Van der Wilk, A. (2018). Cyber violence and hate speech
online against women (PE 604.979). https://
www.europarl.europa.eu/RegData/etudes/
STUD/2018/604979/IPOL_STU(2018)604979_
EN.pdf
Wilkinson, C. (2014). Putting “Traditional Values”
Into Practice: The Rise and Contestation of Anti-
Homopropaganda Laws in Russia. Journal of
Human Rights, 13(3), 363–379. https://doi.org/10.
1080/14754835.2014.919218
Zhao, S. (2005). The Digital Self: Through the
Looking Glass of Telecopresent Others.
Symbolic Interaction, 28(3), 387–405. https://doi.
org/10.1525/si.2005.28.3.387
TORTURE Volume 30, Number 1, 2020
23
SCIENTIFIC ARTICLE
Abstract
Introduction: Torture is an assault on the
physical and mental health of an individual,
impacting the lives of survivors and their fami-
lies. The survivor’s interpersonal relationships,
social life, and vocational functioning may be
affected, and spiritual and other existential
questions may intrude. Cultural and historical
context will shape the meaning of torture expe-
riences and the aftermath. To effectively treat
torture survivors, providers must understand
and address these factors. The Complex Care
Model (CCM) aims to transform daily care for
those with chronic illnesses and improve health
outcomes through effective team care.
Methods: We conduct a literature review of
the CCM and present an adapted Complex
Care Approach (CCA) that draws on the
Harvard Program in Refugee Trauma’s five-do-
main model covering the Trauma Story,
Bio-medical, Psychological, Social, and Spiri-
tual domains. We apply the CCA to the case of
“Joshua,” a former tortured child soldier, and
The complex care of a torture survivor in
the United States: The case of “Joshua”
S. Megan Berthold1, Peter Polatin2, Richard Mollica3, Craig Higson-Smith4,
Frederick J. Streets5, Caitrin M. Kelly6, and James Lavelle7
Key points of interest
•
To effectively treat torture survivors,
providers must understand and address
multiple and complexly related factors.
•
A Complex Care Approach (CCA),
an adaptation of the Chronic Care
Model, is presented. The CCA in-
cludes five-domains, including the
Trauma Story, Bio-medical, Psycho-
logical, Social, and Spiritual domains.
1) S. Megan Berthold, PhD, LCSW, Associate
Professor and Director of Field Education,
University of Connecticut School of Social Work
(and Co-Chair of the NCTTP Research and
Data Project)
Correspondence to: megan.berthold@uconn.edu
2) Peter Polatin, M.D., MPH, Faculty, HPRT;
Psychiatric consultant, IRC/Dallas; Adjunct
Associate Professor of Global Mental Health,
George Washington University; Associate
Professor of Anesthesia/Pain and Psychiatry
(retired) UTSW; Health Program Consultant,
DIGNITY - Danish Institute Against Torture
(retired)
Correspondence to: peter.polatin@gmail.com
3) Richard Mollica, MD, MAR, Director of Harvard
Program in Refugee Trauma, Massachusetts
General Hospital Professor of Psychiatry,
Harvard Medical School
Correspondence to: rmollica@partners.org
4) Craig Higson-Smith, MA, Director of Research,
Center for Victims of Torture
Correspondence to: chigsonsmith@cvt.org
5) Frederick J. Streets, M.Div., DSW, LCSW,
Associate Professor (Adjunct) Pastoral Theology,
Yale University Divinity School
6) Caitrin M. Kelly, MD, Massachusetts General
Hospital
7) James Lavelle, LICSW, Co-Founder of Harvard
Program in Refugee Trauma (HPRT)
https://doi.org/10.7146/torture.v30i1.113063
International Rehabilitation Council for Torture Victims. All rights reserved.
TORTURE Volume 30, Number 1, 2020
24
SCIENTIFIC ARTICLE
discuss the diagnosis and treatment across the
five domains of care.
Findings: The CCA is described as an ef-
fective approach for working with torture
survivors. We articulate how a CCA can be
adapted to the unique historical and cultural
contexts experienced by torture survivors and
how its five domains serve to integrate the ap-
proach to diagnosis and treatment. The bene-
fits of communication and coordination of care
among treatment providers is emphasized.
Discussion / Conclusions: Torture survivors’
needs are well suited to the application of a
CCA delivered by a team of providers who ef-
fectively communicate and integrate care ho-
listically across all domains of the survivor’s
life.
Keywords: complex care approach, five-domain
model, torture survivors.
Introduction
Torture is an assault on the physical and
mental health of an individual, typically
having an impact on multiple domains of the
lives of survivors and their families. The sur-
vivor’s interpersonal relationships, social life,
and vocational functioning may be affected,
and spiritual and other existential questions
may intrude. His or her cultural and historical
context will shape the meaning of their torture
experiences and the aftermath. Furthermore,
torture impacts larger social and/or political
networks and the community (Mollica, 2006;
National Partnership for Community Train-
ing, 2011).
To effectively treat torture survivors, pro-
viders must understand and address these
multiple and complexly related factors. Treat-
ment approaches developed in Western coun-
tries to attend to the psychological domain of
care typically focus on post-traumatic stress
disorder (PTSD), failing to address the full
range of impacts of torture (Bandeira, 2013).
Interdisciplinary care can be expensive and
many treatment centers are doing what they
can with limited resources, recognizing that
rehabilitation services are very often incom-
plete (Jorgensen et al., 2015; Quiroga & Ja-
ranson, 2005).
Methods
The Complex Care Approach (CCA) with five
domains (i.e., trauma story, bio-medical, psy-
chological, social, and spiritual) is described
as an adaptation to the Chronic Care Model
(CCM) that has been used in many countries
to treat individuals with chronic health con-
ditions. The CCA is an effective approach to
treat torture survivors with complex presenta-
tions in contexts that are rich in resources. In
other contexts that do not have access to such
services as primary care and extensive psycho-
logical and social services, a different approach
is needed. A de-identified fictional composite
case is presented of “Joshua,” a former child
soldier who has experienced torture, adapted
from real life experiences of multiple survivors
in order to protect their confidentiality and
identities. The CCA is applied to discuss the
diagnosis and treatment of Joshua across each
of the five domains of care. The severity of
Joshua’s depression and post-traumatic stress
symptoms are assessed using the Hopkins
Symptom Checklist-25 and Harvard Trauma
Questionnaire (Mollica, McDonald, Massagli
& Silove, 2004). Emphasis is given to the need
to prioritize interventions, establishing safety
first, and to the importance of integration
across all domains of care.
The Chronic Care Model (CCM)
Practitioners and researchers in the United
States have been among the leaders in the
field of complex care of chronic health con-
TORTURE Volume 30, Number 1, 2020
25
SCIENTIFIC ARTICLE
ditions, perhaps in part due to an influential
report issued by the Institute of Medicine
(IOM) in 2001 that called for far reaching
changes to the U.S. health system (Institute
of Medicine Committee on Quality of Health
Care in America, 2001). This IOM (2001)
report noted, in part, major shortcomings in
care coordination and problems when treat-
ment focuses narrowly on only one disorder
in those who have multiple diagnostic condi-
tions. Despite advances in the effectiveness of
treatment, a random survey of patients with
chronic conditions in the United States found
that only 56.1% received the recommended
care (McGlynn et al., 2003). Less than half of
U.S. patients with asthma, depression, hyper-
tension, or diabetes were receiving appropriate
medical care (Clark et al., 2000; Joint National
Committee on Prevention, 1997; Legoretta et
al., 2000; Young et al., 2001). Given the addi-
tional barriers that refugees and torture sur-
vivors often face in accessing treatment (e.g.,
language and cultural barriers, trauma history,
provider knowledge gaps, lack of health insur-
ance [Esala et al., 2018]), it is likely that these
populations are even less likely to receive ap-
propriate care in the United States.
The Chronic Care Model (CCM) was
developed to improve health outcomes and
promote effective delivery of evidence-based
and patient-centered care. Its aim is to trans-
form daily care for patients with chronic ill-
nesses from acute and reactive to proactive,
planned, and population-based. It is designed
to accomplish these goals through a combina-
tion of effective team care and planned inter-
actions; self-management support bolstered
by more effective use of community resources;
integrated decision support; and patient reg-
istries and other supportive information tech-
nology (see Figure 1). These elements are
designed to work together to strengthen the
provider-patient relationship and improve
health outcomes (Coleman et al., 2009, p. 75).
Figure 1. The Chronic Care Model (CCM)
Reproduced from Epping-Jordan, Pruitt, Bengoa & Wagner, 2004, with permission from BMJ Publishing Group Ltd.
TORTURE Volume 30, Number 1, 2020
26
SCIENTIFIC ARTICLE
Practitioners have applied the CCM to a
wide range of chronic health and mental health
conditions and diverse populations in high-in
-
come and low and middle-income countries
(LMICs). Successful implementation of inte-
grated care models require that health systems
are strengthened (Thornicroft et al., 2018).
Budget constraints and increased volumes of
referrals of refugees or other traditionally un-
derserved individuals pose challenges to care
in high-income countries. Innovations made in
LMICs such as task-sharing and the growth
in services provided by non-specialists may be
beneficially applied in these high-income set-
tings (Thornicroft et al., 2018).
Adaptation of the CCM for treatment of refugees
and torture survivors: A complex care approach
Refugees and torture survivors commonly
experience multiple traumas that add com-
plexity to their treatment. Psychiatric prac-
titioners working transculturally and in war
zones with refugee families have long recog-
nized that the appropriate care of refugees re-
quires complex care approaches and systems
that address not only individual, family,
and interactional psychological factors, but
also attend to culture, social, and politi-
cal domains (Rezzoug et al., 2008). Many
torture treatment specialty clinics provide
interdisciplinary care (Vukovich & Esala,
2016). Research on collaborative care for
complex conditions experienced by refugees
and torture survivors is sparse but promis-
ing, warranting further study (Esala et al.,
2018).
Torture survivors differ from other patients
in some key respects that have implications for
the adaptation of the CCM. Torture survivors
as a group have been victims of serious violent
crime that is intentional, targeted, human-per-
petrated, and planned. These crimes are often
implemented by institutions and systems of
the state including, in some cases, health care
institutions and personnel (Boyd, 2016; Mc-
Carthy, 2013). Therefore, establishing trust
and addressing perceived issues of impotence
and helplessness are often more critical when
working with torture survivors compared to
other patients. Some torture survivors are dis-
located from their communities of origin and
separated from traditional family and commu-
nal systems of support and affiliation. There-
fore, for these survivors, establishing new
systems of support and connection can be vital.
Survivors often come from cultures with which
providers in countries of exile are less famil-
iar and cultural competency is essential so that
these providers have a better understanding of
these patients and do not react with xenopho-
bia and bias. For those who flee to other coun-
tries from very different societies and cultures,
the health care system may be very unfamiliar
and even frightening. Certain procedures used
in medical assessment or treatment for various
conditions such as phlebotomy, the use of elec-
trical stimulation, or even noises or close con-
finement in enclosed spaces for MRI or CT
imaging may serve as retraumatizing triggers.
Five domains of the complex care approach
(CCA)
The CCM is quite biomedical in nature.
Therefore, four additional domains that
emerged out of work at the Harvard Program
in Refugee Trauma (Mollica et al., 2017)
have been added to compliment the biomed-
ical domain. These five domains of care (i.e.,
trauma story, bio-medical, psychological,
social, and spiritual) comprise a Complex
Care Approach (CCA) to the care of torture
survivors. Of particular note, the trauma story
was added as an important domain for assess-
ment and treatment with torture survivors. A
key emphasis of the approach is that interdis-
ciplinary treatment team members must work
TORTURE Volume 30, Number 1, 2020
27
SCIENTIFIC ARTICLE
collaboratively, such that the assessment and
intervention plan must be integrated in nature
across all domains of care (Mollica, 2006;
Mollica et al., 2017). In addition, the ap-
proach is participatory, with the survivor fully
engaged in and driving treatment directions
and decisions. Cultural adaptations must be
made to the CCA in all domains to match the
culture and worldview of each torture survi-
vor. All of these components work together
to shape the approach with torture survivors
(National Partnership for Community Train-
ing, 2011), and influence the outcomes and
quality of life of survivors.
Practitioners should begin with establish-
ing intervention priorities, foremost of which
is stabilizing and attending to safety and other
survivor-identified concerns first, an approach
common to many trauma-specific treatments
(Mollica, 2006; National Partnership for
Community Training, 2011). We recommend
starting with the social domain, identifying
and building on existing social support in a
manner that is non-stigmatizing and promotes
the establishment of an empathic and trust-
ing relationship with the treatment team. In
the early phase of treatment, coping and af-
fect-regulation skills training will likely be a
focus (Mollica, 2006). Only after the survivor
is stabilized and if it is determined that they
can tolerate it (e.g., they have sufficient affect
regulation strategies), an in-depth trauma
history (Mollica, 2006) can be conducted to
fully assess the impact of the trauma(s) on
the physical and mental health of the survivor
across five key domains, making cultural adap-
tations as appropriate (see Figure 2).
A deidentified fictitious composite case of
torture survivor “Joshua” is presented below,
followed by application of the CCA, used to
design an assessment and treatment plan.
Trauma
Survivor
Experience
Health
Impact
Biomedical Psychological
Cultural
Adaptations
Trauma
Story
Spiritual
Outcomes
Social
Five Domains
Figure 1. Complex Care Approach with Torture Survivors
TORTURE Volume 30, Number 1, 2020
28
SCIENTIFIC ARTICLE
Joshua: Clinical case of a torture survivor
Joshua is a 32-year-old Liberian male, un-
married, who lives with his mother, sister,
niece and nephew in Dallas, Texas in the
United States.
Referral: by a Dallas refugee agency
case worker because of perceived difficul-
ties functioning and inability to hold a job.
Source of information: personal interview
as well as collateral information from family
and case worker.
Chief complaint: “I am hot over my body
and I feel weak a lot. It feels like ants crawl-
ing over me. My head hurts so, so much.
There is a soft spot in my head, and I am
afraid that it will get worse.”
Present illness: Joshua arrived in Dallas 12
years ago in 2006 after his mother, herself
an asylee, successfully petitioned for him to
join her. Joshua’s mother had come to the
United States before he did. She had applied
for and been granted asylum, therefore be-
coming an “asylee.” A year later, she peti-
tioned for Joshua to join her in the United
States as a derivative asylee. Joshua later ad-
justed his status and became a Lawful Per-
manent Resident. At the time that Joshua’s
mother submitted her petition, asylees were
eligible to sponsor unmarried children who
were under the age of 21 at the time of their
own original asylum application as derivative
asylees. Joshua did not disclose his history
as a former child soldier in his application.
He fears that his legal status in the United
States as a Lawful Permanent Resident may
be in jeopardy as a result.
His family reports that he secludes
himself in his room and at times talks to
himself or shouts. His sister says that she
has heard him crying and praying to die. He
hardly sleeps and has disturbing nightmares
when he does. Joshua expresses suspicion of
others, including his family, suggesting that
people are spying on him or following him.
When he does go out, he often becomes ex-
tremely agitated, demanding to return home.
He is fearful of utilizing public transpor-
tation. His family says that when he first
arrived in Dallas, he seemed normal. But,
over a six-month period, his symptoms wors-
ened. The family has no idea what triggered
his symptoms. Joshua complains of inter-
mittent severe headaches but refuses to see
a doctor. He also complains of some dis-
comfort when moving his bowels and pain
in his lower back, neck, and shoulders. He
has mild systolic hypertension and smokes
2 packs a day.
He has made several attempts to seek
employment, but because of his extreme dis-
comfort and limited education, he is limited
in his job skills. He has made no attempt
to reach out to anyone for support, either
within his family or to others in the Libe-
rian community. His family attends a United
Methodist church with a number of Libe-
rian refugees in the congregation. At the
request of his family, the local pastor visited
him at home and tried to engage him, but
Joshua became agitated, accused the pastor
of spying on him, and asked him to leave the
house, much to the embarrassment of his
family. In spite of a number of invitations, he
has refused to attend services at this church.
Psychosocial history
Joshua is functionally illiterate with
almost no formal education. He was born
during the war years in Liberia, in a small
village outside of Gbargna, a large town
about 100 miles from the capital, Monro-
via. His family are members of the Kpelle
tribe. He did not attend school, because there
were no teachers available during the war
years of his youth. When he was 7 years old,
TORTURE Volume 30, Number 1, 2020
29
SCIENTIFIC ARTICLE
Charles Taylor’s rebels, who had been active
for several years in this part of the country,
destroyed his village. He witnessed the rape
of his mother and sister. He was captured
by a warlord, given a gun and was forced
to shoot and kill his father. He remembers
that he was unfamiliar with the gun, and was
shaking so much that he took multiple shots,
and watched as his father slowly died. That
memory has stayed with him. Thereafter, he
fought for Taylor as a child soldier. During
this time, he was given “brown” (heroin),
cocaine, marijuana, and sleeping pills, while
he and the group of child soldiers to whom he
had been assigned systematically attacked vil-
lages, torturing, killing, and raping the popu-
lation. He suffered two gunshot wounds, but
fortunately they were superficial and were
treated with herbal poultices, with which he
healed uneventfully. During one occasion,
toward the end of this period and just before
Taylor was elected president, Joshua was cap-
tured by a rival group. He was beaten se-
verely, tortured with cigarette burns, and
knocked out. He was rescued after a few days
by his compatriots.
After the war, he lived on the streets of
Monrovia. He did not know whether his
mother and sister were alive, or where to
look for them. He was arrested several times,
but released each time after a few months.
Finally, however, he was given a longer sen-
tence in a prison where many of the other
prisoners came from opposing sides of the
war. He had been using opioids, and went
through opioid withdrawal “cold turkey”
during each of his imprisonments. Although
it was available, “for a price” in prison, he
finally decided not to use it anymore, even
though he continued to sell it.
There was much conflict within the prison
and the guards did not do much to control
the violence. Joshua allied himself with others
of his tribe, and had no choice but to partici-
pate in the fights which occurred daily. Joshua
was placed on the list for family reunification
to the United States although he remained in
prison initially to finish the last few months
of his sentence. Eighteen months later he was
granted a visa and joined his family in Dallas.
At that time, he was 20.
Joshua lives with his mother, sister, niece,
and nephew. His mother and sister are both
working as nurses in a local health center.
His sister is divorced with two teenage chil-
dren. Before Joshua joined the family, his
mother and sister had many friends, includ-
ing people in the Liberian-American com-
munity. Now that Joshua is with them, many
friends avoid contact with them knowing
his history as a child soldier and expressing
anger towards him. Joshua is alienated in
the United States because of his history as a
perpetrator. He does not understand why his
family remains distant from him and blames
him for his past. Overall, Joshua’s quality of
life is poor.
Screening Instruments:
1. Hopkins Symptom Checklist 25
(HSCL-25)
Depression Score 3.2; 1.75 = Cut off
point; possible range 1-4
2. Harvard Trauma Questionnaire (HTQ)
Score 3.48; 2.5 = Cut off point; possi-
ble range 1-4
TORTURE Volume 30, Number 1, 2020
30
SCIENTIFIC ARTICLE
Findings
Five domains of the CCA applied to the case of
Joshua
The work with Joshua is discussed from the
perspective of each of the five domains of the
CCA. Clinical teams may want to start with
the social domain to facilitate engagement with
Joshua and establish a foundation of support
and safety to promote his health and wellbe-
ing across the realms of his life. Throughout,
emphasis is placed on evidence-based treat-
ment options. While psychiatric diagnoses are
utilized in this case example, it is understood
that there may be limitations to this in the care
of survivors. Team members are encouraged
to interact with Joshua from a person-cen-
tered approach, avoiding medical jargon and
labels and framing his condition and situation
in a non-stigmatizing manner. It would be
vital for the treatment team members, in con-
sultation with Joshua, to make an integrated
treatment plan that accounts for the timing
and sequencing of each component.
1. Trauma story: The trauma story domain is
envisioned as the central domain that affects
all others, although it is generally not rec-
ommended to begin treatment by gathering
a detailed trauma history until the person is
stabilized and safety has been established. The
enormity of the horror and scale of Joshua’s
abuse over time is almost unimaginable. It is
clear that his personality, including trust in
others and his ability to form relationships
with loved ones, was severely disturbed due
to the extreme forms of interpersonal violence
he has experienced. The therapist must con-
sider that the major research on child soldiers
reveals that the developmental trajectories of
child soldiers are severely and chronically im-
pacted, leading to inappropriate social and de-
fensive behaviors (D’Alessandra, n.d.; Umiltà
et al., 2013). Trust must be built with Joshua
over multiple sessions so that he becomes
more comfortable talking about his trauma
story.
Before working with Joshua, it is import-
ant that his therapist understands that storytell-
ing plays an important role in Liberian society
and culture. The therapist must be very careful
that the repetition by Joshua of his dehumaniz-
ing early traumatic life experiences (e.g., being
made to kill his father), which by their very
nature are difficult to share, do not lead to his
increased lack of social connection and that he
is able to tolerate engaging in this work. Prior
to initiating work with his trauma story, Joshua
may benefit from psychotropic medication to
diminish his dissociation and hyperarousal and
better regulate his affects, thus enabling him
to talk about his traumatic narrative. In addi-
tion, if there is cognitive impairment from a
TBI, it should be determined to what extent
this may interfere, if at all, with being able to
cognitively process his trauma story. Justice
and potentially, forgiveness may play a role in
the therapy. While the therapist cannot bring
the rebels to justice, the need for justice can
be discussed fully in therapy. In some cases, a
survivor may have the opportunity to engage
in a court or other formal process that seeks
to bring the truth of their torture to light and
pursue forms of redress. In these situations,
the team may refer the survivor to an attor-
ney and work closely with the survivor (and
sometimes their legal team) to provide psy-
chosocial support before, during, and after the
proceedings.
2. Biomedical: Torture survivors frequently
present with multiple medical complaints or
conditions which must be carefully assessed
(Mollica, 2011). Joshua has several medical
issues that are chronic and non-urgent (i.e.,
mildly elevated blood pressure, active or
TORTURE Volume 30, Number 1, 2020
31
SCIENTIFIC ARTICLE
past Hepatitis C infection, mildly elevated
liver enzymes, current smoking, and chronic
pain). It is recommended to address these in
a time appropriate manner in conjunction
with his psychiatric treatment plan and in a
patient-centered approach.
Joshua’s chronic pain complaints, includ-
ing headaches, cervical and lumbar pain,
and bilateral shoulder pain, are consistent
with those seen in many survivors of torture
(Quiroga & Jaranson, 2005), and it cannot
be assumed that the etiology is psychologi-
cal. Although there is a certain amount of co-
morbidity between physical and psychological
symptoms of pain (Defrin et al., 2017), Wil-
liams and colleagues (2010) found a physi-
cal etiology to the pain complaints in 78% of
a random sample of survivors of torture. Re-
gardless of whether the etiology of the pain is
primarily physical or psychological, it is ben-
eficial to address it within the context of a ho-
listic, interdisciplinary program. This would
ideally include education (“pain school”),
physiotherapy, and a cognitive behavioral re-
structuring of the patient’s pain perception.
3. Psychological: There are five broad areas of
psychological concern in Joshua’s case, in-
cluding Complex PTSD with dissociation,
depression with paranoid delusions, suicidal
ideation, substance use, and the need to rule
out a possible Traumatic Brain Injury (TBI).
It is recommended that the therapist utilize a
consultative approach with Joshua and, given
his agitated state of presentation, an initial
priority would be to stabilize Joshua. Engag-
ing familial and other supports would be vital
to this effort. While some mental health teams
may seek to admit Joshua to a psychiatric in-
patient unit where he can be fully evaluated
within an atmosphere of relative safety, this is
not initially recommended given how stigma-
tizing, frightening, potentially re-traumatizing,
and culturally dystonic a psychiatric hospi-
talization would likely be for him. Instead,
efforts to engage Joshua in treatment might
begin with home visits from a social worker
or visiting nurse. Such an approach would be
more likely, compared to hospitalization, to
reduce the chance of Joshua’s experiencing
stigma or ostracization. Suicidality should be
assessed and, if he becomes at high risk for
attempting or completing suicide, despite the
implementation of prevention efforts includ-
ing a safety plan (Stanley & Brown, 2012),
then a psychiatric hospitalization would be
indicated.
An introduction to a therapist and a
Kreyol1 interpreter for further assessment and
treatment are recommended to address his
extreme fear and paranoia, and to establish,
for him, a safe and trusting therapeutic rela-
tionship. Many clinicians avoid trauma-focused
treatment for patients with psychosis for fear of
symptom exacerbation and relapse. However,
this has not been found to be the case, and it
is recommended that trauma-focused thera-
pies be initiated early on (van den Berg et al.,
2016). There is significant evidence that the
reprocessing of traumatic memories is funda-
mental to treatment for PTSD (Schnyder et
al., 2015). A number of studies as well as sys-
tematic reviews and meta-analyses have con-
cluded that both Trauma-Focused Cognitive
Behavior Therapy (TF-CBT) and Narrative
Exposure Therapy (NET) are most efficacious
in treating PTSD in adult survivors of war and
torture (McPherson, 2012; Robjant & Fazel,
2010; Weiss et al., 2016), including former
child soldiers (Onyut et al., 2005; McMullen
et al., 2013). Eye Movement Desensitization
1 Liberian English is a derivative of English, but
has its own idiosyncratic expressions and words.
TORTURE Volume 30, Number 1, 2020
32
SCIENTIFIC ARTICLE
and Reprocessing (EMDR) may also be valu-
able (Schnyder et al., 2015).
The process of re-exposing Joshua to his
traumatic memories should be titrated as he
is helped to differentiate his experiences in
time and space. The therapist may strive to
locate Joshua’s traumas in a Liberia of the past,
thereby releasing him to live more confidently
in his adopted country in the present. In order
to learn how to control his emotional reactions
to his traumatic experiences, Joshua would
likely benefit from understanding where they
are coming from (through psychoeducation)
and how to control them (through relaxation
training, cognitive restructuring). Using ap
-
proaches aligned with Joshua’s own body-ori-
ented description of his suffering, the therapist
may assist Joshua to increase his awareness
of his physiological arousal and affective state
from moment to moment, and to increase his
ability to modulate his baseline arousal and his
reactivity to distressing triggers. The inclusion
of body-oriented approaches to arousal regu-
lation (including muscle relaxation, stretching,
and diaphragmatic breathing) in CBT have
been shown to be effective for the manage-
ment of persistent arousal related symptoms
with people from various cultural backgrounds
(Hinton et al., 2012). Joshua’s therapist can
also start to tackle some of his more delusional
and paranoid beliefs and attributions, deter-
mining whether they are rational fears given
his torture experiences. Research in multi-
ple contexts has demonstrated the benefits of
assisting war survivors to dispute unhealthy
thought beliefs and thought patterns (Schulz
et al., 2006; Kaysen et al., 2013).
Many torture survivors are resistant to the
use of medications in treatment, particularly
if this was used as part of the torture as in the
case of Joshua (e.g., Joshua was often drugged
as a child soldier). Psychiatric consultation may
be considered to assess whether Joshua would
benefit from pharmacotherapy aimed at reduc-
ing his most debilitating symptoms in consulta-
tion with him. This may allow Joshua to more
easily engage in evaluation and therapy earlier
on and with less disruptive anxiety. Further
medication might be indicated at a later stage
if Joshua’s progress in psychotherapy is modest
because of disruptive symptoms of emotional
traumatization.
A neuropsychological assessment may be
beneficial due to Joshua’s history of concus-
sions and loss of consciousness, as well as
his difficulties with memory and emotional
lability. This assessment would identify the
likelihood of Joshua having suffered a TBI.
Symptoms of even minor TBI may be long
lasting and are easily confused with those of
PTSD and depression. The presence of co-
morbid TBI is typically associated with poorer
therapeutic outcomes (Iverson, 2005) but may
benefit from cognitive therapy.
As Joshua gains greater control over his
symptoms through symptom management and
through the integration of traumatic memo-
ries, and as he replaces the defensive schemas
that kept him alive as a child soldier with
beliefs and thought patterns that allow him
to thrive as an adult in a more peaceful world,
his relationships at home and in the commu-
nity will hopefully improve.
4. Social: The team’s social worker or related
staff might initially engage Joshua through the
social domain, identifying and building on his
existing social supports in a manner that is
non-stigmatizing and promotes the establish-
ment of an empathic and trusting relationship.
The most pressing immediate intervention
recommended in the social domain is to assist
Joshua and his family members in the United
States to collaborate in formulating a viable
therapeutic plan, one that is person-centered
and prioritizes Joshua’s concerns and goals.
TORTURE Volume 30, Number 1, 2020
33
SCIENTIFIC ARTICLE
Engaging the support of Joshua’s mother and
sister in encouraging him to seek treatment
may be valuable and would provide an oppor-
tunity for them to express care and concern
for him and strengthen their relationship. If
Joshua begins to experience a reduction of
symptoms, he may be more receptive to psy-
chotherapy, a healing modality which is prob-
ably quite foreign to him.
It is likely that his mother decided to sponsor
Joshua as a derivative asylee to promote family
reconnection and healing. His case is complex.
Although his experiences meet the U.S. defini-
tion for torture (18 U.S.C. § 2340[1]), he would
also be considered a perpetrator, which led him
to not disclose his history as a former child
soldier. He has experienced stigma as a former
child soldier from most fellow-Liberians. His
main problem in this domain is one of tension
and strained relationships within his family as a
result of him being forced to murder his father
and other experiences as a child soldier, exac-
erbated by his own internal world that is full
of feelings of suspicion, anxiety, guilt, and fear.
Joshua is particularly fearful that he will be
harmed because of his past perpetrator behav-
ior, either by losing his legal status in the United
States or by other Liberians seeking retaliation.
Joshua’s treatment should extend beyond
individual therapy to include family therapy
as “[d]uring post-conflict reintegration, child
soldiers with self-reports of supportive families
and communities endorse better mental health
and psycho-social functioning than those re-
porting discrimination” (Kohrt, 2013, p. 165).
Family therapy should start at a point at which
Joshua feels ready (in individual therapy) to
include his family in his recovery, and from
that point individual and family work should
continue in parallel. Using a narrative/trauma
story approach with the family will help both
Joshua and his immediate family to fill in the
blanks regarding what happened to each of
their family members during the war and
their years of disconnection and disrupted at-
tachment. After some stability is achieved by
Joshua and his family, a larger engagement
plan might explore how to connect him with
the Liberian-American community in Dallas.
It remains to be seen if his current strug-
gle to trust others will be more complicated
as a result of his legal concerns, including fear
of possible deportation. Referral to an immi-
gration attorney is recommended. It may be
valuable for Joshua to consider longer-term
skill-based education for his future and a re-
ferral for vocational training could be made.
Gaining acceptance from his family and com-
munity may, if successful, take time and even-
tually may benefit from participating in a
community support group. A first step may
be for Joshua to forgive himself. The work in
the social domain would build on the work
Joshua does in psychotherapy.
Some former child soldiers from Liberia
have engaged in altruistic or other communal
healing endeavors through which to demon-
strate to themselves and the community a
commitment and desire to redress the effects
of their violent actions in the past. Joshua may
or may not choose to (or be psychologically
prepared to) engage in such actions now or
in the future.
5. Spiritual: A person’s religious or spiritual life
is often significantly disrupted and sometimes
completely destroyed by torture. A survivor’s
core beliefs, values, and sense of self may be
greatly damaged whether or not they were ever
part of a religion. Religion, spirituality, and
faith may provide context and meaning to suf-
fering, serve as a framework for many forms of
traditional healing, and be significant factors in
one’s physical and mental health. These factors
may not be central or even present for everyone
and it is important to not assume that they are.
TORTURE Volume 30, Number 1, 2020
34
SCIENTIFIC ARTICLE
Some survivors may reject spirituality and/or
any religious or faith tradition. Spirituality for
some may well encompass much more than or-
ganized religion, and could include such things
as the survivor’s customary beliefs, their core
beliefs about the self, and their understand-
ing of what it means to take a life and suffer
the consequences of such actions. For those
torture survivors who are religious or spiritual,
the cultural role of religion and spirituality,
the resources of religious institutions, and an
understanding of their spiritual worldview is
crucial to consider when planning and provid-
ing them with mental health services (McKin-
ney, 2011; Piwowarczyk, 2005).
A spiritual needs assessment will enable
the care team to better evaluate Joshua’s
views and feelings about religion and spiritu-
ality (Tuskin et al., 2011) and whether being
a part of a faith community may be a source
of strength for him or not. The symbolic rep-
resentation of religion in the person of a clergy
may be too provocative for him at this time,
stimulating in him thoughts and feelings of
guilt and shame.
If Joshua does have a religious or spiritual
orientation to life, whether he shares his family’s
Methodist faith or not, this may make a posi-
tive contribution toward his feeling that his life
is worth living and has a purpose, and possibly
enhance his self-esteem, sustain him and give
him hope. Joshua may find it helpful to partici-
pate in religious or spiritual rituals such as a tra-
ditional cleansing ritual. Such rituals have been
found to be healing for some Liberian, Burun-
dian, Northern Ugandan, and Sierra Leonean
former child soldiers in dealing with their symp-
toms of posttraumatic stress (Babatunde, 2014;
Schultz & Weisaeth, 2015; Stark, 2006).
Conclusion
The Complex Care Approach is well suited
for the assessment and treatment of torture
survivors such as Joshua who present with
multiple and complex needs in the United
States or another high-resourced country. It is
not feasible, however, to implement the CCA
in lower resourced settings, particularly where
there is limited or no access to primary care,
psychological, or social services. This is a key
limitation of the CCA. Another limitation is
that outcome data using the CCA has not yet
been collected.
The CCA is closely related to the bio-
psychosocial model of health and illness de-
veloped by George Engel (1977), adding
additional components such as the trauma
story and spirituality that are highly relevant
for torture survivors. Like with the biopsy-
chosocial model before it, care team members
should be aware of the potential strengths and
weaknesses of the CCA. Key strengths of both
include: emphasis on a person-centered and
empathic approach to care; the benefits of psy-
choeducation; and collaboration between mul-
tiple providers, patients and family members
(Papadimitriou, 2017; Hong et al. 2014;
Koponen et al., 2017). These characteristics
are vital when serving individuals who have
experienced human-perpetrated trauma such
as torture, and who often have great difficulty
initially trusting others and engaging in a ther-
apeutic process.
Key weaknesses identified with the biopsy-
chosocial approach include: challenges with
coordinating the responsibilities and work of
multiple providers; it is often not implemented
in a fully integrated fashion; lack of guidance
regarding how the various domains interact in
the manifestation of the condition or health of
the patient; and lack of clarity regarding when
various interventions should be applied and in
what order (Papadimitriou, 2017). Additional
criticism from some includes, in part, promo-
tion of eclecticism without ensuring balance
across the different domains, as well as insuf-
TORTURE Volume 30, Number 1, 2020
35
SCIENTIFIC ARTICLE
ficient attention and weight given to the sub-
jective experience of patients (Benning, 2015).
When applying the CCA to the treatment
of torture survivors, conscious attention to the
risks of these weaknesses and implementation
of strategies to prevent them from occurring
are recommended. Establishing a team leader
at the outset and regular team meetings held at
least once per month would be important for
coordinating and ensuring integration of care.
In the absence of this, members of the complex
care team may easily become overwhelmed, du-
plicate efforts, and work at cross purposes with
one another to the detriment of the torture sur
-
vivor and their family. Figure 3 outlines a three-
phased process of care for Joshua.
Establishing safety and stabilization at the
outset are important foundational steps in the
CCA. Ideally, once a therapeutic relationship
is formed and Joshua has built some trust in
his care team members and feels ready, re-
ferrals for additional adjunctive services (e.g.,
legal services and vocational training) would
provide the opportunity to assess his legal
options that may contribute to increased safety
and to prepare him for vocational opportuni-
• Establish safety and strengthen social supports
• Stablize complex PTSD & depression symptoms
• Evaluate and begin to treat medical conditions, including Hepa-
titis C, hypertension, & possible TBI
• Assess suicidality and put safety plan in place as indicated (hos-
pitalize if at high suicide risk)
• Legal services
• Vocational training
•
Establish Complex Care Team: Primary Care Phy-
sician, psychiatrist, psychotherapist/family ther-
apist, case manager, pastoral care specialist
• Provide outpatient care and case management
Establishing
Safety &
Stabilization
Outpatient
Case
Management
Supportive
Care
Figure 3. Phased Process of Care for Joshua
TORTURE Volume 30, Number 1, 2020
36
SCIENTIFIC ARTICLE
ties. Given his negative experiences with others
who know about his history as a child solider
and his concerns about the possible impact of
his past history as a child soldier on his legal
status, Joshua may be reluctant or anxious
about consulting with an immigration attor-
ney. Joshua’s derivative asylee status may be in
jeopardy given the bar to asylum in the United
States for those who perpetrate serious harm
on others (with limited exceptions for acting
under duress) (Board of Immigration Appeals,
2018). Support from his care team, as well as
gaining understanding that his communica-
tion with an attorney would be privileged, may
facilitate his seeking legal consultation. Care
team members could also work with the at-
torney, as needed, to ensure that he or she is
trauma-informed.
Providers require specialized knowledge of
the history and culture of the survivor’s country
of origin, the impact of his or her torture ex-
perience(s), and his or her experiences before
and after arrival in the new country of reset-
tlement, including during transit. Assessment
must be multi-dimensional and holistic, as well
as ongoing. Treatment planning is informed
by the specifics of client’s historical and cul-
tural background and intentional strategies
are utilized to overcome barriers to entering
and completing treatment. Given the impact
of their human perpetrated traumas, torture
survivors typically benefit from overt transpar-
ency and predictability in their relationships
with providers (Mollica, 2006). Care should be
given to the prioritizing, ordering, and spacing
of interventions and efforts to secure early
wins, no matter how small, and in multiple
domains can promote continued motivation
for engaging in treatment as well as opportuni-
ties to reinforce interventions across domains.
Throughout, the CAA supports the mobiliza-
tion of existing strengths and resources, in-
cluding family and community support, and
the development of new ones.
It is important to recognize that not all
torture treatment programs have access to an
in-house primary care physician, psychiatrist,
social worker, or other care team members and
do not have existing linkages to a full range
of services. In the case presented here, Joshua
cannot be successfully treated without access
to primary care and holistic services covered
by the five domains. If a treatment program
does not have access to essential resources
within their center, linkages to primary care and
other collaborative services are recommended
given the promising outcomes of such care on
health and mental health outcomes relevant to
torture survivors from studies with other pop-
ulations (Esala et al., 2018). The complex mul-
tiple trauma experiences and associated effects
found in Joshua and other torture survivors
requires an interdisciplinary and holistic ap-
proach such as that of the CCA. With holistic
complex care it is likely that Joshua will ex-
perience significant and sustained relief from
his distress and regain a positive quality of life.
For those torture survivors in the United
States or other settings with major medical,
social, and psychological problems, the CCA
is a promising approach. Of course, the trau-
matic life experiences of the survivor affects
all domains. In a resource poor setting where
a multidisciplinary team is not available, the
clinician can establish the diagnosis and treat-
ment implication of each of the domains and
set treatment priorities based upon the avail-
ability of resources.
References
Babatunde, O. A. (2014). Harnessing traditional
practices for use in the reintegration of child
soldiers in Africa: Examples from Liberia and
Burundi. Intervention, 12(3), 379-392. https://doi.
org/10.1097/wtf.0000000000000057
Bandeira, M. (2013). Developing an African torture
rehabilitation model: A contextually-informed,
TORTURE Volume 30, Number 1, 2020
37
SCIENTIFIC ARTICLE
evidence-based psychosocial model for the rehabilitation
of victims of torture. Johannesburg, South Africa:
The Centre for the Study of Violence and
Reconciliation. http://www.csvr.org.za/images/docs/
Other/developing_african_rehabilitation_model_
part1_setting_foundations.pdf
Berthold, S.M., Mollica, R.F., Silove, D., Tay, A.K.,
Lavelle, J., Lindert, J. (2019). The HTQ-5:
revision of the Harvard Trauma Questionnaire for
measuring torture, trauma and DSM-5 PTSD
symptoms in refugee populations. Eur J Public
Health, 29(3), 468-474. https://doi.org/10.1093/
eurpub/cky256.
Benning, T. B. (2015). Limitations of the
biopsychosocial model in psychiatry. Adv Med
Educ Pract, 6, 347-352. Doi: 10.2147/AMEP.
S82937
Board of Immigration Appeals (2018). 27 I&N Dec.
347. Interim Decision #3930. Retrieved from
https://www.justice.gov/eoir/page/file/1075801/
download
Boyd, K. (2016). Medical involvement in torture
today? Journal of Medical Ethics, 42(7), 411-412.
https://doi.org/10.1136/medethics-2016-103737
Clark, C. M., Fradkin, J. E., Hiss, R. G., Lorenz, R.
A., Vinicor, F., & Warren-Boulton, E. (2000).
Promoting early diagnosis and treatment of Type
2 diabetes. JAMA, 284(3), 363–365. https://doi.
org/10.1001/jama.284.3.363
Coleman, K., Austin, B. T., Brach, C., & Wagner,
E. H. (2009). Evidence on the chronic care
model in the new millennium. Health Aff
(Millwood), 28(1), 75–85. https://doi.org/10.1377/
hlthaff.28.1.75
D’Alessandra, F. (n.d.). The psychological
consequences of becoming a child soldiers: Post-
traumatic stress disorder, major depression, and
other forms of impairment. Harvard Carr Center.
https://carrcenter.hks.harvard.edu/les/cchr/les/
dalessandra_pshychol_cons_of_childsoldiers.pdf
Defrin, R., Lahav, Y., & Solomon, Z. (2017).
Dysfunctional pain modulation in torture
survivors: The mediating effect of PTSD. Journal
of Pain, 18(1), 1-10. https://doi.org/10.1016/j.
jpain.2016.09.005
Engel, G. L. (1977). The need for a new medical
model: A challenge for biomedicine. Science, 196,
129-136.
Epping-Jordan, J. E., Pruitt, S. D., Bengoa, R., &
Wagner, E. H. (2004). Improving the quality
of health care for chronic conditions. Qual
Saf Health Care, 13(4), 299-305. https://doi.
org/10.1136/qshc.2004.010744
Esala, J. J., Vukovich, M. M., Hanbury, A., Kashyap,
S., & Joscelyne A. (2018). Collaborative care
for refugees and torture survivors: Key findings
from the literature. Traumatology, 24(3), 168-185.
https://doi.org/10.1037/trm0000143
Hinton, D. E., Rivera, E. I., Hofmann, S. G., Barlow,
D. H., & Otto, M. W. (2012). Adapting CBT
for traumatized refugees and ethnic minority
patients: Examples from culturally adapted CBT
(CA-CBT). Transcultural Psychiatry, 49(2), 340–
365. https://doi.org/10.1177/1363461512441595
Hong, C. S., Siegel, A. L., & Ferris, T. G. (2014).
Caring for high-need, high-cost patients: What
makes for a successful care management program?
Commonwealth Fund pub. 1764, Vol. 19. The
Commonwealth Fund.
Institute of Medicine Committee on Quality of
Health Care in America (Eds.). [IOM] (2001).
Crossing the quality chasm: A new health system for
the 21st century. National Academies Press.
Iverson, G. L. (2005). Outcome from mild traumatic
brain injury. Current Opinion in Psychiatry,
18(3), 301-317. https://doi.org/10.1097/01.
yco.0000165601.29047.ae
Joint National Committee on Prevention (1997).
Detection, evaluation, and treatment of high
blood pressure, Sixth Report. Archives of Internal
Medicine, 157(21), 2413–2446. https://doi.
org/10.1001/archinte.157.21.2413
Jorgensen, M. M., Modvig, J., Agger, I., Raghuvansh,
L., Shabana Khan, S., & Polatin, P. (2015).
Testimonial therapy: Impact on social
participation and emotional wellbeing among
Indian survivors of torture and organized
violence. Torture, 25(2), 22-33.
Kaysen, D., Lindgren, K., Zangana, G. A. S., Murray,
L., Bass, J., & Bolton, P. (2013). Adaptation of
cognitive processing therapy for treatment of
torture victims: Experience in Kurdistan, Iraq.
Psychological Trauma: Theory, Research, Practice,
and Policy, 5(2), 184-192. https://doi.org/10.1037/
a0026053
Kohrt, B. (2013). Social ecology interventions for
post-traumatic stress disorder: What can we
learn from child soldiers? The British Jour nal of
Psychiatry, 203, 165-167. https://doi.org/10.1192/
bjp.bp.112.124958
Koponen, A. M., Simonsen, N., & Suominen, S.
(2017). Quality of primary health care and
autonomous motivation for effective diabetes
self-management among patients with type
2 diabetes. Health Psychology Open, 4(1), 1-7.
https://doi.org/10.1177/2055102917707181
Legoretta, A. P., Liu, X., Zaher, C. A., & Jatulis,
D. E. (2000). Variation in managing asthma:
Experience at the medical group level in
California. American Journal of Managed Care,
TORTURE Volume 30, Number 1, 2020
38
SCIENTIFIC ARTICLE
6(4), 445–453.
McCarthy, M. (2013). US health professionals aided
detainees’ torture. BMJ, 347(7932), 1. https://doi.
org/10.1136/bmj.f6680
McGlynn, E. A., Asch, S. M., Adams, J., Keesey,
J., Hicks, J., DeCristofaro, A., & Kerr, E. A.
(2003). The quality of health care delivered to
adults in the United States. New England Journal
of Medicine, 348(26), 2635–2645. https://doi.
org/10.1056/NEJMsa022615
McKinney, M. M. (2011). Treatment of survivors of
torture: spiritual domain. Torture, 21(1), 61–66.
McMullen, J., O’Callaghan, P., Shannon, C., Black,
A., & Eakin, J. (2013). Group trauma-focused
cognitive-behavioural therapy with former child
soldiers and other war-affected boys in the DR
Congo: A randomised controlled trial. Journal
of Child Psychology & Psychiatry, 54(11), 1231–
1241. https://doi.org/10.1111/jcpp.12094
McPherson, J. (2012). Does narrative exposure
therapy reduce PTSD in survivors of mass
violence? Research on Social Work Practice, 22(1),
29–42. Doi: 10.1177/1049731511414147
Mollica, R. F. (2006). Healing invisible wounds: Paths
to hope and recovery in a violent world. Harcourt.
Mollica, R. F. (2011). Medical best practices for the
treatment of torture survivors. Torture, 21(1), 8-17.
Mollica, R., Lavelle, J., Fors, U., Ekblad, S., & Wadler,
B. (2017). Using the virtual patient to improve
the primary care of traumatized refugees. Journal
of Medical Education,16(1), 2-16.
Mollica, R. F., McDonald, L. S., Massagli, M. P.,
& Silove, D. M. (2004). Measuring trauma,
measuring torture: Instructions and guidance on
the utilization of the Harvard Program in Refugee
Trauma’s versions of the Hopkins Symptom
Checklist-25 (HSCL-25) & the Harvard Trauma
Questionnaire (HTQ) [Manual]. Harvard Program
in Refugee Trauma.
National Partnership for Community Training
(2011). Best, promising, and emerging practices:
A compendium for providers working with
survivors of torture. Thematic Issue of Torture
Journal, 21(1), 1-66.
Onyut, L. P., Neuner, F., Schauer, E., Ertl, V.,
Odenwald, M., Schauer, M., & Elbert, T. (2005).
Narrative Exposure Therapy as a treatment for
child war survivors with posttraumatic stress
disorder: Two case reports and a pilot study in an
African refugee settlement. BMC Psychiatry, 5(7),
1–9. https://doi.org/10.1186/1471-244X-5-7
Papadimitriou, G. (2017). The “Biopsychosocial
Model”: 40 years of application in psychiatry.
Psychiatriki, 28(2), 107-110. https://doi.
org/10.22365/jpsych.2017.282.107
Piwowarczyk, L. (2005). Torture and spirituality:
Engaging the sacred in treatment. Torture, 15(1),
1-8.
Quiroga, J., & Jaranson, J. (2005). Politically motivated
torture and its survivors, Torture, 16(2-3), 1-111.
Rezzoug, D., Baubet, T., Broder, G., Taïeb,
O., & Moro, M. R. (2008). Addressing
the motherinfant relationship in displaced
communities. Child and Adolescent Psychiatric
Clinics of North America, 17(3), 551-568. https://
doi.org/10.1016/j.chc.2008.02.008
Robjant, K., & Fazel, M. (2010). The emerging
evidence for Narrative Exposure Therapy: A
review. Clinical Psychology Review, 30(8), 1030–
1039. https://doi.org/10.1016/j.cpr.2010.07.004
Schnyder, U., Ehlers, A., Elbert, T., Foa, E. B.,
Gersons, B. P. R., Resick, P. A., … Cloitre,
M. (2015). Psychotherapies for PTSD: What
do they have in common? European Journal of
Psychotraumatology, 6(1), 28186. https://doi.
org/10.3402/ejpt.v6.28186
Schulz, P. M., Resick, P. A., Huber, L. C., &
Griffin, M. G. (2006). The effectiveness of
Cognitive Processing Therapy for PTSD with
refugees in a community setting. Cognitive &
Behavioral Practice, 13(4), 322–331. https://doi.
org/10.1016/j.cbpra.2006.04.011
Schultz, J.-H., & Weisaeth, L. (2015). The power of
rituals in dealing with traumatic stress symptoms:
cleansing rituals for former child soldiers in
Northern Uganda. Mental Health, Religion &
Culture, 18(10), 822-837. https://doi.org/10.1080/
13674676.2015.1094780
Stanley, B., & Brown, G. K. (2012). Safety planning
intervention: A brief intervention to mitigate
suicide risk. Cognitive and Behavioral Practice,
19(2), 256-264. https://doi.org/10.1016/j.
cbpra.2011.01.001
Stark, L. (2006). Cleansing the wounds of war:
An examination of traditional healing,
psychosocial health and reintegration in Sierra
Leone. Intervention, 4(3), 206–218. https://doi.
org/10.1097/WTF.0b013e328011a7d2
Thornicroft, G., Ahuja, S., Barber, S., Chisholm, D.,
Collins, P. Y., Docrat, S., . . . Zhang, S. (2018).
Integrated care for people with longterm mental
and physical health conditions in low-income
and middle-income countries. Lancet Psychiatry,
6(2),174-186. https://doi.org/10.1016/S2215-
0366(18)30298-0
Tuskin, J. J., Streets, F. J., & Basit, A. (2011).
Religion, spirituality and faith. In R. F. Mollica
(Ed.), Textbook of global mental health: Trauma and
recovery, a companion guide for eld and clinical
care of traumatized people worldwide (pp. 285-300).
Harvard Program in Refugee Trauma.
TORTURE Volume 30, Number 1, 2020
39
SCIENTIFIC ARTICLE
Umiltà, M. A., Wood, R., Loffredo, F., Ravera, R.,
& Gallese, V. (2013). Impact of civil war on
emotion recognition: The denial of sadness in
Sierra Leone. Frontiers in Psychology, 4, 523.
https://doi.org/10.3389/fpsyg.2013.00523
Van den Berg, D. P., de Bont, P. A., van der Bleugel,
B. M., de Roos, C., de Jongh, A., van Minnen,
A., & van der Gaag, M. (2016). Trauma-Focused
Treatment in PTSD Patients With Psychosis:
Symptom Exacerbation, Adverse Events, and
Revictimization. Schizophrenia Bulletin, 42(3),
693-702. https://doi.org/10.1093/schbul/sbv172
Vukovich, M., & Esala, J. (2016, September 12).
Integrated behavioral health care with survivors
of torture: Learning from the data and from
each other. Measured Impact Webinar. Heal
Torture. http://www.healtorture.org/webinar/
integratedbehavioral-health-care-survivors-
torture-learningdata-and-each-other
Weiss, W. M., Ugueto, A. M., Mahmooth, Z., Murray,
K., Hall, B. J., Nadison, M., … Bass, J. (2016).
Mental health interventions and priorities for
research for adult survivors of torture and
systematic violence: A review of the literature.
Torture, 26(1), 17–44.
Williams, A. C., Peña, C. R., & Rice, A. S. (2010).
Persistent pain in survivors of torture: A
cohort study. J Pain and Symptom Management,
40(5), 715-722. https://doi.org/10.1016/j.
jpainsymman.2010.02.018
Young, A. S., Klap, R., Sherbourne, C. D., & Wells,
K. B. (2001). The quality of care for depressive
and anxiety disorders in the United States.
Arch Genl Psychiatry, 58(1), 55–61. https://doi.
org/10.1001/archpsyc.58.1.55
Acknowledgements
The authors wish to thank the Bellevue/NYU
Program for Survivors of Torture.
Funding
This literature review was developed under the
National Capacity Building (NCB) technical
assistance project funded by the U.S. Office
of Refugee Resettlement (ORR) through co-
operative agreement number 90ZT0142. The
views expressed are those of the National Ca-
pacity Building Project and may not reflect
the views of ORR.
TORTURE Volume 30, Number 1, 2020
40
SHORT SCIENTIFIC REPORT
Abstract
Introduction: Since the 20th century, electric
shock torture has become one of the most
prevalent methods of torture partly because it
produces sequelae that are more challenging to
visibly detect, particularly when administered
using high voltage and low current. In sexual
torture, a wire is wrapped around the head of
the penis and a wire electrode is inserted into
the urethra. This produces unbearable pain and
can lead to urethral strictures with devastating
physical and psychological consequences.
Objective: To document electric shock
torture to genitals as an etiologic agent in
urethral stricture and erectile dysfunction
amongst survivors of electric torture introduc-
ing the term “parrilla urethra” for the electric
shock torture urethral stricture.
Materials and methods: The study included
40 patients who attended the Department of
Urology, Directorate of Health services, Sri-
nagar, Kashmir, India with obstructive lower
urinary tract symptoms (LUTS) / obstructive
uroflowmetry between March 2010 and No-
vember 2014. All cases had an antecedent of
electric shock torture to genitals six months to
one year prior to examination. Pre-post psy-
chological impact and well-being was used
through Global Assessment of Functioning
(GAF) scores.
Results: The mean age of patients was 35.6
years. Most of the urethral strictures were
located in the anterior urethra. Some degree of
erectile dysfunction was present in all (100%)
of patients. Psychological sequelae including
depression, anxiety, acute stress disorder and
symptoms of post-traumatic stress disorder
were observed. Patients were treated with stan-
dard urethroplasty procedures after address-
ing the urethral stricture. This improved both
physical and psychological sequelae of torture.
Keywords: electric shock; parrilla; torture; ure-
thral stricture
Introduction
The Kashmir region is a geographical area
split between Indian, Pakistani and Chinese
jurisdiction, that has suffered from protracted
political conflict and where ill-treatment and
torture has been widely documented (Deol &
Ganai, 2018; Haq, 2017, 2018; Human Rights
“Parrilla urethra”: A sequalae of electric
shock torture to genitals in men. A 40 case
series in Kashmir (India)
Abdul Rouf Khawaja1, Manzoor Dar2, Yasir Dar3, Javeed Magray4,
Tariq Sheikh5, Suhail Zahur6
1) Department of Urology. Directorate of Health
Services Srinagar, 190011. India.
Correspondence to: roufkhawaja@rediffmail.com
2) Delhi University
Correspondence to: drmanzoor996@gmail.com
3) Institute of Urology Dhule Mumbai.
Correspondence to: yasserahmad009@gmail.com
4) Directorate of Health Services Kashmir.
Correspondence to: drjavaid82@gmail.com
5) Directorate of Health Services Kashmir.
Correspondence to: drtariq.sheikh@gmail.com
6) Directorate of Health Services Kashmir.
Correspondence to: suhaelz@gmail.com
https://doi.org/10.7146/torture.v30i1.105661
International Rehabilitation Council for Torture Victims. All rights reserved.
TORTURE Volume 30, Number 1, 2020
41
SHORT SCIENTIFIC REPORT
Watch, 1993; Institut of Strategic Studies,
2019; JKCCS, 2019). In many of the reports
available there have been reports of electric
torture (Amnesty International, 1995; Deol
& Ganai, 2018; Haq, 2017; Human Rights
Watch, 1993; Tahir Tabassum, 2012).
Electrical injury is a physiological reaction
caused by electric current passing through
the human body (Rybarczyk et al., 2017).
Electric shock torture is widespread with
Amnesty International (1997) finding that
electric shock torture and ill-treatment have
been reported in 62 countries in the period
1990-1997, and is commonly used by law
enforcement officers with easily concealable,
electro-shock weapons (TASERs and similar
devices) (Amnesty International, 1997). Elec-
tric shock torture has become one of the most
prevalent methods of torture since the 20th
century, partly because it produces sequelae
that are more challenging to detect visibly,
particularly when administered using high
voltage and low current. The method there-
fore assists perpetrators with circumventing
the negative political consequences posed by
human rights monitoring mechanisms and
from human rights advocates discovering and
reporting torture (Amnesty International,
1997). One particular form of electric shock
torture is parrilla torture. Parrilla, a term that
stems from the Spanish word meaning a grill
or barbeque for cooking meat, is a method of
torture in which a victim is strapped to a metal
frame and subjected to electric shock torture
(Gómez-Barris, 2009). This torture method
produces devastating psychological and phys-
ical consequences. The method was used by
a number of countries in South America, in-
cluding during the “dirty war” (1974-1983)
in Argentina and in Chile during the Pino-
chet regime (1973-1990) as an interrogation
method (Villani, 2011).
The three major mechanisms of electri-
cal injuries are direct tissue damage, thermal
injury and mechanical injury (Dzhokic¨et al.,
2008). However, virtually every part of the
body can be injured by the electric current and
the extent of injury to body tissue is influenced
TORTURE Volume 30, Number 1, 2020
42
SHORT SCIENTIFIC REPORT
by a plethora of factors, including the type of
body part targeted, the number of torture ep-
isodes, the duration of each torture episode,
and the strength of the electric current. Alter-
nating current (AC) is three times more dan-
gerous than direct current (DC) of the same
voltage. Nerves, muscles, and blood vessels
have lower resistance and are better electrical
conductors compared to bone, tendon and fat
with nerve tissue having the least resistance to
current flow, and are thus more susceptible to
damage (Dzhokic et al., 2008).
Commonly, bare wire electrodes are
applied to or inserted into different sensi-
tive body parts, including genitalia, breasts,
buttocks, fingers, toes, tongue, and head.
For males, during electric torture to genitals,
the fixed wire is wrapped around the head
of the penis and a bare wire is inserted into
the urethra. This results in mechanical ure-
thral trauma in addition to electric injury to
the urethra and other tissues. Some victims
may consequently develop obstructive voiding
symptoms and erectile dysfunction depend-
ing on the severity of the torture episode(s).
The most frequent psychological sequelae
include sleep disturbances, being uncomfort-
able in situations reminding of past torture
experiences, stigma and social isolation, rumi-
nations about traumatic events, emotional in-
stability and violence towards family members
and suicidal attempts (Araujo et al., 2019; Ba
& Bhopal, 2017; Crescenzi et al., 2002; Cun-
ningham & Cunningham, 1997; Masmas et
al., 2008; Suhaiban et al., 2019; Tamblyn et
al., 2011).
Although electric torture to genitals has
been previously described (i.e. Iran Human
Rights Documentation Center, 2011; Weishut,
2015), no known research exists that investi-
gates the sequelae and optimum rehabilitation
procedures for patients presenting with ure-
thral sequelae. This paper aims to help address
this gap with two objectives:
1. To describe electric shock torture as an
aetiological factor for urethral strictures
and erectile dysfunction.
2. To introduce the term “parrilla urethra”
into the literature for the urethral stric-
ture disease resulting from electric shock
torture to genitals.
Methods and materials
Sample. Survivors of electric shock torture
(n=40, age 28-60 years) presenting with ure-
thral strictures at a Directorate of health care
centre in Kashmir, India, between March
2010 and November 2014. All the patients in-
cluded were from Kashmir valley (India) and
had suffered torture at the hands of security
personnel/armed groups as per narrated in
clinical alleged history to our initial examina-
tion. We did not assess who was responsible
for the violence because it was not relevant
for our medical needs assessment.
Methods. Patients were self-referred or re-
ferred by human rights organizations. There
was not a full systematic medical exploration
of torture although patients were referred to
other services in the hospital when required.
Torture was defined using the Convention
against Torture (UN General Assembly, 1984).
All patients had a history of trauma inflicted
upon the urethra via electric shock six months
to one year prior to presentation. Patients with
earlier lower urinary tract symptoms and any
past history of urethral instrumentation were
excluded from the study.
Erectile dysfunction was measured using
the International Index of Erectile Function
(IIEF-5) (Rosen et al., 1999; Rosen et al.,
1997). It is a 5-item measure, each one scored
from 1 to 5 and giving a composite score of
TORTURE Volume 30, Number 1, 2020
43
SHORT SCIENTIFIC REPORT
5-25. The patients were classified as having no
ED (22-25), mild ED (17-21), mild to mod-
erate ED (12-16), moderate ED (8-11) and
severe ED (5-7).
Retrograde and micturating cystourethro-
gram testing were obtained in all patients to
determine stricture location and length.
Patients were screened for psychological
consequences as part of the standard clinical
interview and referred to psychiatric assess-
ment when required.
The Global Assessment of Function
(GAF) was used as a WHO recommended
overall measure of global mental health and
functional impact of psychological symptoms.
This is a Likert-scale ranked 0 to 100; 100
being optimal functionality (Aas, 2011).
Ethical elements. The study was approved
by the departmental committee that also looks
into ethical aspects of biomedical research con-
ducted in the department. This being a retro-
spective audit of the anonymised records, the
committee did not deem it necessary to refer
the study to the main institutional ethics com-
mittee (IEC) as there was no ethical issues in-
volved and hence exempt from ethical review.
Results
Pre-operative data. The stricture length ranged
from 4 cm to 12 cm with a mean of 6.8 cm
affecting the bulbar (n=22), penobulbar
(n=7), and penile (n=6) urethra. In 5 cases
there was pan-urethral damage (table 1). 28
patients had a history of painful acute urinary
retention (AUR). All patients also had erec-
tile dysfunction secondary to electric shock
as defined by IIEF-5 Scores 12 patients had
severe ED, 21 had moderate ED, and 7 pa-
tients had mild to moderate ED. A subsection
(n=16) patients also had uncontrollable urine
loss which was the result of overflow incon-
tinence from chronic retention or a result of
detrusor overactivity. An obstructive pattern
was observed on uroflowmetry in all patients.
Psychological sequelae including anxiety,
acute stress disorder/post-traumatic stress dis-
Figure 1. Anterior urethral stricture due to electro shock weapon (Parrilla Urethral stricture). Arrow
showing stricture.
TORTURE Volume 30, Number 1, 2020
44
SHORT SCIENTIFIC REPORT
Figure 2. On MCU. Arrow shows post operative one side dorsal onlal buccal mucosal gaft urethroplasty
in parrilla urethra
Table 1. Clinical Characteristic of the Patients
(n=40 patients)
Table 2. GAF-Score
N=40
Age (years) 28-60yrs
Length of stricture (cm) 6.8 (4-12)
RGU/MCU-site of stricture
Bulbar 22 (55.0)
Penobulbar 7 (17.5)
Penile 6 (15.0)
PanUrethral 5 (12.5)
Before surgery
Poor Urinary Flow 40 (100%)
Erectile Dysfunction 40 (100%)
- Severe (IIEF 5-7) 12 (30%)
- Moderate (IIEF 8-12) 20 (50%)
- Mild (IIEF 12-16) 8 (20%)
Painful Acute Urinary Retention 28 (70%)
Uncontrollable Urinary Loss 16 (40%)
Pre-Surgery
M : 47
6-12 m.
Post-Surgery
M : 68
91-100 0 7 (17.5%)
81-90 0 8 (20%)
71-80 3 (7.5%) 20 (50%)
61-70 6 (15%) 5 (12.5%)
51-60 11 (27.5%) 0
41-50 20 (50%) 0
Chisq: 65.90, p<0.000
TORTURE Volume 30, Number 1, 2020
45
SHORT SCIENTIFIC REPORT
order, and depressive disorder were observed
amongst the victims who were referred for psy-
chiatric/psychologist evaluation before man-
agement of urethral stricture disease (see table
1). This was in part secondary to torture and
in part due to the presence of the suprapubic
catheter, social isolation and continuous am-
moniac smell of urine.
Patients with acute retention symptoms
were initially managed by suprapubic cathe-
terization (SPC) and drainage. All patients
were later managed by substitution urethro-
plasty using oral mucosal graft placed dor-
sally after mobilization of urethra on one side
only (Horiguchi, 2017) decreasing the urinary
stream. Its surgical management is a challeng-
ing problem, and has changed dramatically in
the past several decades. Open surgical repair
using grafts or flaps, called substitution ure-
throplasty, has become the gold standard pro-
cedure for anterior urethral strictures that are
not amenable to excision and primary anasto-
mosis. Oral mucosa harvested from the inner
cheek (buccal mucosa).
GAF scores measure the overall deterio-
ration in functioning (see table 2). After ure-
throplasty none of the patients had to use a
urobag. There were also improvements in erec-
tile function. This is reflected in an overall im-
provement in GAF scores (Chisq: 65.90, df:
39, p<0.000). We could not assess whether
the improvement in overall well-being had
an impact on primary PTSD and depression
symptoms directly related to torture, although
this seemed the case in conversations with the
psychiatrist and psychologist where the pa-
tients were referred.
Discussion
The “parrilla urethra” (electric shock) is a
torture method used to cause pain and fear
without necessarily causing any immediate
visible harm. The patients subjected to such
torture complained of erectile dysfunction,
dysuria and haematuria, difficulty in mictu-
rition as also reported by previous studies
(Lunde I, 1992; Petersen et al., 1985). Elec-
tric shock torture to genitals is a predomi-
nantly physical torture method with both
physical and psychological consequences,
and with relentless long-term psychological
sequelae (Araujo et al., 2019; Ba & Bhopal,
2017; Miles & Garcia-Peltoniemi, 2012). In
Kashmir Valley, suicide seems a hidden con-
sequence of the protracted conflict (Wani et
al., 2011).
To the urologist, these patients present
with predominantly obstructive voiding symp-
toms with associated poor self-esteem and psy-
chological sequelae. There is, as such, a need
for an interdisciplinary approach that is holis-
tic and that addresses both mental and psy-
chological well-being of both mind and body.
Most of these patients were on urinary diver-
sion in the form of suprapubic catheter (SPC)
with an external urine collection bag (urobag)
attached to it for collection of urine result-
ing in change in bodily image and a constant
smell of urine. As a result, these patients prefer
social isolation which leads to further deterio-
ration of their social, physical and psychologi-
cal wellbeing. Addressing the urological issues
results in freedom from an SPC and conse-
quent improvement in bodily image, which
boosts self-esteem and confidence to social
-
ise, thereby having a positive impact on overall
wellbeing.
In the literature, the incidence of erectile
dysfunction (ED) ranges from 20% to 84% in
patients with urethral injury secondary to per-
ineal trauma or pelvic fractures (Blaschko et
al., 2015). ED caused by such trauma is due
to lesions of the cavernous nerves or branches
of the internal pudendal arteries that pass in
close proximity to the pelvic bones and poste-
rior urethra. The intimate relationship of the
TORTURE Volume 30, Number 1, 2020
46
SHORT SCIENTIFIC REPORT
soft tissues and the bony pelvic ring result in
a high risk of concomitant local injury associ-
ated with fractures of the pelvis. Even without
severe urological injury, damage to the deli-
cate vascular and nervous tissues supplying
the genitalia can result in sexual dysfunction
(Barratt et al., 2018).
In electric torture (“parrilla urethra”) the
erectile dysfunction is secondary to electric
current injury and adds to the psychological
consequences. Penile neurovascular tissue has
the least resistance to current flow of all the
tissues in the pubic area and is the most sus-
ceptible to damage with resultant neurovas-
cular dysfunction and numbness of phallus.
The electric current may result in coagulation
of small vessels supplying the erectile tissue in
addition to causing direct myogenic damage.
We thus presume a multifactorial neurovascu-
lar and neuro-myogenic basis for erectile dys-
function in our sample of tortured patients.
In the majority of our cases the strictures
were in anterior urethra likely due to the diffi-
culty in negotiating bare wire through the an-
atomical course of bulbar urethra.
The urogenital problems were further
compounded and complicated by neuropsy-
chiatric sequalae of torture in our study group
and patients were seen by psychiatrist during
and after the treatment of urethral stricture.
All the patients showed an improvement in
GAF score after urethroplasty.
“Parrilla urethra” seems to be an appropri-
ate term to define the urethra with sequalae of
urethral trauma, particularly urethral stricture
resulting from electric shock torture to geni-
tals. The term will help to differentiate it from
other aetiologies of urethral stricture.
Limitations
The sample size is low. We could not use psy-
chometric measures of mental health changes
and data is based on overall measures of well-
being and clinical information from treating
professionals. There is a need for prospective
studies that carry out a pre-post measure of
mental health impact, whilst distinguishing
those impacts related to torture and those
related to the psychosocial consequences of
urethral stricture.
Conclusion
Survivors of electric shock torture to genitals
often suffer from chronic debilitating urethral
strictures with a poor quality of life and psy-
chological distress, necessitating multidisci-
plinary and individualized treatment. The
term “parrilla urethra” defines and differenti-
ates these cases of urethral stricture disease
from strictures from other aetiologies. Our
study shows preliminary evidence that elec-
tric shock torture to genitals has devastating
consequences on survivors and that address-
ing the physical consequences can ultimately
improve the overall well-being of patients.
Future studies need to address whether ure-
throplasty also has an impact on posttraumatic
symptoms derived from torture.
References
Aas, I. H. M. (2011). Guidelines for rating Global
Assessment of Functioning ( GAF ). Annals
of General Psychiatry, 10(1), 2. https://doi.
org/10.1186/1744-859X-10-2
Amnesty International. (1995). India. Torture and
deaths in custody in Jammu and Kashmir (ASA
20/01/95). https://www.amnesty.org/download/
Documents/176000/asa200011995en.pdf
Amnesty International. (1997). Arming the torturers:
electro-shock torture and the spread of stun technology
(ACT 40/04/97). London.
Araujo, J. de O., Souza, F. M. de, Proença, R.,
Bastos, M. L., Trajman, A., & Faerstein, E.
(2019). Prevalence of sexual violence among
refugees: a systematic review. Revista de Saude
Publica, 53, 78. https://doi.org/10.11606/s1518-
8787.2019053001081
Ba, I., & Bhopal, R. S. (2017). Physical, mental
and social consequences in civilians who have
experienced war-related sexual violence: a
systematic review (1981–2014). Public Health,
TORTURE Volume 30, Number 1, 2020
47
SHORT SCIENTIFIC REPORT
142, 121–135. https://doi.org/10.1016/j.
puhe.2016.07.019
Barratt, R. C., Bernard, J., Mundy, A. R., &
Greenwell, T. J. (2018). Pelvic fracture
urethral injury in males-mechanisms of injury,
management options and outcomes. Translational
Andrology and Urology, 7(29), S29–S62. https://
doi.org/10.21037/tau.2017.12.35
Blaschko, S. D., Sanford, M. T., Schlomer, B. J.,
Alwaal, A., Yang, G., Villalta, J. D., … Breyer, B.
N. (2015). The incidence of erectile dysfunction
after pelvic fracture urethral injury: A systematic
review and meta-analysis. Arab Journal of
Urology, 13(1), 68–74. https://doi.org/10.1016/j.
aju.2014.09.004
Crescenzi, A., Ketzer, E., Van Ommeren, M.,
Phuntsok, K., Komproe, I., & de Jong, J. T. V.
M. (2002). Effect of political imprisonment and
trauma history on recent Tibetan refugees in
India. Journal of Traumatic Stress, 15, 369–375.
https://doi.org/10.1023/A:1020129107279
Cunningham, M., & Cunningham, J. D. (1997).
Patterns of symptomatology and patterns of
torture and trauma experiences in resettled
refugees. Australian and New Zealand Journal of
Psychiatry, 31, 555–565.
Deol, S. S., & Ganai, R. A. (2018). Custodial
violence in Kashmir by the Indian security forces:
A spontaneous consequence or a deliberate
counter-insurgency policy? International Journal
of Criminal Justice Sciences, 13(2), 370–384.
https://doi.org/10.5281/zenodo.2657636
Dzhokic, G., Jovchevska, J., & Dika, A. (2008).
Electrical injuries: Etiology, pathophysiology
and mechanism of injury. Macedonian Journal
of Medical Sciences, 1(2), 54–58. https://doi.
org/10.3889/MJMS.1857-5773.2008.0019
Gómez-Barris, M. (2009). Where memory dwells.
Berkeley, Calif.: University of California Press.
Haq, I. (2017). Exploring the Concept of Torture:
An Analysis of Kashmir Valley. SSRN Electronic
Journal, 1–19. https://doi.org/10.2139/
ssrn.2954374
Haq, I. (2018). Torture in the Kashmir Valley and
Custodial Deaths in India. Torture Journal,
27(3), 109–110. https://doi.org/10.7146/torture.
v27i3.103972
Horiguchi, A. (2017). Substitution urethroplasty
using oral mucosa graft for male anterior urethral
stricture disease: Current topics and reviews.
International Journal of Urology, 24(7), 493–503.
https://doi.org/10.1111/iju.13356
Human Rights Watch. (1993). The Human Rights
Crisis in Kashmir. https://www.hrw.org/sites/
default/files/reports/INDIA937.PDF
International Institute of Strategic Studies. (2019).
Torture in Indian occupied Kashmir. http://issi.
org.pk/report-roundtable-on-torture-in-indian-
occupied-kashmir/
Iran Human Rights Documentation Center. (2011).
Surviving rape in Iran’s prisons. https://iranhrdc.
org/surviving-rape-in-irans-prisons/
JKCCS. (2019). Torture. Indian state’s instrument of
control in indian administered Jamnu and Kashmir.
http://jkccs.net/torture-indian-states-instrument-
of-control-jammu-kashmir/
Lunde I, O. J. (1992). Sexual torture and the
treatment of its consequences. In Torture and its
Consequences- Current Treatment Approaches. (pp.
310–329). Cambridge University Press.
Masmas TN, Moller E, Buhmann C, Bunch V,
Jensen JH, H. T. et al. (2008). Asylum seekers in
Denmark- a study of health status and grade of
traumatization of newly arrived asylum seekers.
Torture, 18(2), 77–86.
Miles, S. H., & Garcia-Peltoniemi, R. E. (2012).
Torture survivors: What to ask, how to document.
The Journal of Family Practice, 61(4), E1–E5.
Petersen, H. D., Abildgaard, U., Daugaard, G.,
Jess, P., Marcussen, H., & Wallach, M. (1985).
Psychological and physical long-term effects
of torture. A follow-up examination of 22
Greek persons exposed to torture 1967-1974.
Scandinavian Journal of Social Medicine, 13,
89–93.
Rosen, R., Cappelleri, J., Smith, M. et al. (1999).
Development and evaluation of an abridged
, 5-item version of the International Index of
Erectile Function ( IIEF-5 ) as a diagnostic tool
for erectile dysfunction. International Journal
of Impotence Research, 11, 319–326. https://doi.
org/10.1038/sj.ijir.3900472
Rosen, R. C., Riley, A., Wagner, G., Osterloh, I.
H., Kirkpatrick, J., & Mishra, A. (1997). The
international index of erectile function (IIEF): a
multidimensional scale for assessment of erectile
dysfunction. Urology, 49(6), 822–830. https://doi.
org/10.1016/S0090-4295(97)00238-0
Rybarczyk, M. M., Schafer, J. M., Elm, C. M.,
Sarvepalli, S., Vaswani, P. A., Balhara, K. S.,
… Jacquet, G. A. (2017). A systematic review
of burn injuries in low- and middle-income
countries: Epidemiology in the WHO-defined
African Region. African Journal of Emergency
Medicine, 7(1), 30–37. https://doi.org/10.1016/j.
afjem.2017.01.006
Suhaiban, H. A., Grasser, L. R., & Javanbakht, A.
(2019). Mental health of refugees and torture
survivors: A critical review of prevalence,
predictors, and integrated care. International
TORTURE Volume 30, Number 1, 2020
48
SHORT SCIENTIFIC REPORT
Journal of Environmental Research and Public
Health, 16(13). https://doi.org/10.3390/
ijerph16132309
Tahir Tabassum, M. (2012). Political Situation in
Kashmir and Role of the United Nations. SCS
Journal, 1(2), 4–28.
Tamblyn, J. M., Calderon, A. J., Combs, S., &
O’Brien, M. M. (2011). Patients from abroad
becoming patients in everyday practice: Torture
survivors in primary care. Journal of Immig rant
and Minority Health, 13(4), 798–801. https://doi.
org/10.1007/s10903-010-9429-2
UN General Assembly. (1984). The Convention
Against Torture and other forms of cr uel, inhuman
and degrading treatment or punishment. 10
December 1984. OHCHR. https://www.ohchr.org/
en/professionalinterest/pages/cat.aspx
Villani, M. (2011). Desaparecido. Memorias de un
cautiverio. Club Atlético. El Banco, El Olimpo, Pozo
de Quilmes y ESMA. Biblos.
Wani ZA, Hussain A, Khan AW, et al. (2011).
Are health care systems insensitive to needs
of suicidal patients in times of conflict? The
Kashmir experience. Mental Illness, 3, 11–13.
Weishut, D. J. N. (2015). Sexual torture of Palestinian
men by Israeli authorities. Reproductive Health
Matters, 23(46), 71–84. https://doi.org/10.1016/j.
rhm.2015.11.019
TORTURE Volume 30, Number 1, 2020
49
SHORT RESEARCH REPORT
Abstract
Introduction: On 14th October 2019, the
Supreme Court of Spain issued a court judg-
ment convicting social and political leaders in
Catalonia, of crimes of embezzlement, sedi-
tion and disobedience. Following this, wide-
spread protests in Catalonia began. During
these protests, there were also numerous
clashes between protesters and members of
different Catalan and Spanish police forces,
which ended with more than 600 people suf-
fering injuries to varying degrees.
Method: Semi-structured interviews in
prison (n=22) with people injured and detained
during demonstrations.
Results: No detainees were informed of their
right to a medical examination. 50% of detain-
ees reported access to medical examinations
in police custody. In all cases this was carried
out in primary healthcare centres in the pres-
ence of police in the examination room. In all
cases the report was given to the police instead
of the detainee. The whereabouts of this docu-
mentation is unknown despite attempts from
the detainees and their lawyers to obtain them.
31% of detainees reported being medically ex-
amined in the courthouse, with police pres-
ence at all examinations. Finally, all detainees
reported routine medical examinations at the
entrance to prison for pre-trial detention, none
of which were carried out in the presence of
police forces. Detainees reported good treat-
ment once in the prison.
Conclusion: The results show a serious
breach of regional, national and international,
regulations and in particular the Istanbul Pro-
tocol principles relating to the medical exam-
ination of detainees.
Keywords: Catalan independence movement,
medical examinations, police, institutional
violence.
Introduction
The Catalan non-violent independence move-
ment has undoubtedly shaped today’s social
and political agenda in the Spanish State. For
Medical examination of detainees in
Catalonia, Spain, carried out in the
presence of police ofcers
Carme Vivancos Sánchez*, Iñaki Rivera Beiras**
*) Sistema de Registre i Comunicació de Violència
Instituciona (SIRECOVI). Barcelona.
**) Observatorio del Sistema Penal y los Derechos
Humanos (OSPDH). Barcelona University
Correspondence to: rivera@ub.edu
Key points of interest
•Medical examinations of detainees
must respect the principles of the
Istanbul Protocol, and with no
exceptions be carried out of the
presence of detention authorities.
https://doi.org/10.7146/torture.v30i1.119257
International Rehabilitation Council for Torture Victims. All rights reserved.
TORTURE Volume 30, Number 1, 2020
50
SHORT RESEARCH REPORT
many years, the operation of the Spanish po-
litical, judicial and social system was clearly
marked by the existence of the separatist group,
Euskadi Ta Askatasuna (hereinafter ETA). Its
disarmament in 2011 ETA (Gallego, 2017)
characterised a shift of focus to the Catalan
pacifist independence movement.
The Catalan self-determination movement
has been gaining strength in recent years, and
in particular, during the referendum that took
place on 1 October 2017. In a civic movement
never before seen in Spain, more than 2.3
million people (43% of the Catalan elector-
ate) voted, despite massive police and military
intervention in an attempt to deter the elec-
torate. 92% of voters supported independence
(Jones & Burgen, 2017). More than 1000 in-
dividuals were injured by Spanish police when
trying either to vote or to preserve the integ-
rity of the ballot boxes (Generalitat de Cata-
lunya, 2017). This resulted in the beginning of
a process of political, economic and civic re-
pression (Palou, 2017).
As part of the country’s legal strategy
against the pacifist movement, on 14
th
October
2019, the Supreme Court of Spain issued a
judgment convicting the main Catalan social
and political leaders to sentences ranging from
one year and eight months to thirteen years,
for crimes of embezzlement, sedition and dis-
obedience (459/2019, 2019). The weeks that
followed the sentencing saw widespread social
protests including mass demonstrations and
a general strike. There were also numerous
clashes between protesters and members of
different Catalan and Spanish police forces,
which ended with more than 200 people de-
tained and approximately 600 people with
varying degrees of injury, which ranged from
superficial injuries to loss of eyes due to rubber
bullets. Alleged injuries to 289 police officers
were also reported (Garcia, 2019).
The SIRECOVI is a Documentation and
Communication System for Institutional Vi-
olence1 that collects data of ill-treatment and
torture. As part of its activities, SIRECOVI
has monitored detention conditions in Cat-
alonia. The results of the research described
here are part of a bigger report (SIRECOVI,
2019) that encompasses the entire process
of deprivation of liberty, including arrest in
public spaces, transportation, conditions in
police stations and judicial courts, respect of
due process in courts, and the initial days
in prisons.
The study focuses on injured detainees
that were transferred to Court and sent to
pre-trial detention.
Methods
From 28th October 2019, members of the
SIRECOVI travelled to 6 penitentiary centers
in the provinces of Barcelona, Tarragona,
Lleida and Girona. In-depth interviews were
carried out with individuals in pre-trial de-
tention (n=22). Initial contact was facilitated
by the prisoners’ lawyers. The process was
complex and lengthy, requiring 3 weeks to
arrange informed consent from all detainees
and to plan the agenda of visits.
Ethical concerns: Participants signed an in-
formed consent document in advance of the
interviews. Special care was taken to ensure
that the recollection of episodes of violence or
other types of abuse did not add to the nar-
1 SIRECOVI is a Documentation and
Communication System for the protection of
victims of Institutional Violence. This system is
put into operation when someone communicates
about a person who has allegedly suffered ill-
treatment or torture in places of deprivation of
liberty (for example prisons or police stations) or
in the public space by an agent of the authority.
SIRECOVI’s website: https://sirecovi.ub.edu/
index_en.html
TORTURE Volume 30, Number 1, 2020
51
SHORT RESEARCH REPORT
rators’ sense of victimisation. The interviews
were recorded as part of the SIRECOVI data-
base which is registered with the Catalan Data
Protection Authority.
Results
In a sample of young people between 18 and 35
years old, 18 (81%) were men and 4 were(19%)
women. 13 (59%) were examined at the police
station or in court. 9 (41%) reported not having
received any medical examination although
their injuries were visually apparent. In all 22
cases, individuals were not informed of their
right to a medical examination.
Police station: 11 individuals (50%) reported
that they were examined by a doctor in police
detention, all in the presence of the police or
security forces. All detainees were taken to a
Primary Healthcare Centre (Centre d’Atenció
Primària – CAP) close to their place of deten-
tion. In 2 cases (18%) the detainees were hand-
cuffed whilst undergoing an examination. In
all 11 cases the report was given to the police
instead of the detainee. The whereabouts of this
documentation is unknown despite attempts
from the detainees and their lawyers to obtain it.
Furthermore, the interviews revealed that
the detainees had found the police presence
intimidating as that they were unable to speak
freely to the doctor. In particular, they were
not able to discuss any ill-treatment they had
endured, nor the physical and psychological
consequences of the treatment. It also trans-
pired that it was impossible to undertake a
medical assessment in the two cases where the
detainees remained handcuffed, despite the
doctors’ positive attempt at documentation.
Courtroom: 7 (31%) individuals reported
being examined by doctors in the courthouse.
In all cases the examination was conducted in
the presence of police. In 1 (14%) case, the in-
dividual was handcuffed during examination.
None of the detainees had access to the report.
Prison: All detainees reported that they
were examined by doctors at the entrance
of the prisons where they were to be held in
pre-trial detention. Security forces were not
present at any point.
The interviews highlighted the good treat-
ment received in the prisons and that the ex-
perience was, paradoxically, one of calmness
and safety that following two days of suffering,
tension, ill-treatment and violence.
In police
detention
In the
courthouse
In penitentiary
centers
0 5 10 15 20 25
11/11
7/7
21/22
WITH THE PRESENCE OF POLICE OR SECURITY FORCES
WITHOUT THE PRESENCE OF POLICE OR SECURITY FORCES
Discussion
The conduct of medical examinations of de-
tainees is regulated by guidelines and proce-
dures. Of particular relevance are the Istanbul
Protocol at the international level and the
Catalonian Charter of Citizens’ Rights and
Responsibilities at the sub-national level.
The Istanbul Protocol is the UN Manual
on Effective Investigation and Documentation
of Torture and Other Cruel, Inhuman or De-
grading Treatment or Punishment. It outlines
international legal standards and sets out spe-
cific guidelines on how to conduct effective
legal and medical investigations into allegations
of torture and ill-treatment. The relevant para-
graphs of the Istanbul Protocol are:
National codes of medical ethics: IP56 “[…]to
avoid harm, help the sick, protect the vul-
nerable and not discriminate between pa-
TORTURE Volume 30, Number 1, 2020
52
SHORT RESEARCH REPORT
tients on any basis other than the urgency
of their medical needs.”
IP61. “[…]doctors must always do what is
best for the patient, including detainees and
alleged criminals.”
Established standards of medical practice: IP83
“…Medical experts involved in the inves-
tigation of torture or ill-treatment should
behave at all times in conformity with the
highest ethical standards and, in particular,
must obtain informed consent before any
examination is undertaken. The examina-
tion must conform to established stand-
ards of medical practice. In particular,
examinations must be conducted in private
under the control of the medical expert and
outside the presence of security agents and
other government officials.”
84. Condentiality. “The report should be
confidential and communicated to the
subject or their nominated representative.”
Additionally, the Standard Minimum Rules
for the Treatment of Prisoners were revised
and adopted as the ‘Nelson Mandela’ rules.
They are often regarded by states as the
primary source of standards relating to treat-
ment in detention, and are the key framework
used by monitoring and inspection mecha-
nisms in assessing the treatment of prisoners.
These rules establish:
Rule 24.1. “The provision of health-care for
prisoners is a state responsibility. Prisoners
should enjoy the same standards of health-
care that are available in the community, and
should have access to necessary health-care
services free of charge…”
Rule 34. “If, in the course of examining
a prisoner upon admission or providing
medical care to the prisoner thereafter,
health-care professionals become aware of
any signs of torture or other cruel, inhuman
or degrading treatment or punishment, they
shall document and report such cases to the
competent medical, administrative or judi-
cial authority…’
The European Committee for the Pre-
vention of Torture (CPT) expressed concern
following its visit to Spain which took place
between 6-13 September 2018:
“the delegation noted that medical exami-
nations, whether in the police stations or
at a medical centre, still took place in the
presence of police officers. (…) the CPT
reiterates its recommendation that steps be
taken to ensure that all health care exami-
nations are conducted out of the hearing
and - unless the doctor concerned expressly
requests otherwise in a given case - out of
the sight of police staff” (CPT, 2020).
Regulations and recommendations in
Catalonia and Spain regarding medical
visits
The Charter of Citizens’ Rights and Respon-
sibilities in relation to health and healthcare
sets out a regulatory procedure to follow in
the doctor-patient relationship. Medical visits
must be confidential and private, and the
presence of anyone other than medical per-
sonnel must be expressly consented to by the
patient (Generalitat de Catalunya, 2015).
Violations of the provisions of the Istanbul
Protocol (among other regulatory provisions)
may act to prevent detainees from giving an
account of the origin of the injuries and might
contribute to impunity. The Spanish Ombuds-
man in its 2019 report expressed concerns
TORTURE Volume 30, Number 1, 2020
53
SHORT RESEARCH REPORT
that medical examinations were carried out
in places of deeprivation of liberty as well as
highlighting the lack of privacy and due guar-
antees (Defensor del Pueblo, 2019).
Conclusions
The subject of medical examinations merits
special consideration since almost all detain-
ees interviewed reported that they were not
informed of their right to a medical examina-
tion, and even being obviously injured, they
either did not receive medical examinations, or
where these had been carried out, police had
been present in the medical units. This repre-
sents a serious breach of national and interna-
tional regulations, which require that medical
examinations are conducted in privacy in the
sole presence of medical personnel, with no
presence of the detention unit.
References
Committee for the Prevention of Torture and
Inhuman or Degrading Treatment or Punishment
(CPT) (2020) To the Spanish Government on
the visit to Spain carried out by the European
Committee for the Prevention of Torture and
Inhuman or Degrading Treatment or Punishment
(CPT) from 6 to 13 September 2018. https://
rm.coe.int/16809a5597
Defensor del Pueblo (2019) Informe anual 2018.
Mecanismo nacional de prevención. Supervisión
de lugares de privación de libertad en España, de
acuerdo con el Protocolo facultativo a la Convención
de las Naciones Unidas contra la tortura y otros tratos
o penas crueles, inhumanas o degradantes (OPCAT).
https://www.defensordelpueblo.es/wp-content/
uploads/2019/09/Informe_2018_MNP.pdf
Gallego, D. (2017) Posibles consecuencias jurídico-
penales de la entrega denitiva de las armas por
parte de la organización terrorista ETA [Possible
criminal legal consequences of the nal delivery of
arms by the terror ist organisation ETA].RJUAM,
n.º 36, 2017-II, pp. 75-94
García, T (28th October 2019). Detenidos de excepción
y heridos por balas de goma [Exceptionally detained
and injured by rubber bullets]. El Salto. https://
www.elsaltodiario.com/cataluna/detenidos-
excepcion-represion-protestas-balas-goma-
sentencia
Generalitat de Catalunya. Departament de Salut
(2015) Carta de drets i deures de la ciutadania en
relació amb la salut i l’atenció sanitària [Charter
of Rights and Duties of Citizens in Relation to
Health and Health Care]. https://catsalut.gencat.
cat/web/.content/minisite/catsalut/ciutadania/
drets-deures/carta-drets-deures.pdf.
Generalitat de Catalunya (2017). Informe sobre els
incidents dels dies 1 al 4 d’octubre de 2017. Pacients
atesos durant la joranda electoral i dies posteriors
a conseqüencia de les càrregues policials de l’Estat
[Report on the incidents from 1 to 4 October 2017.
Patients treated during election day and subsequent
days as a result of state police charges]. https://
www.documentcloud.org/documents/4113650-
232799c8-755f-4810-ba56-0a5bbb78609c.
html#document/p3
Jones. S. & Burgen. S. (2017, Oct 2). Catalan
referendum: preliminary results show 90% in
favour of independence. The Guardian. https://
www.theguardian.com/world/2017/oct/01/
dozensinjured-as-riot-police-storm-catalan-ref-
pollingstations
Palou, J. (2017). Violación de derechos civiles y políticos.
Cataluña, Septiembre y Octubre de 2017 [Violation
of civil and political rights. Catalonia, September and
October 2017]. Iridia. http://iridia.cat/wpcontent/
uploads/Informe-DDHH_1OCT-CAST.pdf
SIRECOVI (2019) Protocol of visits to people imprisoned
since 14th October during social protests against
Supreme Court ruling 459/2019. University of
Barcelona. http://www.ub.edu/ospdh/sites/default/
files/documents/publicacions/sirecovi._report_
people_in_provisional_imprisonment_after_
social_protests_on_supreme_court_sentence.pdf
Supreme Court of Spain, 14 October 2019
(459/2019. Special Proceedings 20907/2017)
Supreme Court of Spain. https://cdn.20m.es/
adj/2019/10/14/4019.pdf. Available in English
from http://www.poderjudicial.es/cgpj/es/Poder-
Judicial/Noticias-Judiciales/El-Tribunal-Supremo-
condena-a-nueve-de-los-procesados-en-la-causa-
especial-20907-2017-por-delito-de-sedicion
United Nations (1999) Istanbul Protocol. Manual on
Effective Investigation and Documentation of Torture
and Other Cruel, Inhuman or Degrading Treatment
or Punishment. Professional Training Series
No.8/Rev.1. OHCHR. https://www.ohchr.org/
Documents/Publications/training8Rev1en.pdf
United Nations (2015) Standard Minimum Rules for
the Treatment of Prisoners (The Nelson Mandela
Rules). United Nations. https://undocs.org/A/
RES/70/175
Tortured, 15 paintings by torture victims
and their families.
Duayjai Group. Full body drawings. Bangkok. Thailand.
The Duayjai Group, in Thailand, organises workshops of art therapy through Body Map activi-
ties. The ones depicted here are part of a collection of paintings made by torture victims and
their families from the Patani area, in South Thailand. These paintings included in the Tortured
Art Exhibition and are part of a book recently published with the support of the Cross Cultural
Foundation.
Further information: duayjaigroup61@gmail.com
TORTURE Volume 30, Number 1, 2020
56
BOOK REVIEW
Civilizing Torture:
An American
Tradition, by
W. Fitzhugh
Brundage
Published by Harvard University Press. 2018.
Cambridge. (ISBN 9780674737662)
John W. Schiemann*
Civilizing Torture: An American Tradition is
part history
of torture in America, from
the colonial period to the present, and part
intellectual history
about the debates sur-
rounding torture in the same time span.
The writing is lively and
engaging despite
its academic heft.
The introduction sets out the book’s
framework, explaining that the phrase
“American Tradition” refers to “the debates
that Americans have waged regarding
torture. Like a minuet . . . the debates
have
unfolded in predictable fashion,” invoking
American exceptionalism of rationality, con-
stitutional protections of liberty, and other
claims to civilization (2).
1
On the assump-
tion that “[t]orture cannot be disentan-
gled from the discourse surrounding it,”
Brundage argues that the historical study of
torture in the US means identifying not
just
acts of violence “but also the explanations,
justifications, and denunciation of them”
and
so he “traces debates over forms of vi-
1 All numbers in parentheses refer to page
numbers in the book.
olence and coercion that at least some con-
temporaries
labeled as torture” (6). Doing
so reveals a “choreography,” “a strikingly
consistent pattern”
in which both those de-
fending torture and those opposed do their
best to align their position with “the na-
tion’s professed principles and with the
dictates of modern civilization”
.
The cho-
reography appears to
have the following
seven stages:
1. Officials respond to allegations of torture
with categorical denials;
2. More evidence by accusers prompts offi-
cials to admit a few exceptional mistakes;
3. Defenders “dismiss victims as neither
credible nor deserving of sympathy;”
4. Supporters of victims risk guilt by
association;
5. Defenders claim that methods were justifi-
able and effective;
6. Opponents claim that methods were
immoral and ineffective;
7.
Once torture ceases the debate shifts to
the significance of practice.
The remainder of the book is organized
chronologically into eight chapters, each of
which
treats a different period or episode
of torture in American history. Chapter one
relays anecdotes, memoirs, and reports of
torture by
both North American Indians
and European colonists in pre-revolutionary
North America, showing how each side be-
lieved the other had violated the norms and
customs of warfare. The second chapter ex-
amines early cycles of prison reform in the
new democracy, resulting in punishments
often amounting to torture and eventually
the establishments of
state institutions with
total control over their charges. Chapter
three turns to the torture
of slaves in the
antebellum South, with a focus on the ex-
*) Professor of Government & Law, Fairleigh
Dickinson University.
Correspondence to: jws@fdu.edu.
https://doi.org/10.7146/torture.v30i1.118434
International Rehabilitation Council for Torture Victims. All rights reserved.
TORTURE Volume 30, Number 1, 2020
57
BOOK REVIEW
ploitation of stories of cruelty to
mobi-
lize support for the abolitionist cause and
the backlash it engendered among slavery’s
southern supporters. Chapter four turns
to bellum: the civil war between
the North
and the South and the conditions that led
to
atrocities on the battlefield and in the
prison camps. Chapter five explores the
episodes of torture prior to 9/11: the Phil-
ippine-American War from 1899-1902. The
chapter summarizes the multiple factors
that led to torture and other abuse
by oc-
cupying American forces. Chapter six re-
counts the post-Civil War emergence and
movement to the shadows of the so-called
“third degree”. Chapter seven traces the US
government’s efforts to develop a
science
of torture early in the Cold War and then
the applications of torture on the “fron-
tiers
of American empire” in Vietnam and
Latin America. The eighth and final chapter
brings the narrative up to the present by
discussing both torture for national secu-
rity
reasons after 9/11 and torture in the
Chicago police department.
The book is organized chronologically
but Brundage does not systematically trace
the debates according to the
choreogra-
phy in the introduction. Each chapter after
the introduction is essentially freestand-
ing. Perhaps given the historical span and
varying contexts
,
it should not be surpris-
ing that there
appears to be no single chore-
ography but rather quite different American
dances with torture over time. Indeed, oc-
casionally the author digresses
from torture
in America or even torture entirely.
Along the way, however, Brundage makes
some valuable points both about elements of
torture
specific to different historical epi-
sodes and more generally. For example, in
chapter
one, “The Manners of Barbarians,”
Brundage notes that “[w]herever Indians
practiced torture, they did so according
to
traditions that were as coherent as any that
regulated in Europe” (15). Ritual torture
cohered with spiritual beliefs about coun-
tering vengeful souls, cultural norms
and
customs related to clan, honor, just retri-
bution, and the practice of Indian warfare,
which did not include prisoner exchanges.
In chapter three on slavery, he demonstrates
the
role of political institutions, including
courts and the law, in carving out a legal
space for
torture and other cruelty in
the private sphere on the plantation. This
served to sustain and maintain
the slave
order by “instilling terror” in the slaves (99,
102). Chapter six on police torture
traces
the connection between the police use of
the “third degree” and the lynching
of Af-
rican-Americans in the US South.
More thematically, his review identifies
some factors common to both the military
and domestic
incarceration contexts as well
as shared features within each. Common to
all is the demonization of a certain class of
people rendering them
“unworthy of sym-
pathy” and so torture-able (331). “The
history of torture, above all, reveals the
toxic consequences when rhetoric and poli-
cies that dehumanize ‘the enemy within’
or a
foreign foe exploit popular anxiety about se-
curity” (332). To this necessary condition
is
added, in the military context, poor train-
ing and counterinsurgency against an indig-
enous population fighting for independence
or counter-terrorism conflicts. In both, the
enemy
blends with the local population.To
the necessary condition of racism in the
domestic incarceration context (whether
prison, plantation, or police station) are
added institutional rules, social
norms, and
cultural practices which formally prohibit
torture but make its informal practice
pos-
TORTURE Volume 30, Number 1, 2020
58
BOOK REVIEW
sible by creating a space for it to flourish
out of sight (333).
Civilizing Torture
amplifies the echoes of
pre-9/11 American experiences with torture
– dehumanization of the
enemy, justifica-
tions for torture, claims of efficacy, the
fleeting nature of the public
debate about
torture and what it meant, and more – and
in so doing reminds us of how the
tradi-
tional seems forever new — and so is re-
peated all too often.
TORTURE Volume 30, Number 1, 2020
59
BOOK REVIEW
Tortura e
migrazioni
Torture and
Migration,
by Fabio Perocco
(ed.)
Published by Ca’ Foscari Editions: Venezia,
2019, 430 p, ISBN [ebook] 978-88-6969-
358-8; [print] 978-88-6969-359-5).
Iside Gjergji*
Reviewing this volume edited by Fabio
Perocco and published as open access by Uni-
versity of Venice Ca’ Foscari Editions1 is no
easy task. What makes it hard to sum up this
work is not its length (430 pages), but rather
its interdisciplinary approach, the depth of
observations, the richness in contents and
points of view and its geographical width. Yet,
these aspects make the book fundamental
for anyone willing to understand migratory
movements in today’s world. Its main merit
is having addressed, consistently and system-
atically, the close relation that has come to be,
over the course of decades, between torture
and migration. Such relation is no recent
piece of news: for a long time, torture has
been indicated as one of the most widespread
reasons for leaving, one of the most frequent
experiences lived along the migration path
and, more and more often, a reality that mi-
1 Free download from: https://edizionicafoscari.
unive.it/it/edizioni4/libri/978-88-6969-359-5/.
grants are forced to tackle in receiving coun-
tries. Nevertheless, the scientific narrative of
such relation is often limited, fragmented and,
sometimes, manipulated. Torture has so far
been extensively studied systematically in re-
lation to power (MacMaster, 2004), wars and
dictatorships (Hajjar, 2013; Cohen, 2005).
It is considered as lying at the basis of mo-
dernity (Reemtsma, 2012) or of the process
of civilization (Linklater, 2007), but it has
been analyzed less intensively as a structured
element of migration. The volume therefore
deserves to be recognized as one of the works
that can pave the way for an innovative field
of research.
The volume, including a broad and
sharp introductory essay by Fabio Perocco,
is divided in three parts. The first part, com-
posed of three essays, is devoted to the the-
oretical analysis of the concepts of torture,
racism, politics, society, law, and migration
policies. It highlights the (historically) un-
breakable bond between torture and racism
and between torture and current social and
political dynamics. Here torture is analysed
as a social phenomenon, produced by state
institutions and by the modelling of relations
within a specific political, legal, economic,
social and symbolic system. The general invi-
tation is to “think from the extremes, think of
torture, of migration with and beyond existing
tools […] to think of the enigmas of the rela-
tionship between torture and migrations and
find again the political freedom to act” (p. 86).
The second part, the core of the volume
(composed of thirteen essays), aims at analys-
ing and proving that, at a global level, there
is a long-lasting war against migrants, which
has created universal preconditions for the
massive use of torture practices against them.
The connection between torture and migra-
tion is considered in the contexts of Spain,
Belgium, United Kingdom, United States,
*) Centre for Social Studies, University of Coimbra,
Portugal
Correspondence to: isidegjergji@ces.uc.pt
https://doi.org/10.7146/torture.v30i1.118739
International Rehabilitation Council for Torture Victims. All rights reserved.
TORTURE Volume 30, Number 1, 2020
60
BOOK REVIEW
Brazil, Argentina, the Balkans, Morocco, Su-
dan-Israel, Libya, the central Mediterranean
and Italy. These essays, though using different
investigation and analysis instruments, paint a
full picture, rich in details, colors and words,
which is also achieved through the use of fresh
and effective language; under this profile, it is
a welcome breath of fresh air within the global
scientific literature, which often stubbornly en-
closes itself in jargon, difficult for others to
understand and to clarify the connections
between history and biographies.
The last part, constituted by four essays,
focuses on the medical-psychological dimen-
sion of torture in migration. There is complete
reconstruction of the state-of-the-art in global
scientific literature starting from 25 years ago,
with the very first epidemiological studies.
Other essays relate migration to mental health,
investigating both psychopathological reac-
tions in traumatized people and the effects
of trauma experienced during their migration
path, together with mental illness issues due to
the harsh living conditions in receiving coun-
tries. It also offers an in-depth look into psy-
chological disorders deriving from torture and
their impact on access to international pro-
tection, in as well as emphasis on the neces-
sary healing process from the damage caused
by torture.
This book is also an important tool to
better understand the present, since it makes
intelligible today’s close port policies in the
Northern Mediterranean, as well as the wall
between Mexico and the US, or the one
between Morocco and Spain. It helps us un-
derstand how these repressive and securitar-
ian migration policies violate the prohibition
of torture and of inhuman or degrading treat-
ment (Algostino p. 110-112; Ounniche, Saaid
p. 291-292; Omizzolo p. 312-316), which
clearly constitute a crime against humanity
under international law. Although criminal
responsibility is personal, i.e. lies with those
who personally practice torture, governments
are not exempt from responsibility: “Those
who, by externalising borders, relocate and
outsource torture and inhuman or degrading
treatment, are co-responsible, as are those
who take measures to close ports, condemn-
ing shipwrecked persons to inhuman or de-
grading treatment” (p. 111).
Moreover, what clearly stands out in the
overwhelming majority of the essays – which
constitutes one of its distinctive analytical fea-
tures – is the fact that the economic dimen-
sion is often included in the analysis. In this
book, torture against migrants is not only ex-
plained through a political dimension (which
includes only government and state actions),
but it also takes into account that the tor-
tured are actually meant to enter the labour
market, both in the countries of arrival and
in transit. Such a perspective, outlined in dif-
ferent nuances, gives the volume a very inter-
esting character.
If a downside were to be identified in this
volume, perhaps it could be that in some essays
there is an overlap between torture and de-
grading or inhuman treatment. Such overlap
may be considered scientifically valid or ac-
ceptable from a medical or sociological point
of view, but from a legal or political perspec-
tive the equivalence runs the risk of banalis-
ing torture.
The essays in the volume are written in
four languages: Italian, English, French and
Spanish. Intertwining reflections by sociolo-
gists, philosophers, lawyers, doctors and ac-
tivists from several countries in the world was
not easy, yet it was certainly needed, especially
for those who conceive research as something
inseparable from social action, who wish for
knowledge not to be left to rot in academa but
rather spread and flourish as energy triggering
social transformations.
TORTURE Volume 30, Number 1, 2020
61
NEWS
References
Cohen, S. (2005). “Post-Moral Torture: From
Guantanamo to Abu Ghraib”. Index on
Censorship, 1, 24-30. https://doi.org/10.1080/0306
4220512331339427
Hajjar, L. (2013). Torture: A sociology of violence and
human rights. Routledge.
Linklater, A. (2007). “Tor ture and Civilisation”.
International Relations, 21, 111-118. https://doi.
org/10.1177/0047117807073771
MacMaster, N. (2004). “Torture: From Algiers to
Abu Ghraib”. Race and Class, 46, 1-21. https://
doi.org/10.1177/0306396804047722
Reemtsma, J. P. (2012). Trust and violence: An essay on
a modern relationship. Princeton University Press.
TORTURE Volume 30, Number 1, 2020
62
NEWS
In 2007, Thailand ratified the UN Conven-
tion Against Torture and in 2012, signed the
International Convention for the Protection
of All Persons from Enforced Disappearance.
13 years on however, the country has yet to
criminalise torture and enforced disappear-
ance under domestic legislation.
Following a recommendation from the UN
Committee Against Torture in 2014, the ‘Sup-
pression and Prevention of Torture and En-
forced Disappearance’ Bill was drafted. At the
time of writing, the Bill remains entangled in
a legislative process fraught with political ob-
stacles and delays.
The failure to criminalise torture and en-
forced disappearances leads to a lack of prompt,
effective, and independent investigations, and
forges a climate of impunity. The UN Working
Group on Enforced or Involuntary Disappear-
ances has recorded 79 cases of enforced dis-
appearance that are pending investigation in
Thailand. No perpetrator in any of these cases
has successfully been brought to justice.
The drafting and passing of legislation is
thereby critical to ensuring effective access to
justice and legal assistance as a means to in-
vestigating and ultimately ceasing violations.
An overview of the timeline and details of
the draft Bill are as follows:
•
In 2012, Thailand signed, but has yet to
ratify, the International Convention for the
Protection of All Persons from Enforced
Disappearance.
•
In 2014, the Suppression and Prevention
and of Torture and Enforced Disappearance
Bill was drafted following the recommenda-
tion of the UN Committee Against Torture.
• In 2016, the draft Bill was submitted before
the Council of State and the National Leg-
islative Assembly for review and final ap-
proval.
•
In October 2018, the draft law was endorsed
by the Council of State, the Cabinet, and the
Coordinating Committee of the National
Legislative Assembly (NLA).
• In December 2018, many civil society or-
ganizations (CSOs), namely the Cross-Cul-
tural Foundation (CrCF), submitted a letter
to the NLA, expressing concerns regarding
the lack of CSO participation in the process
and requesting to observe the ad hoc com-
mittee sessions, but were denied permission.
• In March 2019, the NLA decided to take
the discussion and consideration of the draft
Bill out of their agenda in the second reading
due to strong opposition from high ranking
security officials.
• In May 2019, a new parliament was formed
following a general election. During this
time, CrCF and other human rights organ-
Criminalisation of torture and enforced
disappearance in Thailand: Progress on
draft legislation
Torture Journal Editorial Team* on behalf of
Cross Cultural Foundation (CrCF), Thailand
*) Correspondence to: publications@irct.org
https://doi.org/10.7146/torture.v30i1.120594
International Rehabilitation Council for Torture Victims. All rights reserved.
TORTURE Volume 30, Number 1, 2020
63
NEWS
isations developed the CSO version of the
draft law. This version provides that:
a. Intentional infliction of severe pain
or suffering for any reason based on
discrimination constitutes torture.
b. The act of torture may not be justified
in any circumstances, even in time of
public emergencies.
c. Superiors of the offender must be held
accountable for an act of torture and
enforced disappearance committed by
their subordinates.
d. All persons deprived of liberty must
enjoy fundamental safeguards that
guarantee their freedom from torture,
cruel, inhumane and degrading
treatments or punishments, and
enforced disappearance.
e.
Allegations must be reviewed by
civilian courts which shall be granted
powers to intervene and issue
injunctions that offer immediate
remedies for the victims.
• In early 2020, the Draft Act on Prevention
and Suppression of Torture and Enforced
Disappearance was submitted to the Stand-
ing Committee on Legal Affairs, Justice, and
Human Rights of the Thai Parliament.
Despite efforts to codify the crimes of
torture and enforced disappearance under
Thai law, the country’s pledges to do so
remain unfulfilled. Without this law, there is
no foreseeable end to the rampant culture of
impunity in Thailand. Victims of torture and
enforced disappearance will continue remain
in the shadows without access to protection
from the state.
TORTURE Volume 30, Number 1, 2020
64
NEWS
are identified to include health professionals
(doctors, psychiatrists, psychotherapists pro-
fessional counsellors, sexologists and ayurve-
dic practitioners), with police and religious
practitioners also cited. The paper further
notes that perpetrators conduct this type of
“therapy” under the false guise of medicine
and mental health, although it causes signifi-
cant harm and there is no evidence that it can
be effective.
State Involvement
The report finds that states perpetuate con-
version therapy through direct involvement,
acquiescence, or financial support, as well as
via promotion and endorsement of conversion
practices. It highlights that conversion therapy
is, in some cases, ordered by state officials and
practiced by the police and also finds its prac-
tice in publicly funded religious or educational
institutions, or in government hospitals.
The authors further discuss the widespread
failure of states to regulate conversion prac
-
tices where they occur, noting a prevalence of
practices in government-licensed institutions.
Although they may be qualified as torture or
ill-treatment as well as child abuse and fraud,
practices often remain, the report finds, un-
sanctioned in the majority of legal or regula-
tory frameworks.
Finally, the paper highlights examples in
which States have promoted and legitimised
On 23 April 2020, IRCT published its re-
search on the global practice of conversion
therapy. The report, entitled “It’s Torture
Not Therapy,” compiles information on the
“practices, practitioners and roles of states
in conducting, supporting, promoting and
acquiescing in conversion therapy” and is in-
tended to supplement the Expert Statement
of the Independent Forensic Expert Group on
the same issue, also printed in this edition of
Torture Journal.
The paper identifies a number of practices
as used by at least 68 states in conversion at-
tempts including:
• Aversive treatment
• Electroconvulsive therapy
• Medication
• Forced confinement
• Pyschotherapy
• Corrective violence
• Exorcisms and ritual cleansing
Perpetrators
Whilst the author notes that prevalence of
groups of perpetrators varies by country and
region, a disturbing number of perpetrators
Launch of IRCT Report on Conversion
Therapy*
Torture Journal Editorial Team
*) Full report available at https://irct.org/uploads/
media/IRCT_research_on_conversion_therapy.pdf
https://doi.org/10.7146/torture.v30i1.119655
International Rehabilitation Council for Torture Victims. All rights reserved.
TORTURE Volume 30, Number 1, 2020
65
NEWS
practices through encouragement of its usage
by governmental officials and workers and
through the provision spaces for practices
to be carried out. The report also highlights
cases where crimes of “corrective violence”
are ignored by both the public and by police.
Conclusion and Recommendations
In its conclusion, the report emphasises the
role of the state in providing, financing, or
encouraging conversion therapy, being com-
plicit in acts carried out by state officials or
acquiescing to private practice of conversion
therapy.
IRCT makes 11 recommendations to states
including:
Repeal laws criminalising individuals on the
basis of their sexual orientation or gender
identity (SOGI); issue an apology for dis-
crimination and historical injustices against
lesbian, gay, bisexual, trans and gender
diverse communities; ban conversion therapy
practices; issue and enforce clear guidance to
identified groups of perpetrators that prohib-
its and punishes conversion therapy; establish
a complaints mechanism and programmes to
provide full reparation for those harmed by
conversion therapy and undertake research
on the practice and provide widespread edu-
cation on SOGI and wider human rights prin-
ciples.
TORTURE Volume 30, Number 1, 2020
66
STATEMENTS
Introduction
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 orienta-
tion 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 countries1.
In those countries where it is performed,
a wide and variable range of practices are be-
lieved to create change in an individual’s sexual
orientation or gender identity. Some examples
of these include: talk therapy or psychother-
apy (e.g., exploring life events to identify the
cause); group therapy; medication (including
anti-psychotics, anti-depressants, anti-anxiety,
and psychoactive drugs, and hormone injec-
tions); Eye Movement Desensitization and Re-
processing (where an individual focuses on a
traumatic memory while simultaneously ex-
periencing bilateral stimulation); electroshock
or electroconvulsive therapy (ECT) (where
electrodes are attached to the head and elec-
tric current is passed between them to induce
seizure); aversive treatments (including elec-
tric shock to the hands and/or genitals or nau-
sea-inducing medication administered with
presentation of homoerotic stimuli); exor-
cism or ritual cleansing (e.g., beating the in-
dividual 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
1 IRCT research on conversion therapy available
at https://irct.org/uploads/media/IRCT_research_
on_conversion_therapy.pdf.
Statement on Conversion Therapy
Independent Forensic Expert Group*
*) Djordje Alempijevic, Rusudan Beriashvili,
Jonathan Beynon, Bettina Birmanns, Marie
Brasholt, Juliet Cohen, Maximo Duque, Pierre
Duterte, Adriaan van Es, Ravindra Fernando,
Sebnem Korur Fincanci, Sana Hamzeh, Steen
Holger Hansen, Lilla Hardi, Michele Heisler,
Vincent Iacopino, Peter Mygind Leth, James
Lin, Said Louahlia, Hege Luytkis, Jens Modvig,
Maria-Dolores Morcillo Mendez, Alejandro
Moreno, Valeria Moscoso, Resmiye Oral, Onder
Ozkalipci, Jason Payne-James, Jose Quiroga,
Hernan Reyes, Sidsel Rogde, Antti Sajantila,
Matthis Schick, Agis Terzidis, Jorgen Lange
Thomsen, Morr is Tidball-Binz, Felicitas Treue,
Peter Vanezis, Duarte Nuno Viera
Please send correspondence to irct@irct.org.
For full details about the Independent Forensic
Expert Group, please visit http://www.irct.org/
our-support/medical-and-psychological-case-
support/forensic-expert-group.aspx
https://doi.org/10.7146/torture.v30i1.119654
International Rehabilitation Council for Torture Victims. All rights reserved.
TORTURE Volume 30, Number 1, 2020
67
STATEMENTS
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 “correc-
tive” rape.
Conversion therapy appears to be per-
formed widely by health professionals,
including medical doctors, psychiatrists, psy-
chologists, sexologists, and therapists. It is also
conducted by spiritual leaders, religious prac-
titioners, traditional healers, and community
or family members. Conversion therapy is un-
dertaken both in contexts under state control,
e.g., hospitals, schools, and juvenile deten-
tion 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 instruc-
tions 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-hetero-
sexual 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 state-
ment 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 consti-
tutes cruel, inhuman, or degrading treatment
or torture when individuals are subjected to it
forcibly
2
or without their consent. This medi-
co-legal statement also addresses the respon-
sibility of states in regulating this practice, the
ethical implications of offering or perform-
ing 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 ori-
entation 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 orienta-
tion 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 Homosex-
uality3 and on Forced Virginity Testing4. In
those statements, we opposed attempts to mi-
nimise the severity of physical and psycho-
logical pain and suffering caused by these
2 This statement considers an examination to be
“forcibly conducted” when it is “committed by
force, or by threat of force or coercion, such as
that caused by fear of violence, duress, detention,
psychological oppression or abuse of power,
against such person incapable of giving genuine
consent.” International Criminal Court. Elements
of Crimes. Art. 7(1)(g)-1. RC/11. 2011:8.
3 Independent Forensic Expert Group. Statement
on Anal Examinations in Cases of Alleged
Homosexuality. Torture. 2016; 26(2):85-91.
Available at: https://irct.org/uploads/media/306a5
91c5f8207f6107f5c11e8c5c4fc.pdf.
4 Independent Forensic Expert Group. Statement
on Virginity Testing. Torture. 2015; 25(1):62-68.
Available at: https://irct.org/uploads/media/1d6e1
087759460fd9e473273a85c7e95.pdf
TORTURE Volume 30, Number 1, 2020
68
STATEMENTS
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 sexual-
ity and knowingly or unknowingly support-
ing state-sponsored policing and punishing
of individuals based on their sexual orienta-
tion or gender identity.
About the Authors
The opinions expressed in this statement
are based on international standards and
the experiences of members of the Inde-
pendent Forensic Expert Group (IFEG) in
documenting the physical and psychological
effects of torture and other cruel, inhuman,
or degrading treatment or punishment (also
ill-treatment). Consisting of 39 preeminent
independent medico-legal specialists from
23 countries, the IFEG represents a vast
collective experience in the evaluation and
documentation of the physical and psycho-
logical evidence of torture and ill-treatment.
The IFEG provides technical advice and
expertise in cases where allegations of torture
or ill-treatment are made5. Its members are
global experts on and authors of the Istanbul
Protocol, the key international standard-set-
ting instrument on the investigation and doc-
umentation of torture and ill-treatment6.
5 See, e.g., Independent Forensic Expert
Group. Statement on Hooding. Torture. 2011;
21(3):186-189; Independent Forensic Expert
Group. Statement on access to relevant medical
and other health records and relevant legal
records for forensic medical evaluations of
alleged torture and other cruel, inhuman or
degrading treatment or punishment. Torture.
2012; 22 (Supplementum 1):39-48. Independent
6 United Nations Office of the High Commissioner
IFEG members also hold influential posi-
tions in and act as advisors to governments,
international bodies, professional health as-
sociations, non-governmental organisations,
and academic institutions worldwide on fo-
rensics in general and more specifically on the
investigation and documentation of torture
and ill-treatment.
Medical and Scientific Validity
There is no empirical evidence to support
pathologising or medicalising variations
in sexual orientation and gender identity.
Studies have found that variation in sexual
orientation is ubiquitous and that there is
substantial variability in patterns of sexual
and gender expression both between indi-
viduals and within individuals across time7.
The World Medical Association (WMA)
has strongly emphasised “that homosexuality
does not represent a disease, but a normal var i-
ation within the realm of human sexuality.”8
For almost half a century, the Diagnostic
and Statistical Manual of Mental Disorders
(DMS-III, 1973) has stopped recognising
homosexuality as a disorder. Similarly, for
three decades, the World Health Organisa-
tion (WHO), which issues the International
Statistical Classification of Diseases and
Related Health Problems, has not defined
for Human Rights. Manual on the Effective
Investigation and Documentation of Torture and
Other Cruel, Inhuman or Degrading Treatment
or Punishment (the “Istanbul Protocol”). United
Nations; 2004. HR/P/PT/8/Rev.1.
7 World Health Organization. Proposed
declassification of disease categories related to
sexual orientation in the international statistical
classification of diseases and related health
problems (ICD-11). Bulletin of the World Health
Organization 2014;92:672-679.
8 World Medical Association. Statement on
Natural Variations of Human Sexuality. World
Medical Assembly; 2013.
TORTURE Volume 30, Number 1, 2020
69
STATEMENTS
homosexuality as a disorder (ICD-10, en-
dorsed in 1990). Moreover, in 2018, the
WHO declassified all remaining disorders
correlated with same-sex attraction, such as
ego-dystonic sexual orientation9, which had
been (mis)used in the past to justify conver-
sion therapy, thereby eliminating all medical
bases correlated to sexual orientation that
can be used to justify conversion therapy.
To our knowledge, there also are no
credible scientific peer-reviewed studies that
demonstrate that conversion therapy in any
form is effective. On the contrary, in 2009,
the American Psychological Association con-
ducted a systematic review of peer-reviewed
journal literature on conversion therapy and
concluded that “the results of scientically valid
research indicate that it is unlikely that individ-
uals will be able to reduce same-sex attractions
or increase other-sex sexual attractions through
[sexual orientation change efforts].”10 In 2016,
the World Psychiatric Association issued a
statement finding that “[t]here is no sound sci-
entic evidence that innate sexual orientation
can be changed.”11 Practices that purport to
change an individual’s sexual orientation or
gender identity therefore lack any foundation
9 “The gender identity or sexual preference is
not in doubt but the individual wishes it were
different because of associated psychological and
behavioural disorders and may seek treatment
to change it.” World Health Organization. The
ICD-10 classification of mental and behavioural
disorders: clinical descriptions and diagnostic
guidelines. 1992.
10 American Psychological Association. Task
Force on Appropriate Therapeutic Responses
to Sexual Orientation. Report of the American
Psychological Association Task Force on
Appropriate Therapeutic Responses to Sexual
Orientation. 2009.
11 World Psychiatric Association. Position Statement
on Gender Identity and Same-Sex Orientation,
Attraction, and Behaviours. World Psychiatry.
2016;15(3):299–300.
in science or medicine and are unlikely to be
effective. Instead, they are based on an an-
tiquated misconception about the nature of
sexual orientation and gender identity.
Physical and Psychological Effects
Conversion therapy represents a form of
discrimination, stigmatisation, and social re-
jection. Many conversion therapy practices
bear similarity to acts that are internationally
acknowledged to constitute torture or other
cruel, inhuman, or degrading treatment or
punishment. Those include beatings, rape,
forced nudity, force-feeding, isolation and
confinement, deprivation of food, forced
medication, verbal abuse, humiliation, and
electrocution. These specific acts as well as
the entire period during which the individual
experiences them is recognised internation-
ally to subject individuals to significant or
severe physical and/or mental pain and suf-
fering.
The fact that a treatment or practice has
a valid medical use does not mean that it is
not physically and psychologically harmful
to individuals. In addition, a valid medical
use for some conditions does not mean that
the treatment is valid to treat other condi-
tions under different circumstances. For in-
stance, ECT or electroshock therapy applied
with muscle relaxant and general anaesthe-
sia is a recognised and valid form of treat-
ment for psychiatric patients suffering from
treatment-resistant, life-threatening depres-
sion. But in almost every instance, individu-
als will experience significant disorientation,
cognitive deficits, and retrograde amnesia,
which can be severely distressing. Concern-
ingly, ECT is reportedly used for conversion
therapy in some countries, although it is un-
proven and therefore medically invalid. In
countries where ECT is still administered in
its unmodified form (i.e., without anaesthetic
TORTURE Volume 30, Number 1, 2020
70
STATEMENTS
and muscle relaxants), it not only causes sig-
nificant psychological harm, but leads to
violent convulsions commonly resulting in
joint dislocations and bone fractures.
Medication is also used in conversion
therapy and can cause significant physical and
mental adverse effects. When such medica-
tion is medically inappropriate or used forc-
ibly or without the individual’s consent, it is
likely to intensify the psychological terror or
trauma related to the experience of conver-
sion therapy and has been recognised as a
method of torture or other cruel, inhuman,
or degrading treatment
12
. Neuroleptics,
anxiolytics, and anti-depressants (includ-
ing thioridazine, citalopram, fluoxetine, and
risperidone) have been used on individuals
to diminish their sexual desire. In addition,
they are often prescribed due to the false
belief that psychosis or other mental disor-
der is the underlying cause of an individu
-
al’s particular sexual orientation or gender
expression. These anti-depressants, mostly
from the selective serotonin reuptake inhib-
itor group, may cause sexual dysfunction,
while anti-psychotic medications may cause
movement disorders, mental slowing, tired-
ness, memory problems, numbness of the
body, weight gain, and sexual dysfunction,
among other effects, which serve only to com-
pound an individual’s distress and suffering.
All forms of conversion therapy, includ-
ing talk or psychotherapy, can cause intense
12 UN Human Rights Councils. Report of the
United Nations High Commissioner for Human
Rights. 31 January 2017. A/HRC/34/32.
psychological pain and suffering.
13,14,15,16
All practices attempting conversion are in-
herently humiliating, demeaning, and dis-
criminatory. The combined effects of feeling
powerless and extreme humiliation generate
profound feelings of shame, guilt, self-dis-
gust, and worthlessness, which can result in
a damaged self-concept and enduring per-
sonality changes. The injury caused by con-
version therapy begins with the notion that
an individual is sick, diseased, and abnor-
mal due to their sexual orientation or gender
identity and must therefore be treated. This
starts a process of victimisation through
conversion therapy. Individuals who have
undergone the practice often experience a
decrease in self-esteem, episodes of signifi-
cant anxiety, depressive tendencies, depres-
sive syndromes, social isolation, intimacy
difficulties, self-hatred, sexual dysfunction,
and suicidal thoughts. In many studies, the
rates of suicidal ideation and suicide attempt
are several times higher than in other lesbian,
gay, bisexual, trans, and gender diverse pop-
13 Dehlin J, Galliher R, Bradshaw W, Hyde
D, & Crowell K. Sexual orientation change
efforts among current or former LDS church
members. Journal of Counseling Psychology.
2015;62(2):95-105.
14 Ozanne Foundation. 2018 National Faith &
Sexuality Survey. https://ozanne.foundation/faith-
sexuality-survey-2018/. Published July 8, 2019.
15 Shidlo A & Schroeder M. Changing sexual
orientation: a consumers' report. Professional
Psychology-Research and Practice, 2002;33: 249-
259.
16 Haldeman, D. Therapeutic Antidotes: Helping
gay and bisexual men recover from conversion
therapies. Journal of Gay and Lesbian
Psychotherapy. 2002; 5 (3): 117-130.
TORTURE Volume 30, Number 1, 2020
71
STATEMENTS
ulations who have not been exposed to con-
version therapy17 18 19.
Conversion therapy can often lead to
posttraumatic stress disorder
20,21
. Group
therapy, camps and retreats may incorporate
highly traumatic elements such as exposure to
physical, verbal, and sexual abuse and humili-
ation. Talk or psychotherapy can also become
a repeatedly traumatic event. Session after
session, the individual is confronted with their
own “deviancy,” while repetition and dura-
tion increase its intensity and importance. We
have seen that conversion therapies can lead
to avoidance behaviours, hypervigilance (e.g.,
difficulty falling or staying asleep), intrusive
flashbacks, traumatic nightmares, and other
symptoms of posttraumatic stress disorder.
Children and minors are particularly vul-
nerable1,2,22. In children and minors exposed
to conversion therapy, psychological symp
-
17 Turban JL, Beckwith N, Reisner SL, &
Keuroghlian AS. (2020). Association between
recalled exposure to gender identity conversion
efforts and psychological distress and suicide
attempts among transgender adults. JAMA
Psychiatry. 2020;77(1):68.
18 Ryan C, Toomey RB, Diaz RM, & Russell ST.
Parent-initiated sexual orientation change efforts
with LGBT adolescents: implications for young
adult mental health and adjustment, Journal of
homosexuality, 2009; 67(2):159-173.
19 The Trevor Project. National Survey on
LGBTQ Mental Health 2019. https://
www.thetrevorproject.org/survey-
2019/?section=Conversion-Therapy-Change-
Attempts. Published June 2019.
20 Shidlo A & Schroeder M. Changing sexual
orientation: a consumers' report. Professional
Psychology-Research and Practice, 2002;33: 249-
259.
21 Horner J. Undoing the Damage: Working with
LGBT clients in post conversion therapy.
Columbia Social Work Review. 2010;1:8-16.
22 Fjelstrom, J. Sexual orientation change efforts
and the search for authenticity. Journal Of
Homosexuality, 2013;60(6): 801-827.
toms are expressed in a significant loss of
self-esteem and a sharp increase in suicidal or
depressive tendencies. These can often lead to
school dropout and the adoption of high-risk
behaviours, self-destructive behaviours, and
substance abuse. Conversion therapy causes
a delay in sexual and personal development,
which can lead to depression, increased feel-
ings of guilt and stress, and can also bring
about feelings of social rejection and social
isolation. Minors are at especially high risk to
develop serious psychological disorders after-
wards, due to the loss of self-esteem, negative
feelings toward oneself, self-loathing, feelings
of debasement, and the forced rejection of
one’s own identity.
The long-term duration of many conver-
sion therapies can be particularly harmful.
Individuals often undergo therapy for several
years to more than a decade
23,6
. The long-
term duration creates chronic stress, which
has been known to result in many negative
health consequences, including stomach
ulcers, gastrointestinal disorders, skin dis-
eases, sexual and eating disorders, and mi-
graines. Psychosomatic symptoms can be
especially pronounced in children who are
unable to express their difficulties and may
manifest their distress through eczema break-
outs, insomnia, sleep disorders, vomiting,
asthma, and impaired growth or develop-
ment. Psychological symptoms can become
chronic. Despair, disillusion, and shame can
last for many years. Even into adulthood,
studies have found that exposure to conver-
sion efforts results in adverse mental health
outcomes, including severe psychological dis-
23 Dehlin J, Galliher R, Bradshaw W, Hyde
D, & Crowell K. Sexual orientation change
efforts among current or former LDS church
members. Journal of Counseling Psychology.
2015;62(2):95-105.
TORTURE Volume 30, Number 1, 2020
72
STATEMENTS
tress, lifetime suicidal thoughts, and lifetime
suicide attempts24, 25.
In both adults and minors, the failure of
conversion therapy often exacerbates the in-
dividual’s feelings of inadequacy, self-worth-
lessness, and shame
26,27
. Individuals often feel
intense guilt of failure, reinforced by the idea
that they are ill, unacceptable, incurable, and
a burden to their families.
When health professionals are involved in
the performance of this harmful act, in our
experience, their involvement is likely to ex-
acerbate the pain and suffering experienced
by individuals given the betrayal it represents
of the social norm of trusting health profes-
sionals. Betrayal of the fragile trust between
patient and clinician can have severe conse-
quences, leading to feelings of guilt, rejec-
tion, and humiliation. The individual can lose
self-esteem and may exhibit anger or with-
drawal, which will impair their future in-
terpersonal and romantic relationships and
professional life.
Where conversion therapy is ordered,
conducted, or supported by public authori-
24 Turban JL, Beckwith N, Reisner SL, &
Keuroghlian AS. Association between recalled
exposure to gender identity conversion efforts
and psychological distress and suicide attempts
among transgender adults. JAMA Psychiatry.
2020;77(1):68.
25 Ryan C, Toomey RB, Diaz RM, & Russell ST.
Parent-initiated sexual orientation change efforts
with LGBT adolescents: implications for young
adult mental health and adjustment, Journal of
homosexuality, 2009; 67(2):159-173.
26 Dehlin J, Galliher R, Bradshaw W, Hyde
D, & Crowell K. Sexual orientation change
efforts among current or former LDS church
members. Journal of Counseling Psychology.
2015;62(2):95-105.
27 Haldeman, D. Therapeutic Antidotes: Helping
gay and bisexual men recover from conversion
therapies. Journal of Gay and Lesbian
Psychotherapy. 2002; 5 (3): 117-130.
ties, the experience of being betrayed by the
law likely adds to the individual’s mental pain
and suffering. These amplify any shame and
stigma they may already experience, includ-
ing social rejection, victimisation and punish-
ment by their family or religious community,
and conflict with their faith.
Cruel, Inhuman, and Degrading Treatment
and Torture
Torture and other forms of cruel, inhuman,
or degrading treatment or punishment are
unequivocally prohibited, without exception,
by the UN Convention against Torture28
as well as other international and regional
human rights instruments. The UN Com-
mittee against Torture, the UN Special Rap-
porteur on Torture, the UN Subcommittee
on Prevention of Torture, and the Office of
the High Commissioner for Human Rights
(OHCHR) have stated that conversion
therapy contravenes the prohibition against
torture and other cruel, inhuman, or degrad-
ing treatment or punishment. In its 2015
annual report, the OHCHR stressed that
states “have an obligation to protect all persons,
including LGBT and intersex persons, from
torture and other cruel, inhuman or degrading
treatment or punishment” and found that con-
version therapy breaches this duty29.
In May 2018, the UN Independent
Expert on Sexual Orientation and Gender
28 United Nations Office of the High Commissioner
for Human Rights. Convention Against Torture and
Other Cruel, Inhuman or Degrading Treatment or
Punishment. Available at: http://www.unhchr.ch/
html/menu2/6/cat/treaties/opcat.htm
29 UN Human Rights Council, Report of the Office
of the United Nations High Commissioner for
Human Rights, Discrimination and violence
against individuals based on their sexual
orientation and gender identity. 4 May 2015. A/
HRC/29/23.
TORTURE Volume 30, Number 1, 2020
73
STATEMENTS
Identity observed that: “The violence reported
against persons on the basis of their actual or per-
ceived sexual orientation or gender identity also
includes …so-called ‘conversion therapy’. Consid-
ering the pain and suffering caused and the im-
plicit discriminatory purpose and intent of these
acts, they may constitute torture or other cruel,
inhuman or degrading treatment or punishment
in situation where a State official is involved, at
least by acquiescence.”
30
Subsequently, the UN
Special Rapporteur on Torture in July 2019
affirmed that: “given that ‘conversion therapy’
can inict severe pain or suffering, given also the
absence both of a medical justication and of free
and informed consent, and that it is rooted in dis-
crimination based on sexual orientation or gender
identity or expression, such practices can amount
to torture or, in the absence of one or more of those
constitutive elements, to other cruel, inhuman or
degrading treatment or punishment.”31
Based on these findings, the UN Com-
mittee against Torture, the UN Independent
Expert on Sexual Orientation and Gender
Identity, the UN Special Rapporteur on
Torture, and the OHCHR have all called
upon states to ban the practice. In 2016,
the UN Committee against Torture recom-
mended that a state take “the necessary leg-
islative, administrative and other measures to
guarantee respect for the autonomy and physi-
cal and personal integrity of lesbian, gay, bisex-
30 UN Human Rights Council, Report of the
Independent Expert on protection against
violence and discrimination based on sexual
orientation and gender identity. 11 May 2018. A/
HRC/38/43.
31 UN General Assembly. Interim Report of the
Special Rapporteur on torture and other cruel,
inhuman or degrading treatment or punishment,
relevance of the prohibition of Torture and
other Cruel, Inhuman or Degrading Treatment
or Punishment to the Context of Domestic
Violence. 12 July 2019. A/74/148.
ual, transgender and intersex persons and prohibit
the practice of so-called ‘conversion therapy’.”32
State Involvement and Responsibility
The UN Convention against Torture and
other international and regional human
rights instruments not only prohibit torture,
but oblige states to prevent public authorities
from “directly committing, instigating, inciting,
encouraging, acquiescing in or otherwise partici-
pating or being complicit in any acts of torture”
and other cruel, inhuman, or degrading
treatment or punishment4. In several coun-
tries, we have found that public officials are
directly involved in the provision of conver-
sion therapy. In some cases, the therapy is
offered and performed by medical personnel
in state hospitals, public clinics, schools, and
juvenile detention centres. Sometimes, the
therapy is performed pursuant to an order
by public officials, judges, or the police. All
these acts would seem to contravene the in-
ternational legal obligations of these states
to prohibit and prevent torture and other
cruel, inhuman, or degrading treatment or
punishment.
Furthermore, states have a responsibility to
“prohibit, prevent and redress torture and ill-treat-
ment in all contexts of custody and control,” not
just those operated by public entities
33
. We
have found in almost 30 countries that conver-
sion therapy is being committed, instigated or
supported by private institutions and private
individuals acting in an official capacity and
executing a state function. This includes health
professionals in private clinics performing con-
32 UN Committee Against Torture. Concluding
observations on the fifth periodic report of
China. 3 February 2016. CAT/C/CHN/CO/5
33 UN Committee Against Torture. General
Comment 2, Implementation of article 2 by
States Parties. CAT/C/GC/2/CRP.1/Rev.4.2007
TORTURE Volume 30, Number 1, 2020
74
STATEMENTS
version therapies or private schools providing
it. The UN Convention against Torture and
other human rights instruments require that
states oversee the provision of services that
are in the public interest, such as health and
education. As stated by the UN Committee
against Torture, states have the special duty
to protect the life and personal integrity of
persons by regulating and supervising these
services, regardless of whether the entity pro-
viding them is public or private1. Accordingly,
personnel in private hospitals and clinics as
well as teachers are considered to act in an
official capacity on behalf of the state, as they
are executing a state function
34
and should
similarly be prevented from directly commit-
ting, instigating, inciting, encouraging, acqui-
escing in, or otherwise participating or being
complicit in any acts of torture and ill-treat-
ment, including conversion therapy.
In over a dozen countries, we found that
conversion therapy practices, e.g., beatings,
isolation, exorcisms, and “corrective” rape,
appear to take place primarily in the private
sphere by religious practitioners, traditional
healers, or sometimes by community and
family members. These acts which are not
originally directly attributable to the state
(i.e., acts committed by private individuals)
can nevertheless lead to state responsibil-
ity, due to the lack of due diligence to elim-
inate, prevent, investigate, and punish acts
of torture and other cruel, inhuman, or de-
grading treatment or punishment. The failure
of the state to act in due diligence leads to
a form of encouragement or de facto permis-
sion of those harmful practices1.
34 UN Committee Against Torture. General
Comment 2, Implementation of article 2 by
States Parties. CAT/C/GC/2/CRP.1/Rev.4.2007
The UN Committee against Torture has
applied this principle to states that have
failed to prevent and protect victims from
gender-based violence, such as rape, domes-
tic violence, female genital mutilation, and
trafficking1. A parallel can thus be drawn to
the obligation to ban the practice of female
genital mutilation which also takes place in a
context of profound discrimination. As stated
by the UN Special Rapporteur on Torture:
“Domestic laws permitting the practice contra-
vene States’ obligation to prohibit and prevent
torture and ill-treatment, as does States’ failure to
take measures to prevent and prosecute instances
of female genital mutilation by private persons.”
1
Children enjoy special protection. An
alarming number of minors are subjected
to conversion therapy; indeed, minors may
account for the majority of all cases35. The
UN Convention on the Rights of the Child
requires the best interests of the child to be
a primary consideration in all actions con-
cerning children, whether undertaken by
public or private social welfare institutions,
courts of law, administrative authorities, or
legislative bodies36. The Convention on the
Rights of the Child requires states to take all
measures to “protect the child from all forms
of physical or mental violence, injury or abuse,
neglect or negligent treatment, maltreatment or
exploitation, including sexual abuse, while in the
care of parent(s), legal guardian(s) or any other
person who has the care of the child.”
3
Con-
version therapy, which is rooted in profound
35 Mallory C, Brown TNT, & Conron KJ.
Conversion therapy and LGBT youth. Williams
Institute, UCLA School of Law. https://
williamsinstitute.law.ucla.edu/wp-content/
uploads/Conversion-Therapy-LGBT-Youth-
Jan-2018.pdf. Published January 2018.
36 United Nations. Convention on the rights of the
child. 20 November 1989. United Nations Treaty
Series. vol. 1577. Art. 3(1).
TORTURE Volume 30, Number 1, 2020
75
STATEMENTS
discrimination, lacks scientific and medical
validity, is ineffective, and is likely to cause
the minor significant or severe pain and suf-
fering, clearly violates these standards. When
a minor is subjected to conversion therapy,
in addition to amounting to torture or other
cruel, inhuman, or degrading treatment, it
may constitute a form of child abuse and
neglect.
Professional and Ethical Standards
Conversion therapy is inconsistent with the
fundamental ethical principles and profes-
sional duties of health professionals for the
following reasons:
1. It is clear that conversion therapy is a
form of cruel, inhuman, or degrading
treatment when it is conducted forcibly
on individuals or without their consent
and may amount to torture depending on
the circumstances, namely the severity of
physical and mental pain and suffering
inflicted. International standards of pro-
fessional ethics unequivocally prohibit
health professionals from participating in
or condoning any treatment or procedure
that may constitute cruel, inhuman, or
degrading treatment or torture37,38.
2. Variation in sexual orientation and gender
identity is not a disease or disorder. Health
professionals, therefore, have no role in
diagnosing it or treating it. The provision
37 World Medical Association. Declaration of Tokyo
- guidelines for physicians concerning torture
and other cruel, inhuman or degrading treatment
or punishment in relation to detention and
imprisonment. World Medical Assembly; 1975.
Rev. 2006.
38 United Nations. Body of principles for the
protection of all persons under any form of
detention or imprisonment. United Nations; Dec.
1988. A/RES/43/173.
of any intervention purporting to treat
something that is not a disease or disorder
is wholly unethical39. If adults voluntarily
seek out assistance in hope of changing
their sexual orientation, ethical profes-
sionals are advised to explain why they
don’t attempt this type of practice and not
to refer clients to someone who does40.
3. Conversion therapy is ineffective and
harmful. Health professionals must
abide by their core ethical principles
to act in the best interests of patients
(beneficence) and to “do no harm” (non-
maleficence)41. The likely harm of con-
version therapy cannot be outweighed by
any clinical benefits, as there are none.
Moreover, health professionals are pro-
hibited from offering treatments that
are recognised as ineffective or purport
to achieve unattainable results. Offering
conversion therapy thereby constitutes a
form of deception, false advertising, and
fraud42.
4. Ensur ing informed consent may be impos-
sible in most circumstances. As noted in
previous statements, examinations based
on profound discrimination may create
situations where a person is incapable of
39 World Psychiatric Association. WPA position
statement on gender identity and same-sex
orientation, attraction, and behaviours. World
Psychiatry. 2016;15(3):299–300.
40 American Counseling Association. Ethical
issues related to conversion or reparative
therapy. https://www.counseling.org/news/
updates/2013/01/16/ethical-issues-related-to-
conversion-or-reparative-therapy. Published 16
January 2013.
41 World Medical Association. Declaration of
Geneva. World Medical Assembly; 1948. Rev.
2017.
42 World Medical Association. International Code
of Medical Ethics. World Medical Assembly;
1949. Rev. 2006.
TORTURE Volume 30, Number 1, 2020
76
STATEMENTS
giving genuine consent43. This is likely
the case when conversion therapy is being
conducted based on the order of a public
authority, when the individual’s liberty
is restricted, or when the individual is
a minor coerced by family members or
others in a position of authority or trust.
In the case of conversion therapy,
informed consent would require that an
individual is informed about the prac-
tices that will be applied, as well as their
ineffectiveness, the likely physical and
psychological harm that will result, and
the inability to achieve the desired result.
The individual’s consent must be con-
sidered invalid if acquired without this
knowledge or as a result of false informa-
tion; and it should be considered suspect,
particularly in the case of minors.
5.
Conversion therapy creates an inher-
ently discriminatory environment. Even
when an individual wants the therapy,
the individual may be motivated by
self-hatred or a conflict between their
actual sexual orientation or gender
identity and the self-image that they
feel it is safe or acceptable to present
to themselves and others. It would be
counter therapeutic for the practitioner
to add to those internalised feelings.
Their efforts would be ineffective in
reducing the individual’s desires even
if the individual’s behaviour changes,
leaving the client with unexpressed feel-
ings that have the potential to be very
damaging
44
. Instead, any psychiatric or
43 Independent Forensic Expert Group. Statement
on Anal Examinations in Cases of Alleged
Homosexuality. Torture. 2016; 26(2):85-91.
Available at: https://irct.org/uploads/media/306a5
91c5f8207f6107f5c11e8c5c4fc.pdf.
44 British Psychological Society. Guidelines and
psychotherapeutic approaches to treat-
ment must not focus on the individual’s
sexual orientation or gender identity,
but on the conflicts that may arise
between their orientation, identity, and
religious, social, or internalised norms
and prejudices
45
.
Role of Health Professionals in Policing
and Punishing Sexual Orientation and
Gender Identity
The practice of conversion therapy runs con-
trary to respect for the dignity, humanity, and
rights of individuals, including to privacy,
self-determination, non-discrimination, and
to be free from torture and ill-treatment.
Most major medical and mental health
organisations have repudiated the practice of
conversion therapy. It continues, however, to
be widespread and practiced by health profes-
sionals and others due to pervasive discrim-
ination and societal bias against lesbian, gay,
bisexual, trans, and gender diverse individu-
als. This represents a challenge to individual
health professionals and medical and mental
health professional organisations.
Health professionals who are conduct-
ing conversion therapies are contributing to
a social, cultural, or state-sponsored system
of profound repression and stigmatisation
against their patients, targeted on the basis
of their sexual orientation and gender iden-
tity. Health professionals should understand
that by providing these treatments, they are
serving to perpetuate social customs and
literature review for psychologists working
therapeutically with sexual and gender minority
clients. February, 2012: 71-73.
45 World Medical Association. Statement on
Natural Variations of Human Sexuality. October,
2013.
TORTURE Volume 30, Number 1, 2020
77
STATEMENTS
norms that are in conflict with their ethical
obligations and respect for the rights and
dignity of individuals, and that, ultimately,
they may be facilitating or participating in
cruel, inhuman, or degrading treatment or
torture.
The WMA has condemned conversion
therapy as a violation of human rights and has
called for its practitioners to be denounced
and subject to sanctions and penalties
46
. It
has also called on national medical associa-
tions to “promote ethical conduct among phy-
sicians for the benet of their patients. Ethical
violations must be promptly corrected, and the
physicians guilty of ethical violations must be
disciplined and rehabilitated.”47
As more awareness is raised about the
issue of conversion therapy both globally
and nationally, national medical and mental
health associations should create accessible
mechanisms for the public to register com-
plaints against health professionals who offer
conversion therapy or who have harmed them
by performing this practice. Health profes-
sionals who conduct conversion therapies
violate the basic standards and ethics of our
profession and should be reported by their
colleagues to the appropriate authorities
48
.
National medical and mental health associ-
ations should encourage and support health
professionals in denouncing this practice and
reporting colleagues who practice it.
Recently, there has been a growing trend
to call for a ban on conversion therapy in
46 World Medical Association. Statement on
Natural Variations of Human Sexuality. October,
2013.
47 World Medical Association. Declaration of
Madrid on Professional Autonomy and Self-
Regulation. 2009.
48 World Medical Association. International Code
of Medical Ethics. World Medical Assembly;
1949. Rev. 2006.
many parts of the world, although few coun-
tries have done so yet
49
. National medical and
mental health associations should support
these legislative initiatives and the develop-
ment of programmes to support individuals
who have been harmed by the practice50.
Conclusion
Conversion therapy has no medical or sci-
entific validity. The practice is ineffective,
inherently repressive, and is likely to cause
individuals significant or severe physical and
mental pain and suffering with long-term
harmful effects. It is our opinion that con-
version therapy constitutes cruel, inhuman,
or degrading treatment when it is conducted
forcibly or without an individual’s consent
and may amount to torture depending on the
circumstances, namely the severity of physi-
cal and mental pain and suffering inflicted.
As a form of cruel, inhuman, or degrad-
ing treatment or torture, states have an obli-
gation to ensure that both public and private
actors are not directly committing, instigat-
ing, inciting, encouraging, acquiescing in or
otherwise participating or being complicit
in conversion therapy. States also have a re-
sponsibility to regulate all health and educa-
tion services, which may be promoting this
harmful practice.
Health professionals that offer conversion
therapy are violating the basic standards and
ethics of our profession. Health profession-
als should understand that by offering these
treatments, they are serving to perpetuate
49 End of a 'cure'? U.S. ban on gay conversion
therapy gains ground. Reuters. 13 June 2019.
https://www.reuters.com/article/us-usa-lgbt-
religion/end-of-a-cure-us-ban-on-gay-conversion-
therapy-gains-ground-idUSKCN1TE2AA.
50 American Psychiatric Association. Position
Statement on Conversion Therapy and LGBTQ
Patients. 2018.
TORTURE Volume 30, Number 1, 2020
78
STATEMENTS
social customs and norms that are in conflict
with respect for the rights and dignity of in-
dividuals; they are engaging in false advertis-
ing or fraud; and they may be facilitating and
participating in cruel, inhuman, or degrad-
ing treatment or torture. Where minors are
concerned, in addition to torture and other
cruel, inhuman, or degrading treatment, they
may be facilitating or perpetrating child abuse
and neglect.
Health professionals should refuse to
conduct conversion therapy and report their
colleagues who advertise, offer, or perform
them to the appropriate authorities. Na-
tional medical and mental health associa-
tions should take steps to hold practitioners
accountable and work with civil society and
government officials to pass laws that ban
conversion therapy.
TORTURE Volume 30, Number 1, 2020
79
LETTER TO THE EDITOR
The right to work, one of the fundamental human
rights, expresses the right of all individuals to
maintain a dignified life by having an income,
earned through work (UDHR, 1948). Following
the coup attempt on 15 July 2016, the Turkish
government declared a state of emergency on
20 July 2016. This lasted 730 days until 20 July
2018. During this period, 32 decrees were issued
by the Turkish government. With these decrees,
150,348 public officials including judges, pros-
ecutors, civil servants, teachers, bureaucrats,
medical doctors and academics were dismissed
without any investigation (Turkey Purge, 2019).
With regard to the group of forensic professional
experts, many have been dismissed following
decrees issued by the Turkish government.
It was found that 105 forensic experts and/
or forensic professionals were dismissed by gov-
ernment decrees. Nearly all of the dismissed
specialists were male (n =101, 96.04%). Nine
(8.57%) were doctors of medicine working in fo-
rensic medical sciences and 96 (91.43%) were fo-
rensic specialists. Thirty (14.25%) of these were
working at a higher educational institution and
75 (85.75%) were working at the Council of Fo-
rensic Medicine. Five (4.76%) of these cases were
professors and directors of an institute. Thirteen
(12.38%) were associate professors, 3 (2.85%)
were assistant professors, 54 (51.42%) were spe-
cialists, and 30 (14.25%) were assistants.
Protecting freedom and human rights in
various ways is essential to democracy. The
freedom of the press and civil society movements
was significantly suppressed by the Turkish gov-
ernment. Many professional groups, including
forensic specialists and medical doctors, have
an important role in preventing the abuse of
power. Following the coup attempt, many fo-
rensic experts were dismissed by the Turkish
government. The number of forensic experts dis-
missed in Turkey is higher than the sum of foren
-
sic experts found in many European countries.
Forensic services in Turkey are mainly pro-
vided by forensic institutions. There is also a
forensic medicine department in almost all
medical faculties in Turkey. According to official
data, there were nearly 600 forensics experts
in Turkey (The Society of Forensic Medi-
cine Specialists, personal communications,
July 15-19, 2019). When the number of dis
-
missed forensic experts is examined, it is seen
that approximately 20% have lost their jobs.
As in Continental Europe, an important func-
tion of forensic experts in Turkey is to identify
and prevent human rights violations. Foren-
sics experts should perform these tasks ob-
jectively according to international protocols
(Istanbul Protocol, The Minnesota Protocol,
etc.). The expulsion and detention of many fo-
rensic experts without investigation has led to
many undesirable effects, including the dis-
continuation of forensic services and intimida-
tion of other experts. However, the dismissal
of so many forensic experts is used to intimi-
date other professionals and prevent them from
*) Institute of Forensic and Traffic Medicine,
Heidelberg University, Heidelberg, Germany
Correspondence to: alper.keten@med-uni.
heidelberg.de
Evaluation of the dismissed forensic
medicine specialists and other forensic
professionals in Turkey
Alper Keten, MD*
https://doi.org/10.7146/torture.v30i1.117717
International Rehabilitation Council for Torture Victims. All rights reserved.
TORTURE Volume 30, Number 1, 2020
80
LETTER TO THE EDITOR
objectively reporting and investigating human
rights violations. In addition, it is difficult for fo-
rensics experts to exercise their profession freely
within the established legal practices in Turkey,
since they are actually prohibited from working
as independent experts. This situation is con-
troversial in terms of universal legal norms that
provide occupational safety (UDHR,1948).
Many international organisations have re-
ported on these human rights violations. Nils
Melzer, the United Nations Special Rapporteur
on Torture and other Cruel, Inhuman or De-
grading Treatment or Punishment, has noted an
increase in torture and maltreatment practices in
Turkey and has suggested, that these are carried
out by designated teams within the state’s secu-
rity services. According to his report, the Turkish
State has refused to comment on the allegations
(OCHCR, 2016). Furthermore, The Stockholm
Freedom Center reports that family members
of detainees are also under threat (2017). In
another report on the subject, the US-based
human rights organisation, Human Rights Watch
(HRW), provides further details on torture and
also alleges, that kidnappings by state forces are
also present (HRW, 2017).
Prof Dr. Sebnem Korur Fincanci, who is
a forensics expert and president of the Turkish
Human Rights Association, was sentenced to
prison and dismissed from her job as a university
lecturer after signing a so-called peace statement,
which urged an end to state-sponsored violence
in Turkey. She had decided to independently in-
vestigate the case of a detainee who allegedly died
from torture in detention (Cumhuriyet, 2018).
She found, that the official autopsy records
made no mention of torture, despite previous al-
legations by the detainee that he was subjected
to torture in detention, which raises questions
about forensics experts’ objectivity when carry-
ing out their duties.
The Turkish State also issued a decree that
permanently prevented persons dismissed, in
the aftermath of the attempted coup d’état and
the subsequent state of emergency from working
in civil service again. They are also often inten-
tionally prevented from completing the admin-
istrative and legal procedures that would allow
them to work privately and employees of public
administration are given the right to subjec-
tively refuse service to anyone without facing
any legal action. This leaves many highly qual-
ified forensic science and other experts unable
to find employment and support themselves
and their families.
The suppression or dismissal of forensic
experts or other medical professionals for po-
litical reasons can lead to serious human rights
issues. In order to prevent such issues, neces-
sary policies should be developed within legal
limits by the international community.
References
Gözaltında işkence sonucu ölen Gökhan öğretmen, 1.5 yıl
sonra ‘pardon’ denilerek görevine iade edildi. (2018,
February 28). Cumhuriyet. http://www.cumhuriyet.
com.tr/?aspxerrorpath=/haber/turkiye/935144/
Gozaltinda_iskence_sonucu_olen_Gokhan_
ogretmen__1.5_yil_sonra__pardon__denilerek_
gorevine_iade_edildi.html
OHCHR. (2016, December 2). OHCHR | Preliminary
observations and recommendations of the United
Nations Special Rapporteur on torture and other cruel,
inhuman and degrading treatment or punishment,
Mr. Nils Melzer on the Official visit to Turkey –
27 November to 2 December 2016. https://www.
ohchr.org/EN/NewsEvents/Pages/DisplayNews.
aspx?NewsID=20976&LangID=E
Police Tor ture and Abductions in Turkey. (2017, October
12). Human Rights Watch. https://www.hrw.org/
report/2017/10/12/custody/police-torture-and-
abductions-turkey
Stockholm Centre for Freedom (SCF). (2017).
Mass Torture and Ill-treatment in Turkey. https://
stockholmcf.org/wp-content/uploads/2017/06/Mass-
Torture-And-Ill-Treatment-In-Turkey_06.06.2017.
pdf
Turkey Purge | Monitoring human r ights abuses in Turkey’s
post-coup crackdown. (n.d.). https://turkeypurge.com/
UN General Assembly arts 23-24. (1948). “Universal
declaration of human rights” (217 [III] A). United
Nations. http://www.un.org/en/universaldeclaration-
human-rights/
TORTURE Volume 30, Number 1, 2020
81
IN MEMORIAM
Johan Lansen, a deeply valued colleague,
teacher, advisor, clinical supervisor and per-
sonal mentor for many, died at age 86 on
November 26, 2019 in his hometown of Am-
ersfoort in the Netherlands.
I first met Johan at a human rights con-
ference in Norway in 1990. His presentation
“Psychiatric Experience with perpetrators and
countertransference feelings in the therapist”
(Lansen, 1991) impressed me profoundly.
It was unusual at the time for a trauma and
human rights professional to talk about per-
petrators. Reflecting on the abyss, the dark
side of the human condition, was an import-
ant dimension of Johan’s professional life. His
contribution to the first book published by the
Berlin Center for the Treatment of Torture
Victims carried the title “What does it do to
us?” In this chapter he describes how care-
givers working with torture survivors can be
drawn into the client experience, and how the
client’s feelings of humiliation, anxiety, power-
lessness and worthlessness can be transmitted
to the therapist. Johan had faced this abyss as
a child survivor during the Nazi occupation of
the Netherlands.
During that first encounter, I sensed some
defense and distance, an unspoken message
from him: “Can one trust this young German?”
So it was all the more surprising that we even-
tually became confidantes and friends. How
did this happen?
As head physician of the Sinai Center, a
Jewish psychiatric hospital for Holocaust sur-
vivors in Amersfoort, he was invited in 1991 to
assist the foundation of the psychosocial coun-
seling center for Nazi Victims ESRA, located
in the Berlin Jewish Hospital. During his trips
to ESRA1 he also visited our newly-founded
Center for the Treatment of Torture Victims.
Over time he came to appreciate our work and
1 More information on ESRA can be found (in
German): https://www.hagalil.com/esra/esra-3.
htm
Johan Lansen 1933 – 2019
Christian Pross*
*) Christian Pross, MD
Center UEBERLEBEN, Germany
www.christian-pross.de
Johan Lansen, painting by Anne Pross, 2013.
https://doi.org/10.7146/torture.v30i1.119738
International Rehabilitation Council for Torture Victims. All rights reserved.
TORTURE Volume 30, Number 1, 2020
82
IN MEMORIAM
the “young German” who was its director. We
hired him as our first clinical case-supervisor.
On his first visit to Berlin he only stayed a
few days, on the next one a little longer, and
so forth. He gradually managed to overcome
his reservations and distrust of the country of
his persecutors. After leaving the Sinai Center
he shifted a large part of his work to Germany,
where trauma therapy was unknown territory
in the early 1990s. As a result, Johan was much
in demand as an expert, consultant and su-
pervisor for a number of German treatment
centers.
These centers and I personally, are deeply
grateful and enormously indebted to Johan.
He was our anchor, guiding us through the
difficulties of our founding period, seeing us
on our way to professionalization and co-au-
thoring some of our key publications.
I quote from the prologue of my book
“Wounded Healers” (Pross, 2009) in which I
portrayed Johan under the pseudonym: “Jens”.
Whenever an institution is on fire, it
is Jens who will be called for help. At the
source of the fire, where the ceiling is about
to tumble down, at the hottest and most
dangerous spot – that is where Jens sits.
People run out of meetings crying, slam-
ming doors, ranting and raving, insulting
each other. Jens cannot be taken aback,
does not lose control. He does not say
much, he gets up and drafts a scheme on
the flipchart. It is not so much what Jens
says. It is how Jens says it. It is his appear-
ance, his charisma. He sits amid this mine-
field with the simple message: “As long as
I sit here, no bomb will go off.”
Jens conveys an aura of maturity, be-
nevolence, heartiness and dignity but also
of a certain strictness. He stands above
things - serene, with a great sense of humor
and a bit of rascality, as if saying: “Well this
is just how it goes, when human beings are
together…” Everybody in the room feels
that Jens is a man who has been confronted
with much more severe and threatening sit-
uations in his life, who knows how to deal
with that and what can happen to people
working with survivors. Jens is a modest,
rather inconspicuous man who does not
make a big fuss about himself. One can
imagine him as a coxswain on a fishing
boat in the open sea. Such deep sea fish-
ermen are often silent people who for days
stoically endure a heaving deck, hold the
rudder and ship the cutter safely back to
the port.
Several times a year Johan came to Berlin
accompanied by his faithful companion Harrie
van Dooren. I went to see him as often as pos-
sible in Amersfoort. Eventually, Johan would
invite me for an expert talk, where he presided
amid his huge library. Here I was his student
and he was my teacher.
One of Johan’s achievements is the co-foun-
dation of the training institute for supervi-
sion in the Berlin Center for the Treatment
of Torture victims in 2006. Johan together
with his colleague, Ton Haans from Centrum
45, the Dutch trauma center for survivors of
war and persecution, trained a dozen care-
givers in Berlin – including me – to become
clinical supervisors. Since then around 130
health professionals have been trained at this
institute in the “Lansen/Haans” trauma-spe-
cific supervision technique. These training
courses continue to this day, directed by the
psychologist and supervisor Nora Balke at the
Center Ueberleben (former Treatment Center
for Torture Victims), and include instruction
abroad in Turkey, Iraq, Georgia and Ukraine.
Johan served as a consultant, trainer and
supervisor in many countries in Africa, the
Middle East, Eastern and South Eastern
TORTURE Volume 30, Number 1, 2020
83
IN MEMORIAM
Europe. He worked for the International Re-
habilitation Council for Torture Victims, the
War Trauma Foundation of the Netherlands
and the Editorial Board of Intervention – In-
ternational Journal of Mental Health, Psy-
chosocial Work and Counselling in Areas of
Armed Conflict. His publications on trauma
therapy, vicarious traumatization and super-
vision have served as a guide for caregivers
worldwide.
For many of us Johan was a role model
and a father figure. We have learned so im-
measurably much from him and will always
carry him in our hearts.
References
Lansen, J. (1991). Psychiatric experience with
perpetrators and countertransference feelings
in the therapist. Journal of Medical Ethics, 17
(Suppl), 55–57. https://doi.org/10.1136/jme.17.
suppl.55
Pross, C. (2009). Verletzte Helfer (pp.18-19). Klett-
Cotta Verlag.
TORTURE Volume 30, Number 1, 2020
84
IN MEMORIAM
Former Medical Director of Sinai Centrum, the
Jewish Community Mental Health Services in
The Netherlands, PO Box 66, 3800 AB Amers-
foort, The Netherlands and Johannes Wier Foun-
dation for Human Rights and Health Care, The
Netherlands
Therapeutic work on man-made disaster
victims is work which leaves no one un-
touched. It is the kind of work that, in many
ways, frequently involves therapists person-
ally. It may also be the cause of vehement
disagreements about treatments, resulting in
fights and splits in treatment teams. The work
may end tragically.
I think this also applies to treatment
of that other
category of people involved
in man-made disaster, the perpetrators.
However, we know much less about this.
Danieli (1984) made a study of the counter-
transference
feelings of about 60 Holocaust
survivors’ therapists. She came up with,
among others, the following
themes: guilt,
rage, dread and horror, grief and
mourning,
shame, inability to contain intense emotions,
and utilization of defenses such as numbing,
denial and avoidance.
It is remarkable to find in her description
the way in which therapists are inclined, with
regard to Holocaust
survivors, to act as their
‘parent(s)’ or their ‘child’.
Acting the part of the parent, in terms
of
Transactional Analysis, the Negative Nur-
turing
Parent, the therapist especially wants
to prevent, out of
fear and guilt, the patients
from suffering again. The
therapist may also
move into the position of the
Negative Con-
trolling Parent when he/she gets
infuriated
by the patient because of his/her very obsti-
nate complaints, or because the patient attri-
butes
the part of the persecutor (the Nazis)
to the therapist.
In terms of Transactional Analysis one
may also watch the therapist taking up the
Child-part. This is expressed in many ways
in the above-mentioned thematical row
and the reason behind this is that the ther-
apist wants to behave like a good child, with
respect to the parents who have already suf-
fered very much and who have to be spared
by all means. Furthermore, the therapist is
a fearful child, because he cannot cope with
these horrible stories. The therapist is also
ashamed because he has not experienced
anything of this suffering himself. Moreover,
the therapist may act like a strong child that
Psychiatric experience with perpetrators
and countertransference feelings in the
therapist1
J. Lansen MD
1) Reprinted from: Lansen, J. (1991).
Psychiatric experience with perpetrators and
countertransference feelings in the therapist.
Journal of Medical Ethics, 17(Suppl), 55–57. doi:
https:/doi.org/10.1136/jme.17.suppl.55
© 1991 BMJ Publishing Group Ltd & Institute
of Medical Ethics. All rights reserved.
https://doi.org/10.7146/torture.v30i1.118585
International Rehabilitation Council for Torture Victims. All rights reserved.
TORTURE Volume 30, Number 1, 2020
85
IN MEMORIAM
would preferably quickly save its parents by
means of its power ( nd impatience!). Even-
tually, the therapist may come to look at
these helpless, unsavable parents, as being
quite tiresome. Also the danger exists that a
sadistic child will look for sensational stories
that may offer extra suspense: the ‘child’ in
the therapist will continue to ask exagger-
ated and needless questions about persecu-
tion and war stories.
The psychological effects of working
with victims are described in a different way
by McCann and Pearlman (1990). The sig-
nificance of their account is that because
of the material - the patient’s state of being
traumatized - the therapist risks the danger
of becoming traumatized himself. Therapists
themselves get nightmares, fearful thoughts,
intrusive images and become suspicious
towards their fellowmen. These authors
think the nature of the material itself is dan-
gerous to several basic securities that the
therapist, as a human being, has concern-
ing himself and the world. Under the influ-
ence of the powerlessness of the patients the
idea arises that having a grip on life is an il-
lusion. In addition, the therapist working
with victims may become estranged from
his family, his friends and his colleagues,
because he is exposed to tales of horror and
confronted with a cruel reality.
Perpetrators of violence against their
fellowmen are numerous in our world. At
first sight, it is remarkable that we do not
know much about the psychological effect
that treating dangerous criminals, torturers
and war criminals of major or minor caliber
has upon a therapist. Part of the explana-
tion may be that treatment is often restricted
to somatic treatment by a general practi-
tioner, a jail practitioner or an internist; as
far as psychological or social guidance is
concerned, it is frequently of a psychotech-
nical or psychosocial nature. From forensic
psychiatry we know something of the psy-
chological effect on therapists treating per-
petrators. Nevertheless, one might expect
more literature on the topic, besides that to
do with the treatment method and psycho-
dynamic observations. Treating those who
commit incest will, for example, indubitably
provoke several reactions from the therapist.
The following may be looked upon as a
series of impressions gained over the last 25
years or so. These are mainly related to psy-
chiatric examinations, psychiatric-medical,
and social psychiatric contacts, as well as
psychotherapeutic treatment. Being a con-
sultant in the field of psychosomatic dis-
eases, and, later on, working for the Jewish
community and for victims of World War II, I
came into contact with many former victms,
but also with some ex collaborators from
World War II. Some had committed quite
severe crimes for which they had been pun-
ished. In addition, I got in touch with Re-
sistance people who misbehaved after the
war as collaborators’ camp guards, with
Dutch ex-soldiers from the war between
our country and Indonesia who took part in
severe repressive actions against the Indone-
sian people, with several Jewish people who
were able to take revenge after their libera-
tion from the concentration camp. All in all,
I reached about 50 male perpetrators, amo
ngst whom there were at least 12 with whom
I had a longstanding and intensive contact.
It was striking, but not contradictory
to information amassed by others, that in
hardly any of the cases was moral need
brought up; at any rate, it was not noticeable
in the first instance. As Lifton (1984, 1986)
remarks about the Nazi doctors, (and as was
also observed earlier by a journalistic inves-
tigation in Holland on SS men [Armando
and Sleutelaar (1978)]), it is the common-
TORTURE Volume 30, Number 1, 2020
86
IN MEMORIAM
ness, the triviality, almost the banality, of
many of these people which strikes one. In
a way, these collaborators seem to feel like
the losers in a football match who believe
they have only lost because of bad luck or
circumstances beyond their control. They
felt as if they had been on the right side and
had really done a good job.
In this article the point at issue is not a
psychological typology of the collaborator,
the murderer, or the torturer. My primary
issue is the feelings they have as they work
with therapists, the feelings which determine
and restrict their freedom of action and of
treatment. Repeatedly I was asked why I
treated this category of people (there is no
formal obligation in my case). My answer is
that I actually offered some of them further
contact out of a kind of benevolent curios-
ity, when I noticed they were not unwill-
ing to talk. In case of consultations with
people who came, hesitatingly motivated,
of their own accord (for instance, people
who went to the Indies, some ex-Resistance
people who were transformed from pris-
oner into persecutor, the few Jewish per-
petrators, some doctors too), I was more
likely to offer further contact. However, I did
not force myself upon these people; rather I
allowed the contact to proceed almost from
session to session with the possibility on
their behalf to stop at any moment, unless
we had decided on regular treatment after
going through some kind of initial discus-
sion. Still, even then continuity remained
less guaranteed than is the case with ‘regular’
therapy. Notwithstanding good contact, the
feeling that ‘this session might also be the
last one’, always prevailed. This element
came from both sides, from the therapist’s
as well as from the patient’s.
The most positive approach I could
manage in the case of the perpetrators was
usually, initially no more than that of inter-
ested curiosity. I was repeatedly assured by
them that they did not sense any condemna-
tion or fear within me, nor anything resem-
bling the cold, objective scientist, but rather
they saw me more as being something like a
Maigret who interestedly looks for the answer
to how something fits into the image he forms
of a person.
Many of these people show - and this is
common knowledge - a strong sense of dis-
avowal, of denial.
They spirited away behind thick walls
those mental images and memories, those
thoughts which would, if allowed to pervade
their humanity, be experienced as a very
tragic failure of their existence. They re-
treated into a kind of superiority: ‘I was
right, even if what I did then is being looked
upon as wrong now’. But sleeplessness, de-
pressive feelings overwhelming one unex-
pectedly, physical complaints for which no
somatic cause can be found, excessive drink-
ing, defective, poor - and time and again
failing - relationships: this too, often was
their destiny.
Against a background of what I would
like to call therapeutic, obliging skepticism,
treatment appears, however, to be possible
after all. People let themselves go, people
talked, people seemed to know very well
what they did at that time, people under-
went confrontations with their denial-mech-
anisms.
Whenever, once in a while, they asked
me whether I thought them bad, or whether
I thought they should do penance, I was
perfectly straightforward: ‘I don’t approve
of those deeds. I do not say I am essentially
better than you are. You may not have had
complete freedom of choice, but you should
look into yourself and make sure whether
TORTURE Volume 30, Number 1, 2020
87
IN MEMORIAM
you are being honest about the (im)pos-
sibilities’.
It is of major importance that the thera-
pist dares to account for the personal sym-
pathetic feelings that may occur towards the
person facing him. One may enter into his
world, into the limitedness of his choice, into
the miscarriage of his views on man, into the
psychological rightness of the then man who
was very wrong ethically. At the same time
it is crucially important to that man not to
concur in some kind of assumed solidarity-
in that case one would come to be an accom-
plice. On the one hand, we should judge these
people, identifying ourselves with them as
much as possible. On the other hand, we have
to keep our distance and should not join in
the ‘old-chap’ game. In order to relieve their
own tension, to avoid exposing nasty feelings
of self-reproach and fear, they try to get the
therapist to go along with them. This sym-
pathy may occur more easily as the therapist
becomes more conscious of his own feelings
of aggression, of his own sadism, of his own
destructive urges. In every one of us hides a
minor fascist that, under the ‘right’ circum-
stances, might turn into a major fascist. The
client’s intuition often leads him to know
exactly how the therapist wrestles with his
own ‘bad’ side. The position from which the
therapist threatens to slide into a feeling of
dislike towards the patient who confronts him
with his own shady side and his own unsolved
problem, cannot be an easy one. And this gets
me to the thematic as Danieli describes them.
The therapist’s feelings of guilt, rage, horror,
the threat of being carried away by intense
emotions, by defense mechanisms such as
denial and avoidance: they can all occur.
With perpetrators we do not usually ex-
perience the same kind of appeal for help
as with the victims; our fantasies of being
able to save someone are less stimulated
by the perpetrators than the victims. On
the contrary, we are rather keen to play the
part of the prosecutor. We clearly feel better
and superior and we get angry when the
client does not regard us any differently
from himself.
We saw the way in which countertrans-
ference feelings in the treatment of victims
may be arranged in order of Transactional
Analysis’s views. This may happen here as
well. We occupy the position of the Nur-
turing Parent less often, but all the more
often we threaten to end up as the Nega-
tive Controlling Parent. We allow ourselves
to be guided into this position by feelings
that satisfy us because they confirm our
notion of being better than the perpetrators
are (apparently we need this to protect us
against our own evil), our notion of being in
the right facing these persistent attempts at
self-justification on the part of the patient
as a result of the patient’s self-deception.
And sometimes we feel like a frightened
child, unable to cope with these stories, or
a child looking for sensation, or a child who
feels trapped.
The material that is introduced during
the treatment of perpetrators is shocking:
the therapist is confronted with the world
of evil. In a way he is tempted to become
disloyal towards his belief that, in princi-
ple, there is a significant human existence
in which human dignity and values prevail,
and that it is useful to aim at helping es-
tablish such a world, if only in a very small
way, by treating perpetrators of torture. This
may turn the therapist into a somber man:
your partner, your children and your col-
leagues all notice that for quite a long time
after treating perpetrators you do not spon-
taneously join in the ordinary, nice things
anymore. Estrangement threatens to take
place. Treatment themes sometimes preoc-
TORTURE Volume 30, Number 1, 2020
88
IN MEMORIAM
cupy the world of your thoughts. A distur-
bance of the inner, psychic balance threatens
to occur. Basically this is no different from
McCann and Pearlman’s account of the
dangerousness of the material captured
within the victim’s experiences.
It will be obvious that in this context
psychotherapy or, when there is not any
mention of long-standing intensive psycho-
therapy, at any case working with a psycho-
therapeutic attitude concerning psychiatric
and psychological research and advice, is a
risky profession. With respect to the profes-
sion, as Kohut says (1976), a connection
between art and psychotherapy is indispens
-
able. The profession demands a certain kind
of childlike openness to new experiences
by the grace of a (temporary) lapse of psy-
chological buffers both inside and outside.
Some kind of ‘lying openly’ is required. Bion
(Grinberg, Sor, & Bianchedi, 1974) gave
a function analysis of the psychotherapist
working with (difficult) patients’ problems.
He uses the notion ‘to contain’. The thera-
pist has to be able to contain, to absorb, but
also to restrict and restrain; the patient de-
posits the overwhelming emotional excite-
ment adherent to his problems within the
therapist. Winnicot (1965, 1974) uses the
concept ‘holding environment’ with respect
to the therapist’s position. The therapist has
to be capable of enduring the flow of feeling,
excitement, mourning and pain. He must
innerly transform these and return them di-
gestibly to the patient.
It is common knowledge that it is im-
possible for patients in treatment- victims
as well as perpetrators - to get far beyond
the therapist’s stage. Therefore, the thera-
pist has to expand and re-organize his inner
world. Furthermore, I can only briefly indi-
cate the importance for therapists treating
victims and perpetrators of trauma, partic-
ularly man-made disaster, to protect them-
selves and at the same time offer optimum
treatment conditions, by taking psycho-hy-
gienic precautions in carrying on their pro-
fession. I mention in this connection the
importance of good, personal therapy and
of good supervision and regular case-discus-
sions with colleagues during which the ther-
apist’s own feelings may also be presented
for discussion. And eventually there should
be professional consideration with respect to
the ethical aspects of our functioning.
References
Armando, H. S. (1978). De SSers. De Bezige Bij.
Danieli Y. (1984). Psychotherapists’ participation in
the conspiracy of silence about the Holocaust.
Psychoanalytic Psychology; 1(1),: 23-42. https://
doi.org/10.1037/0736-9735.1.1.23
Grinberg, L., Sor, D., & Bianchedi, E. T. de. (1975).
Introduction to the work of Bion. Clunie Press.
Kohut H.(1978).Childhood experience and creative
imagination. In: Ornstein PH, ed. The search for
the self, (vol 1). International University Press.
Lifton, R. J. (1984). Medicalized killing in
Auschwitz. In S. A. Luel & P. Marcus (Eds.),
Psychoanalytic reections on the Holocaust: Selected
essays. Holocaust Awareness Institute, Centre
for Judaic Studies, University of Denver and the
Ktav Publishing House.
McCann, I. L., & Pearlman, L. A. (1990). Vicarious
traumatization: A framework for understanding
the psychological effects of working with
victims. Journal of Traumatic Stress, 3(1), 131–
149. https://doi.org/10.1007/BF00975140
Winnicot, D. W. (1965).The maturational processes
and the facilitating environment. Hogarth Press.
Winnicot, D. W. (1974). The use of an object
and relating through identifications. In D. W.
Winnicot (Ed.), Playing and reality (pp. 101–
111). Penguin Books.
TORTURE Volume 30, Number 1, 2020
89
CALL FOR PAPERS
Call for papers. Physiotherapy for torture
survivors: Is there evidence of its utility in
in torture rehabilitation?
Pau Pérez Sales - Editor-in-Chief, Torture Journal
Guest Editor: Eric Weerts - Senior Consultant, Handicap International
Background
Physiotherapy, whilst a classical domain in torture rehabilitation since the 1980s, has since
been subject to a gradual incline in scrutiny. Although some studies suggest positive out-
comes, especially in the framework of combined treatment packages, there is a dearth of
both meta-analyses and reviews that support the claim that physiotherapy per se signifi-
cantly contributes to the overall results of an intervention with survivors of torture.
Some authors suggest that physiotherapy should be part of more holistic Body Aware-
ness Therapy or Narrative Sensorimotor Therapies, thus integrated with psychological ther-
apies. Others suggest that its main field of application is to treat chronic pain in complex
cases, although results appear unclear and are subject to debate. Similarly, some authors
suggest that excessive psychologisation of pain might hinder the fact that many patients
experience physical pain from physical torture that requires both proper medical and trau-
matological assessment and treatment. They argue against lending excessive weight to psy-
chosomatic theories.
The scarce research available suggest that the best results are obtained through a medical
and traumatological in-depth assessment of pain in addition to therapies in which physi-
cal exercises and psychological therapy are integrated. Such therapy and physical exercises
should be structured to focus on mobility or pain whilst working simultaneously with the
memories, emotions and physical consequences of the situations that caused the pain, in-
cluding, but not limited to, the way in which it is experienced in the body, the relationship
between pain and torture and the ways this can be expressed when under pressure. There
are a lack of studies however contrasting different approaches to this idea.
Call for papers
Torture Journal encourages authors to submit papers with a psychological, medical or legal
orientation, particularly those that are interdisciplinary with other fields of knowledge. We
welcome papers on the following:
a. Reviews, meta-analysis or analytical reflections on models of work.
b. Evidentiary studies on the efficacy of physiotherapy in the work with torture survivors
and victims of sexual violence.
c. Selection of patients and programmes – Short-term versus long-term physiotherapy.
Minimum interventions in conflict areas.
d. Coordination with primary care, trauma departments and pain units.
TORTURE Volume 30, Number 1, 2020
90
CALL FOR PAPERS
e. Measuring pain in multicultural complex environments. Concepts and measures of pain
and suffering.
f. Monitoring and measurement tools, beyond pain management. Functional and well-
being, psychosocial and mental health measures.
g. Models integrating physiotherapy and psychological processes feasible in low- and middle-
income countries.
h. Avoiding dependency with the physiotherapist: models fostering self-sufficiency and
promoting resilience in patients.
i. Experiences in group work.
j.
Models and evidence in somatosensory therapies.
Added value for relevant research papers:
• Papers that try to isolate the effect of physiotherapy from other elements in a global package
of care. Papers that show effects that can reasonably be attributed to physiotherapy.
• Papers that include outcome measures besides qualitative and satisfaction measures.
• Sample sizes that allow for meaningful conclusions with a recommendation of 30 cases as
a minimum when conducting statistical analysis.
Deadline for submissions
31st August 2020.
For more information
Contact Editor-in-chief (pauperez@runbox.com) and Guest-Editor (e.weerts@hi.org) if you
wish to explore the suitability of a paper to the Special Section.
Submission guidelines and links
•
To make a submission, navigate here: https://tidsskrift.dk/torture-journal/about/submissions
•
Author guidelines can be found here: https://irct.org/uploads/media/2eefc4b785f87c
7c3028a1c59ccd06ed.pdf
• Read more about the Torture Journal here: https://irct.org/global-resources/torture-journal
For general submission guidelines, please see the Torture Journal website (https://tidsskrift.
dk/index.php/torture-journal/index). Papers will be selected on their relevance to the field,
applicability, methodological rigor, and level of innovation.
About the Torture Journal
Please go to https://tidsskrift.dk/torture-journal - a site devoted to Torture Journal readers
and contributors – to access the latest and archived issues.
TORTURE Volume 30, Number 1, 2020
91
CALL FOR PAPERS
Call for papers. Continuous Traumatic
Stress (CTS): An essential paradigm for un-
derstanding the experience and rehabilita-
tion of torture survivors, or an unnecessary
distraction?
Pau Pérez-Sales - Editor-in-Chief, Torture Journal
Guest Editor: Craig Higson-Smith - Director of Research, The Center for
Victims of Torture (CVT), USA
Background
Conceptualisations of traumatic stress that consider traumatic exposure that occurred exclu-
sively in the past may be of limited use when applied to torture survivors who continue to live in
real danger. Such danger might arise in many ways, including from continued surveillance and
intimidation by agents of authoritarian regimes, enduring conditions of war, or xenophobic vio-
lence aimed at refugees and asylum seekers targeting torture survivors living in exile. It was the
recognition of the limitation of concepts like posttraumatic stress disorder (PTSD) and complex
PTSD that led a group of mental health practitioners in apartheid-era South Africa to coin the
term continuous traumatic stress (CTS), which emphasised the challenges of coming to terms
with past traumatic events whilst still enduring the threat of current or future harm. Simultane-
ously, practitioners in Chile and El Salvador were exploring related concepts. More recently, a
special edition of Peace and Conict, The Journal of Peace Psychology made progress in this field of
research, examining healthy and pathological responses to continuous threat, as well as interven-
tion approaches that explicitly address contexts of ongoing violence.
Regardless of the intuitive appeal of theoretical constructs like CTS, empirical support is scarce,
and the posttraumatic stress paradigm remains dominant in scientific writing about torture. The
question arises: Does the construct of continuous traumatic stress meaningfully add to practitioners’ under-
standing of the experience of torture and support more effective rehabilitation approaches, or is it an unnec-
essary distraction that takes away from the core issue of coming to terms with past traumatic experiences?
Objective
To gather and disseminate scientific perspectives on the utility of continuous traumatic stress
and related constructs to understand the experiences and rehabilitation needs of torture sur-
vivors globally.
Call for papers
Torture Journal encourages authors to submit papers with a psychological, medical or legal ori-
entation, particularly those that are interdisciplinary with other fields of knowledge. We welcome
papers on the following:
TORTURE Volume 30, Number 1, 2020
92
CALL FOR PAPERS
a. Empirical evidence documenting torture survivors’ experience of, and response to, ongoing
threat and danger in different contexts;
b. Exploration of the links between ongoing threat, continuous traumatic stress and the
fundamental rights of torture survivors and refugees;
c. Approaches to the forensic documentation of continuous traumatic stress in torture sur vivors;
d. Discussion of the role of continuous traumatic stress in transitional justice and peace-
building interventions involving torture survivors;
e. Conceptualisations of healthy and pathological responses to ongoing threat in torture
survivors;
f. Evidence linking ongoing threat and danger to torture survivors’ needs and rehabilitation
outcomes;
g. Approaches to assessment of safety, threat and continuous traumatic stress in torture sur vivors;
h.
Clinical approaches to working with torture survivors under conditions of ongoing threat.
Deadline for submissions
30th September 2020
For more information
Contact Pau Pérez-Sales, Editor in Chief (pauperez@runbox.com) or Chris Dominey, Editorial
Assistant (cdo@irct.org).
For more general enquiries, please write to publications@irct.org
Submission guidelines and links
• To make a submission, navigate here: https://tidsskrift.dk/torture-journal/about/submissions
•
Author guidelines can be found here: https://irct.org/uploads/media/2eefc4b785f87c
7c3028a1c59ccd06ed.pdf
• Read more about the Torture Journal here: https://irct.org/global-resources/torture-journal
For general submission guidelines, please see the Torture Journal website (https://tidsskrift.dk/
index.php/torture-journal/index). Papers will be selected on their relevance to the field, appli-
cability, methodological rigor, and level of innovation.
About the Torture Journal
Please go to https://tidsskrift.dk/torture-journal - a site devoted to Torture Journal readers and
contributors – to access the latest and archived issues.
References
Martín-Baró, I. (1989). Political violence and war as causes of psychosocial trauma in El Salvador. International
Journal of Mental Health, 18(1), 3–20. https://dx.doi.org/10.1080/00207411.1989.11449115
Stevens, G., Eagle, G., Kaminer, D., & Higson-Smith, C. (2013). Continuous traumatic stress: Conceptual
conversations in contexts of global conflict, violence and trauma. Peace & Conict: Journal of Peace
Psychology, 19(2), 75-84. http://dx.doi.org/10.1037/a0032484
Straker, G. & The Sanctuaries Treatment Team. (1987). The continuous traumatic stress syndrome: The single
therapeutic interview. Psychology in Society, 8, 48–78.
How to support
the Torture Journal
Help us to continue keeping the
Torture Journal open access and freely
sharing knowledge by donating to
the IRCT and subscribing. You can
donate online at https://irct.org/
Alternative methods are also detailed
below.
By credit card
Please visit www.irct.org to make a donation
using a credit card. All transactions are
guaranteed safe and secure using the latest
encryption to protect your personal
information.
By bank transfer
Danske Bank
Holmens Kanal Branch
Holmens Kanal 2
1090 Copenhagen K
Denmark
SWIFT code: DABADKKK
Danish Kroner (DKK) account
Registration No. 4183
Account No. 4310-821152
IBAN DK90 3000 4310 8211 52
Euros (EUR) account
Registration No. 4183
Account No. 3001-957171
IBAN DK69 3000 3001 9571 71
U.S. Dollars (USD) account
Registration No. 4183
Account No. 4310-005029
IBAN DK18 3000 4310 0050 29
The Torture Journal is a scientific journal
that provides an interdisciplinary
forum for the exchange of original
research and systematic reviews by
professionals concerned with the
biomedical, psychological and social
interface of torture and the rehabilitation
of its survivors. It is fully Open Access
online, but donations are encouraged to
ensure the journal can reach those who
need it (www.irct.org). Expressions of
interest in the submission of manuscripts
or involvement as a peer reviewer are
always welcome.
The Torture Journal is published by the
International Rehabilitation Council for
Torture Victims which is an independent,
international organisation that promotes
and supports the rehabilitation of torture
victims and the prevention of torture
through its over 150 member centres around
the world. The objective of the organisation
is to support and promote the provision of
specialised treatment and rehabilitation
services for victims of torture.
Subscription:
Write to publications@irct.org to receive an email when a new issue is published or for
a printed version (stipulating your profession and address).
With the generous support of
Individual donations
from readers ISSN 1018-8185
COVID-19 and Torture
Internet and Communications as elements
for CIDT and Torture. Initial reflections in an
unexplored field
SCIENTIFIC ARTICLE: The complex care of a
torture survivor in the United States: The
case of “Joshua”
SHORT SCIENTIFIC ARTICLES: “Parrilla
urethra”: A sequalae of electric shock
torture to genitals in men. A 40 case series
in Kashmir (India)
Medical examination of detainees in
Catalonia, Spain, carried out in the presence
of police officers
STATEMENT: Statement on Conversion
Therapy
LETTER TO THE EDITOR: Evaluation of the
Dismissed Forensic Medicine Specialists and
Other Forensic Professionals in Turkey
IN MEMORIAM: Johan Lansen 1933 – 2019
Psychiatric experience with perpetrators
and countertransference feelings in the
therapist
CALL FOR PAPERS: Physiotherapy for Torture
survivors: Is there evidence of its utility in
in torture rehabilitation?
Continuous Traumatic Stress (CTS): An
essential paradigm for understanding the
experience and rehabilitation of torture
survivors, or an unnecessary distraction?
