THE WOUNDS AND SCARS OF TORTURE - Frank Arnold

Senior Clinical Assessor, Medical Justice Network

Every year, several thousand men, women and children who have been tortured consult nurses and doctors in the UK. Almost all are refugees or asylum seekers. On average, a GP practice is likely to have one such patient per 1000 people in their care.

Most practitioners understandably find them difficult to help. They are usually inhibited from talking about their experiences, often have little English, far more organic pathology than is common for their age, and complex psychological and social problems. Despite this many torture survivors remarkably resourceful, intelligent and lucky, and were, by the standards of their homelands, relatively well to do. They have to have been all these things in order to survive, escape and get here. That makes working with them a privilege. But it is also difficult and painful.

Reasons for making a diagnosis of torture?

Under the Geneva convention, asylum seekers who have a ‘well founded fear’ of cruel or inhumane treatment on return to their country of origin should be granted leave to remain in a host country. Evidence that the person has previously so suffered (usually as a medico-legal report) can strongly support a claim for ‘leave to remain’. Such reports usually assess the likelihood that the person’s lesions (characteristic scars and burns and/or psychological injuries) are attributable to the causes cited by the victim, according to standard definitions (see box 1).

Torture survivors are prone to post-traumatic stress disorder, panic attacks and depression. Differentiating between physical and psychological causes of presentations can be difficult. The recognition of a history of torture can be facilitate management of perplexing symptoms. Continuing detention of torture survivors can cause severe harm, through retraumatisation.¹

Torture can cause specific physical ailments which can be ameliorated by treatment. It is a duty upon every doctor to report evidence of torture. This can be important in conflict resolution through truth and reconciliation, though mechanisms for doing so are often lacking.

Box 1: Istanbul Protocol: Criteria for the attribution of lesions:⁵

1. Not consistent: the lesion could not have been caused by the trauma described;
2. Consistent with: the lesion could have been caused by the trauma described, but it is non-specific and there are many other possible causes;
3. Highly consistent: the lesion could have been caused by the trauma described, and there are few other possible causes;
4. Typical of: this is an appearance that is usually found with this type of trauma, but there are other possible causes;
5. Diagnostic of: this appearance could not have been caused in any way other than that described.

'Ultimately, it is the overall evaluation of all lesions and not the consistency of each lesion with a particular form of torture that is important in assessing the torture story.'

Physical evidence of torture:

Some conditions are so closely associated with torture and so rarely caused in any other way that they are worth noting in any patient. A partial list is given in box 2.

Box 2: Common stigmata of torture:

• Cigarette burns
• Foot changes due to falaka
• Wide laceration scars without suture marks
• Bullet wounds (usually low velocity)
• Chemical and flame burns
• Electrical burns (hard to identify especially if to genitals)
• Other genital injuries
• Post-inflammatory hyper-pigmentation
• Neurological sequellae of significant head injury
• Rape (bite marks, anal fissure, STDs - vaginal scarring in < 10% of cases)
• Psychological injuries - depression, panic attacks, post-traumatic stress disorder

Some of the commoner and more definitive lesions encountered in the UK (usually after a delay of months or years) include:

Cigarette burns are typically circular or ovoid and approximately 0.6-1.2 cm in diameter. They have a dark periphery and where scarring is more intense, a pale centre. Only splattered metal droplets (in metal workers) can readily be confused with them.2 When a long burning tip is applied tangentially to the skin, elongated scars can occur; burns inflicted by rubbing out the cigarette over an area, can cause mottling. Hypertrophic or keloid scarring can occur but are unusual.

Falaka or falanga is repeated and forceful beating on the soles of the feet usually with a blunt object. It causes swelling, lasting for days or weeks, and is followed by persistent pain on walking. The subdermal plantar fascia is often fragmented and tender, and has been imaged by high resolution dermal ultrasound.³ Lymphatic damage with persistent swelling on dependency can occur. Special footware and shoe inserts can be helpful for symptom control.

Knife and other laceration wounds are often inflicted as part of torture in detention where medical care is often conspicuous by its absence, incompetence, of collusion with authority. Wounds which would ordinarily be sutured in the detainee’s normal life but which are broad and lack suture marks are more likely to have been inflicted where clinical care could not be accessed. Whipping can leave striped scars. Such lesions must (of course) be distinguished from tribal markings.

Post-traumatic hyper-pigmentation occurs most commonly in dark skin after blunt trauma without significant epidermal disruption but in the presence of dermal and subdermal cellular and vascular damage. Resolution is thought to be associated with cytokine signals causing proliferation of melanocytes and secretion of melanin. This appearance can also be allergic in origin.⁴

The age of scars:

It is sometimes important for legal purposes to be able to estimate the time since a particular wound was inflicted. Having discussed the matter with many eminent members of the ETRS and WHS, I have reached the conclusion that it is only possible to distinguish approximately between the various appearances (box 3). Hypertrophic or keloid scarring may also confuse the issue. One should avoid unduly precise formulations (‘This appearance of this scar is consistent with the mature phase, it is probable that it was inflicted six months to one year ago ...')

Box 3: The age of wounds and scars

• Fresh wound: 1-3 days old
• Early healing: 3-10 days
• Later healing: 10-21 days
• Early maturing: 21-42 days
• Intermediate maturing: 42-180 days
• Mature: 180 days-1 year
• Quiescent: > 1 year

The Medical Justice Network (MJ)

MJ is an alliance of clinicians, lawyers, asylum seekers, and researchers. We frequently assist torture survivors, as well as providing other support to asylum seekers and refugees who cannot get help from other sources. We have found that physical evidence of torture is extremely common among asylum seekers detained in the UK’s immigration removal centres. Administrative detention of torture survivors frequently violates government policy and is directly harmful to the victim.

Implications:

Doctors and nurses with expertise in the assessment of wound healing and scarring are well-placed to assist torture survivors, their other clinicians and the courts, by identifying and documenting stigmata of torture.

Like other clinical skills, this requires careful examination of patients, experience, and study.

Support in such work, including reading lists, training, support and a unique opportunity to practice ‘human rights medicine’ in the UK are available through the Medical Justice Network (www.medicaljustice.org.uk).