Blunt traumaBlunt trauma can be divided into three categories: crushing injuries, whipping, and beatings (1-4).
Fingers and genitalia are frequent targets for crushing injuries. Objects commonly used include riffle butts, pliers, heavy rollers, or even the body weight of the perpetrators. Common sequelae of crushing injuries include fractures, dislocations, ankylosis, and deformed limbs.
Classic whip marks are easy to recognize by their appearance—multiple thongs or thin lines. When victims are often flogged with belts, wires, leather ropes, or bamboo canes, however, non-characteristic marks may be present. Whipping usually produces only transient and superficial marks that fade away within days. If permanent marks remain, they can appear as hyperpigmented macula or ill-defined scars.
Beatings are one of the two most common forms of torture, the other being threats (4, 2). Certain forms of beatings have received specific names. For instance "telefono" (the telephone) consists of hitting both ears simultaneously with the palms of the hands. Such trauma may cause hearing loss by rupturing the tympanic membranes. Beating the soles of the feet with a solid object is called "falanga," which has the purpose of disabling the victim and preventing him or her from escaping. The resultant soft tissue swelling frequently may cause a compartmental syndrome serious enough to cause necrosis of the feet. Although perpetrators have their victims wear socks or footwear during "falanga" to prevent lacerations and permanent scarring, these foot coverings do not prevent the compartmental syndrome (1, 5-7).
Beatings may produce a wide range of physical marks. Some marks are transient, such ecchymosis, that resolve within one or two weeks. Others are permanent, including scarring, fractures, or deformed limbs (1,5-7). In general, the long-term external sequelae of beatings do not reflect the severity of a beating. For instance, a beating may cause acute renal failure from rhabdomyolysis, yet leave only small superficial scars or no permanent physical marks.
Crushing InjuryComparative view of index fingers showing a deformity of the distal phalanx of the right finger caused by smashing with the butt of a rifle.
WhippingWhipping of a prisoner with a bamboo cane in Southeast Asia (Courtesy of Physicians for Human Rights
Penetrating InjuriesPenetrating injuries are produced by gunshot wounds, flying shrapnel from explosions, and stabbing—which includes slash and scratch cuts.
Perpetrators typically shoot their victims in the lower limbs to prevent any possible escape (7). Most gunshot wounds cause serious injuries, such as palsy or fractures, and potentially life-threatening conditions like hemorrhages or perforation of a hollow viscera. Death may occur from bleeding or direct damage to a vital organ. Long-term complications include palsy, limb deformity, and organ dysfunction.
Objects used for stabbing include, but are not limited to needles, razor blades, knives, bayonets, and various sharp objects such as glass, scrap metal, and rods. Forms of stab wounds include amputations of earlobes, fingers, and toes, and slash cuts (5). Stabbings may cause pain, bleeding, nerve damage, perforation of a hollow viscera, and infection. Death may occur from bleeding or septicemia from a infected wound or a ruptured hollow viscera. As with beatings, the long-term sequelae of a stab wound do not reflect the severity of the causal insult.
Flying ShrapnelAnterior-posterior and lateral views of the skull showing metallic shrapnel from a projectile.
Stabbing: Slash CutSlash cuts of the interior aspect of the left arm.
SuspensionVictims of torture may be suspended by their wrists or ankles for several hours or even days (4-5,7). Tightening ropes may compromise circulation to hands or feet. Some victims experience permanent neurological damage from nerve compression. Resulting scars from prolonged suspensions are easy to identify: bilateral scars or maculae around the wrists or ankles. Frequently, victims are suspended as high as possible and then released suddenly, causing different forms of blunt trauma such as bruises, fractures, and dislocations.
Perpetrators also suspend their victims transiently from the earlobes, which may cause their avulsion, or the hair, causing traumatic alopecia (4-5,7). Male victims of torture may also endure a form of suspension in which heavy objects are hung from their genitalia.
Certain forms of suspension have received specific names. "La barra" (the rod), is also called the chicken or the wheel of Buddha, consists of tying down the wrists with the ankles while keeping the knees completely flexed. A rod is passed under the knees and in front of the elbows, and then the victim is suspended by lifting the rod (5,7).
"La bandera" (the flag) consists of tying down both wrists on the back of the victim and then suspending the person by the hands. This type of suspension produces intense pain and as soon as muscular fatigue ensues, shoulders dislocate, damaging the brachial plexus.
"The Palestinian suspension" consists of suspending the victim with one hand facing forward and the other one facing backwards. As with "la bandera," this type of suspension produces intense pain and eventually produces shoulder dislocation and brachial plexus injury (7).
Finally, "el quirofano" consists of leaving the upper half of the victim's body suspended in the air, while the victim is laying down and facing up. "El quirofano" produces muscle spraining in the lumbar area (5).
BurnsVictims of torture may endure chemical, thermal, and electric burns. A wide variety of objects are used to inflict this type of injury: cigarettes, hot irons, gas torch, ice, hot liquids like water and oil, electricity from power outlets or stunt guns, acids, and other caustic materials (1-11).
BurnsAnterior aspect of the right foot showing a flash-over burn from a grenade explosion.
AsphyxiationPerpetrators asphyxiate their victims by covering their faces with a plastic bag (dry asphyxiation or dry "submarino"), submerging their faces in fluids (wet asphyxiation or wet "submarino"), and by forcing their victims to inhale chemicals or dust. In general, filthy water, urine, or excrements are used to carry out the wet "submarino" (1-11).
Asphyxiation of a prisoner during human experimentation at the Dachua Concentration during the Holocaust.
Electric ShocksElectric shocks are commonly used in South America and Africa. Sources of electric shocks include power outlets, portable generators, cattle probes, and stunt guns (1-11). Electric probes are often placed on sensitive organs, such as earlobes and genitalia. Long-term physical marks from electric shocks are typically discrete and minor, although some victims may experience a permanent seizure disorder. In contrast, the immediate complications of electric shocks are potentially lethal: tonic-clonic seizures and cardiac arrhythmias.
Forced Human ExperimentationDuring the Nuremberg Trials, physicians were indicted, tried, and convicted for committing crimes against humanity, including forced human experimentation. Although the Nuremberg Code prohibits forced human experimentation, health professionals continue to participate in such activities. Unfortunately, the participation of health professionals in torture goes beyond forced experimentation and includes engaging in torture or in its cover-up by giving false medical certificates (12).
Traumatic Removal of Tissue and AppendagesEarlobes, hair, and nails are often removed traumatically. In addition, an explosive wave may produce avulsion of soft tissues.
Extreme Physical ConditionsVictims of torture recount several different forms of extreme conditions. Many victims have endured detention inside prison cells where a human being only fits squatting, as well as exposure to adverse climatic conditions without shading, water, or appropriate clothing. Others have been forced to remain standing or assume difficult postures for days without rest (1-11).
Sexual TortureSexual torture includes sexual humiliation (e.g. pejorative comments), trauma to genitalia (e.g. suspension of heavy objects from the genitalia, castration, instrumentation), and rape.
The international Crime Tribunals for Rwanda and the former Yugoslavia charged rape as a war crime. Rape is used effectively to terrorize entire communities. In Rwanda and the former Yugoslavia, for instance, women were frequently raped in front of relatives or their communities, leaving them ostracized, repudiated by husbands and other relatives.
Sexual torture produces long-lasting mental and physical sequelae. In rape cases, these include unwanted pregnancy and sexual transmitted diseases.
Mental TortureAlmost all victims of torture suffer some form of mental torture. Direct threats to him/her or to a relative are by far the most common form of torture. Other forms of mental torture include sensory deprivation, poor conditions during detention, mock executions, long interrogations, and being forced to torture another person, witness the torture of another person, or watch killings and rapes. Sensory deprivation includes detention in complete darkness, exposure to bright lights and constant noises, or sleep deprivation. Lack of food, potable water, toilet, bed, windows, aeration, medical care, and communication are examples of poor conditions during detention (1-11).
Mental suffering unique to refugees include enduring battlefield conditions, uprooting, and life in a refugee camp (1-11).
Summary: Most Common Types of Torture(1-11)
1. Shrestha NM and Sharma B. Torture and Torture Victims – A Manual for Medical Professionals. Center for Victims of Torture, Katmandu, Nepal, 1995.
2. Mcivor RJ and Turner SW. Assessment and Treatment Approaches for Survivors of Torture. British J. Psychiatry 1995;166: 705 – 711.
3. Forrest D. The Physical After-Effects of Torture. Forensic Science International 1995; 76: 77 – 84.
4. Petersen HD and Rasmussen OV. Medical Appraisal of Allegations of Torture and the Involvement of Doctors in Torture. Forensic Science International 1992; 53: 97 – 116.
5. Rasmussen OV. Medical Aspects of Torture. Danish Medical Bulletin 1990; 37(Supplement 1): 1 – 88.
6. Goldfeld AE, Mollica RF, Pesavento BH, Stephen VF. The Physical and Psychological Sequelae of Torture – Symptomatology and Diagnosis. JAMA 1988; 259(18): 2725 – 2729).
7. Skylv G. Physical Sequelae of Torture. In: Basoglu M (Ed.). Torture and Its Consequences – Current Treatment Approaches. Cambridge University Press: Cambridge, UK, 1992. p 39 – 53.
8. Sommier F, Vesti P, Kastup M and Genefke IK. Psychosocial Consequences of Torture: Current Knowledge and Evidence. In: Basoglu M (Ed.). Torture and Its Consequences – Current Treatment Approaches. Cambridge University Press: Cambridge, UK, 1992. p 56 – 68.
9. Weinstein HM, Dansky L, and Iacopino V. Torture and War Trauma Survivors in Primary Care Practice. West J Med 1996; 165: 112 – 118.
10. Iacopino V, Ozkalipci O, Schlar C. Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (The Istanbul Protocol). Available at: http://www.phrusa.org/research/torture/index.html
11. American College of Physicians. The Role of the Physician and the Medical Profession in the Prevention of International Torture and in the Treatment of its Survivors. Ann Int Med 1995;122: 607 – 613.
12. Annas GJ and Grodin MA. The Nazi Doctors and the Nuremberg Code - Human Rights and Human Experimentation. Oxford University Press, New York, NY; 1992.