Anahita Sharma, 1st year, reflects on the Medsin torture series and asks: how can we approach and better understand patients who have experienced torture
One need only carry out a simple exercise in observation to conclude that in living here, we are lucky people. Sit down at any table in Saint Andrews and admire the beautiful freedom to think, learn, express, laugh, and interact that is implicit in our motions. No detectable pause to weigh our access to these rights.
Then, take what we have. Break the bridges between human minds, build barriers of mistrust, steal each other’s sense of autonomy, and you are left with a shell of a society – one based on the rationale used to justify torture.
What is torture?
As is true for many words, its meaning has become blurred through general usage. For instance, we may hear it with reference to a particularly onerous or demanding task – “That was sheer torture!” When I first attended the Medsin (a student network advocating against global health inequity) series on torture, I had no sense of how little I knew or how many assumptions I had been making.
The team began by illustrating to us what torture might look like through a scene from Casino Royale, in which Le Chiffre interrogates James Bond. The latter is stripped, bleeding, bound to a bottomless chair, and hit repeatedly in the genital region with a large, heavy, rope. The setting is a musty room illuminated by a single oil lamp, creating silhouettes of thick chains dangling from the ceiling. Le Chiffre murmurs coldly, “I never understood all these elaborate tortures… it’s the simplest thing to cause more pain than a man can possibly endure”.
The terrifying reality is that this situation is largely stylised, and deals with a glamorous protagonist and distinctly inhuman antagonist. Off the silver screen, torture victims are like us – ordinary, human, fragile, and most poignantly, usually innocent. And although we should take care not to over-victimise them or underestimate their resilience, the implications of torture for an individual resonate far beyond one movie.
Where, and when?
If and when we do hear about torture in our culture, it tends to be in fragmented chunks as opposed to a picture we can really understand. It is crucial to remember that torture has fallen into, and even been advocated by, legal policy and justice systems as an acceptable means to obtain information or administer punishment.
What springs to your mind when you think about torture? Is it electrocution, water boarding, mutilation, or the deprivation of food, water, and sleep? Do you see someone strapped helplessly to a chair, or the burning of suspected witches at the stake?
The Medsin team produced a timeline, from historical worldwide examples to present day case studies. Methods in ancient times included The Chair – a chair covered in nails which people were strapped down to, sometimes with a fire lit underneath – or The Rack – a rack people were stretched over until their limbs were dislocated or even ripped off the axial skeleton.
However, such episodes of torture are by no means confined to the history books. The Abu Ghraib Prison Scandal occurred not even one decade ago, and featured as one of the most extreme and widely publicised cases of torture. It occurred in a correctional facility in Iraq by US military personnel on inmates. As one Medsin member described it, the “depravity of the situation was unreal”: “Male prisoners were humiliated, being forced to masturbate in front of other inmates and assume sexually explicit positions with them. Prisoners were dehumanised and were forced to bark like dogs whilst members of the military police urinated on them. It was found that meals were thrown in toilets before being fed to inmates… The chemical lights were also broken and the phosphoric liquid inside poured on detainees. Wires were attached to the hands, feet and genitals of male detainees and shocks administered.”
Further details are left to the discretion of you, the reader. There are, unfortunately, many examples but the point is its continual relevance.
Torture- can it ever be a necessary evil?
Thus far I have made no attempt to empathise with the ‘torturer’ – a label with negative connotations. The reasons for torturing another individual are multifaceted, complicated, and it would be a grave and unfair mistake to generalise torturers as psychopathic or ‘Le Chiffres’ in their own right.
Consider the “Ticking Time Bomb Problem”, which presents this scenario:
A terrorist group states it has concealed a nuclear bomb in London. The authorities have captured the leader of the group, who says he knows where the bomb is, but refuses to reveal the location. In this scenario, torture is guaranteed to produce the information needed so the authorities can defuse the bomb.
What would you do?
The Romans only gained evidence from slaves under torture, because it was believed that they could not be otherwise trusted. In practice, however, torture is not always effective and there is no scientific basis that it is a reliable way to gain information. Rather, rapport-building techniques have been shown to be more effective. Nevertheless, is its use still acceptable in this scenario?
The utilitarian would view the potential saving of thousands of lives as a consequence that outweighs the destructive impact of torture on an innocent individual. The Kantian (or consequentialist) may identify torture as immoral regardless of situation, as it “dehumanizes people by treating them as pawns to be manipulated through their pain” (Kenneth Roth, Getting Away with Torture, Global Governance 2005).
Undeniably, torture violates the human right not to respond to a question. However, in planting a bomb, has a terrorist, by default, revoked his human rights? Now we enter a slippery slope – how do we standardise when torture methods are used and not used? What forms of violence become acceptable?
We must ask ourselves, what is the long-term impact of torture on survivors and torturers alike? Indeed, it is these long term impacts that alone act as the strongest reasons against employing torture.
Impact of torture on survivors
Roy Farquharsons- a mental health nurse and family psychologist from Freedom from Torture addressed this topic in his talk which was part of the lecture series. Roy Farquharsons works with real torture victims and his visit produced a visible impact, shocking us into silence, because the victims’ experiences simply spoke for themselves. An interesting point he made was that sometimes, physicians could be so eager to help that they altogether forget to actively listen.
Torture victims commonly report a feeling of helplessness. Metin Besoglu – who studies the impacts of mass violence trauma – discusses this feeling as intensified when an individual faces a powerful, faceless enemy such as his or her state or a terror regime. A recent example would include the terrible, systematic and ongoing use of torture by Syrian intelligence agencies against civilians, which includes beatings, sexual assault, and the ripping out of fingernails. [3, 4]
Besoglu et al showed that political activists tend to, as a result, suffer less psychological trauma as a strong belief system helps the individual feel less powerless. In truth, the feeling of not being in control of oneself is one of the prime stressors.
There are numerous physical and psychological post-torture symptoms. A major effect is that torture may result in episodes of retaliatory aggression in order to attenuate the feeling of helplessness from trauma. This point is a key argument against the use of torture under any circumstances- the fact that torture itself plants a seed for new violence .
On a positive note, community studies show that a survivors of torture are better equipped to grow out of the traumatic experience- in terms of resilience and tolerance to adversity compared to those who have not been tortured but live in the same environment .
These findings were contrary to the initial hypotheses. Mollica, having treated thousands of torture survivors, observes that the focus on PTSD makes physicians forget that the most common problem in thispopulation is depression. He also observes that professionals are sometimes hesitant to ask for more information for fear of triggering memories of the traumatic event, i.e. “opening a Pandora’s Box” .
There are many reasons why a patient may not disclose their full history. Victims of sexual violence, perhaps out of shame. Others, because they do not expect their doctors to be interested in their private history. And some because they do not recognise an association between torture and their medical problems.
Being aware of common types of torture mechanisms assists assessment of the organ system which may have been affected. “For example, a common form of torture used in Latin America, falanga, in which the soles of the feet are beaten with rods, may lead to acute swelling and vascular compromise of the feet and legs, aseptic necrosis of the toes, chronic venous incompetence of the legs, and pain on walking.”
What can we do?
Besoglu et al state that “recovery from PTSD appears to require specific interventions designed to enhance sense of control over traumatic stressors”. Behavioural intervention is seen to obtain very positive effects, even if the subjects are still in the environment where they continue to risk being tortured. The improvement in communication is perhaps the most important of these all.
The consensus seems to be that it is important to treat a torture survivor as a whole person. The National Torture Survivors’ Handbook believes the most useful thing a survivor can do is “Restore some kind of more normal life. Rebuilding friendships or forging new ones, making a stable home, and creating structure and purpose through study with or without work, are all beneficial. This may not be easy and may need time and support from others” [8, 9.] This is exactly what is implied by the ‘social determinants’ of health. After all, one would hope that we do not view ourselves as reductionist ‘information processing’ machines that are little more than means to an end. Therefore the devaluation, dehumanisation, and desecration of human life through torture would be a poor reflection of how we view ourselves as a species. In order to offer the best care to torture victims, we must ensure a holistic approach to patient care is utilised. The happy news is there are several organisations actively working to help victims – a field of interest for us as doctors-in-training– and shaming officials into addressing their country’s use of torture. One of the most important things I took from this experience was that the ability to experience and filter the stimuli we are exposed to on a daily basis is a privilege we are extremely lucky to have.
Thank you to the Medsin team: Laura Collins, Kathryn Yang, Elspeth Strang, Gabriel Tse, Alisa Jiwani, Joy Ong, Nikhita Joglekar, Sofiane Kouadria, as well as the speakers from Freedom from Torture and Amnesty International.
1.Spagnoli, Filip. “Statistics on Support for Human Rights.” Web log post. PapBlog Human Rights. WordPress, n.d. Web. Nov. 2012
2. “Rehabilitation.” Freedom from Torture: Medical Foundation for the Care of Victims of Torture. Freedom from Torture, n.d. Web. Nov. 2012.
3.Besoglu, Metin, M.D. Ph.D, Maria Livanou, Ph.D, Cvetana Crnobarić, M.D., Tanja Frančišković, M.D. Ph.D, Enra Suljić, M.D., Dijana Đurić, B. Sc., and Melin Vranešić, M.D. “Psychiatric and Cognitive Effects of War in Former Yugoslavia: Association of Lack of Redress for Trauma and Posttraumatic Stress Reactions.” The Journal of the American Medical Association 294.5 (2005): 580-90. JAMA Network. JAMA. Web. Nov. 2012
4.”‘Government Torture Widespread across Syria'” Telegraph UK. The Telegraph, 3 July 2012. Web. Nov. 2012.
5.Pahmoukaghlian, Veronica. “Horror in the Mind: The Psychological Effects of Torture.” Brain Blogger: Topics from Multidimensional Biopsychosocial Perspectives. Brain Blogger, 4 Aug. 2011. Web. Nov. 2012.
6.Kira, Ibrahim A., Thomas Templin, Linda Lewandowski, David Clifford, Peggy Wiencek, Adnan Hammad, Jamal Mohanesh, and Abu-Muslim Al-haidar. “The Effects of Torture: Two Community Studies.” Journal of Peace Psychology 12.3 (2006): 205-28. Web. Nov. 2012.
7.Mollica, Richard, M.D. “Surviving Torture.” New England Journal of Medicine (2004): n. pag. NEJM.org. New England Journal of Medicine. Web. Nov. 2012.
8.”Torture Survivors’ Handbook: Information on Support and Resources for Torture Survivors in theUK and the Possibilities of Obtaining Reparation.”Redress Organisation: Medical Foundation, n.d.Web. Nov. 2012. <http://www.redress.org/downloads/Handbook_En.pdf>.
9.Kira, Ibrahim Aref, Ph. D. “Torture Assessment andTreatment: The Wraparound Approach.”Traumatology 8.2 (2002): 54-86. Torture Assessment and Treatment: The WraparoundApproach. Sage Journals. Web. Nov. 2012.
10.Poster: Amnesty International [Online] Available at <http://godsaveireland.wordpress.com/category/ politics/> [Accessed 18th January 2013]