How to care for survivors of torture

All doctors in the United Kingdom can expect to see patientsat some stage in their career who have been tortured .Caroline Jewels, Helen Maguire,Brian Fine, and Carol Cheal discuss how to identify and support survivors of torture

Imagine you are a junior doctor in east London. Your next patient comes in complaining of chronic back pain. You ask more questions about the history of the pain, and he breaks down into tears. He goes on to explain that he is seeking asylum in the United Kingdom. He fled his country, where he had been held captive and tortured for six months. How do you react to this information? What do you say to him? How will you treat his pain? What support will you provide him with? How do you cope yourself?

What is torture?

The World Medical Association defines torture as "the deliberate, systematic, or wanton infliction of physical or mental suffering by one or more persons, acting alone or on the orders of any authority, to force another person to yield information, to make a confession, or for any other reason."¹ The United Nations condemns any medical professional being involved in any form of torture unless their involvement is to evaluate, protect, or improve the detainees' physical and mental health. The British Medical Association's policy is that medical ethics prohibit any involvement by doctors in torture and that doctors in countries where torture does not occur have a responsibility to help colleagues in countries where it does.²

Methods of torture

Torture is often used to get information or a confession, to punish, to take revenge, or to create terror and fear within a population. Some common methods of physical torture include beating, electric shocks, stretching, submersion, suffocation, and burns. Common methods of psychological torture include isolation, threats, humiliation, mock execution, and witnessing the torture of others.³ Sexual threats and sexual assault are often used in the torture of both men and women.

Why do people torture?

Although torture is designed to break the spirit of an individual to get information, in many situations the intention may be to intimidate or humiliate a minority or dissident group or even an entire population.⁴ Sexual violence is a powerful weapon against individuals, families, and communities; motivated by the desire to dominate and degrade, it is a violent rather than a sexual act.

Many people perform acts of torture, and it would be wrong to suggest that they are all socially unbalanced and psychologically disturbed. Their reasons include obedience to higher authority, paranoia and stereotyping (as in anti-Semitism under the Nazi regime), a perceived threat (from the group being tortured), and gaining power.

ANDREW TESTA/REX

Torture worldwide

Amnesty International estimates that torture currently takes place in 132 countries, approximately two thirds of all countries.⁵ Estimates of the proportion of asylum seekers in the United Kingdom who have been tortured, vary from 5% to 30%, depending on the definition of torture used and the country of origin.⁶ In 2002, the Medical Foundation for the Victims of Torture (a registered UK charity that provides medical treatment, practical assistance, counselling, and psychotherapy to survivors of torture) dealt with 3027 clients from 83 different countries, especially Turkey, the Democratic Republic of Congo, Iran, Sri Lanka, and Iraq.⁷

Effects of torture

The effects of torture are often a combination of physical injuries as a result of the inflicted violence and the mental trauma associated with experiencing such acts. Sexual assault and other sexual violation, including electric shocks applied to the genital area, rarely leave any long term physical signs, but the consequences can include unwanted pregnancies and sexually transmitted infections, especially HIV. It may also result in the victim (both men and women) being shunned by their community and family.³

Survivors of torture and organised violence commonly have flashbacks and avoid anything that reminds them of their ordeal. They also have many symptoms including insomnia, weakness, lethargy, headaches, abdominal pain, and neck and back pains, which do not seem to have a physical basis and may last for many years.³

Many torture survivors have had bad experiences of doctors in their home countries. Such doctors may be unsympathetic employees of an oppressive state or even complicit in torture. Therefore, torture survivors are suspicious of healthcare workers, which can be difficult when you are trying to care for them.

Rights to UK health care

All asylum seekers, refugees, and their dependants are entitled to free NHS care from general practitioners and from hospitals. The only current exception to this is when their claim for asylum has been finally rejected and there are no further appeals available to them. In these circumstances, they might not be eligible for hospital treatment, though they are still entitled to free primary care.

In the United Kingdom, asylum seekers can get free prescriptions by obtaining an HC2 certificate. To get this, they have to complete in English a lengthy HC1 form and wait for several weeks for it to be processed.

What can doctors do?

Knowing about torture and its effects on individuals and families is important for doctors working in any branch of medicine. All doctors can expect at some stage in their career to see patients who have been tortured. Although the patient may not be forthcoming with this information, it is important to consider torture as a cause for unusual symptoms in a patient from a different country.

The problems doctors (and all healthcare workers) face in providing care for torture survivors include language barriers, time pressures, lack of understanding of cultural differences, and a lack of expertise.⁸

Doctors should always try to provide interpreters in the patient's first language, preferably not a family member. Also, explaining the healthcare system in the United Kingdom is helpful but often overlooked if the doctor is not aware of their patient's status as refugee. Doctors should always explain the reason for giving a prescription and provide information about side effects as drugs are often a source of distress to survivors of torture

An important part of the care that doctors provide is giving advice on what useful services to contact, for example, English language classes, counselling, and housing agencies. Referrals to a specialist, such as a psychiatrist, chronic pain clinic, genitourinary medicine clinic, or a neurologist may also be important (box 1).

Doctors can be asked to prepare a medical report describing the scars and injuries resulting from torture and the psychological consequences.

A universal awareness of torture will hopefully increase the number of survivors of torture being reported to the government by doctors and so heighten the UK government's awareness of these atrocities and force them to apply pressure within the United Nation's Committee Against Torture to put a stop to these acts of human violation.⁹

How do doctors cope?

Dealing with survivors of torture can make you feel angry, upset, guilty, frustrated, and impotent, and doctors vary in the ways they cope. Some cope by meeting with others working in this area and gain support from this. Others seem to cope by knowing that they have helped the torture survivor in some way, whether by treating a medical condition, giving advice, writing a medicolegal report, or simply providing support.

It is important not to isolate yourself and to recognise that the consultations can be emotionally draining. At the Medical Foundation, many healthcare workers gain support and guidance from each other. It is important not to become overwhelmed by the patient's problems nor to try to solve them all. Patients should be encouraged to use the skills and strengths they bring from their experiences and home country, to build their new life in the United Kingdom (box 2).

Conclusion

There are many ways in which a survivor of torture can present to the medical profession, such as coming for a new patient health check; presenting with psychological problems or chronic pain; having unusual presentations of physical problems, or requesting a medicolegal report. A history of torture may explain the patient's reluctance to be examined or undergo medical procedures. The care of survivors of torture can be highly specialised but all doctors should be prepared for this situation.

1. Treatment and Rehabilitation Center for the Victims of Torture. Mental health and human rights. www.trc-pal.org/mentalh/mentalh.html (accessed 3 Mar 2004).
2. Working Party of British Medical Association. Medicine betrayed: the participation of doctors in human rights abuses. London: Zed, 1998.
3. Forrest D. The physical after-effects of torture: guidelines for the examination of survivors of torture. 2nd ed. Alden, 2000.
4. Burnett A, Peel M. The health of survivors of torture and organised violence. BMJ 2001;322:606-9.
5. Amnesty International. Annual report 2000. London: Amnesty international, 2000. www.web.amnesty.org/web/ar2000web.nsf/ar2000 (accessed 3 Mar 2004).
6. Burnett A. Guidelines for health workers providing care for asylum seekers and refugees. London: Medical Foundation for the Care of Victims of Torture, 2002. www.torturecare.org.uk (accessed 3 Mar 2004).
7. Medical Foundation Annual Review 2002-2003: Pawns in a game: caring for victims of torture: www.torturecare.org.uk/index.htm
8. Burnett, A: Guidelines for health workers providing care for Kosovan refugees: London: Medical Foundation for the Care of Victims of Torture and DoH, 1999
9. UN Committee Against Torture. www.un.org.uk (accessed 3 Mar 2004).