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ISTANBUL PROTOCOL V. PHYSICAL EVIDENCE OF TORTURE AND ILL-TREATMENT

examination. Dental care may be purposefully still be documented. Pain may be specific to the torture
withheld to allow caries, gingivitis or tooth abscesses mechanism or non-specific and generalized. Physical
to worsen. A careful dental history should be taken examination should include testing for mobility of
and, if dental records exist, they should be requested. the joints, spine and extremities. Clinicians should
Tooth avulsions, fractured teeth, dislocated fillings note: pain on palpation or with motion, muscle
and broken prostheses may result from direct strength, contracture, evidence of compartment
trauma or electric shock torture. Dental caries and syndrome, fractures with or without deformity and
gingivitis should be noted. Poor quality dentition dislocations. In the case of severe beatings, muscle
may be due to conditions in detention or may have tissue breakdown may lead to myoglobin release into
preceded the detention. The oral cavity must be the blood circulation in large amounts, potentially
carefully examined. During application of an electric leading to acute kidney failure. The urine myoglobin
current, the tongue, gums or lips may be bitten. level may be tested when and if available in severely
Lesions might be produced by forcing objects or beaten survivors during the acute phase. 424 Suspected
materials into the mouth, as well as by applying dislocations, fractures and osteomyelitis should be
electric current. Impact to the face may result in evaluated radiologically. Injuries to tendons, ligaments
patterned abrasions or bruises on the buccal aspect and muscles are best evaluated with MRI, although
of the cheek. The frena may be torn. Radiological arthrography can also be performed. In the acute stage,
techniques should be used to confirm the extent of this can detect haemorrhage and possible muscle tears.
soft tissue, mandibular and dental trauma. Caries Muscles usually heal completely without scarring;
are more likely to develop in broken teeth, possibly thus, later imaging studies will be negative. MRI
leading to the loss of the tooth. Absence of a tooth and CT images of denervated muscles and chronic
may therefore be due to trauma directly or indirectly. compartment syndrome may demonstrate muscle
fibrosis. Bone bruises can be detected by MRI or
3. Chest and abdomen scintigraphy. Bone bruises usually heal without leaving
traces. Vitamin D deficiency due to lack of sunlight
413. Examination of the torso, in addition to noting lesions and poor diet can also be a cause of musculoskeletal
of the skin, should be directed towards detecting pain and responds to replacement therapy.
regions of pain, tenderness or discomfort that would
reflect underlying injuries of the thoracic muscles 5. Genito-urinary system
and skeleton or abdominal organs. The examiner
must consider the possibility of intramuscular, 415. If genital examination is necessary, it must be
retroperitoneal and intra-abdominal haematomas, performed only with the specific consent of the
as well as laceration or rupture of an internal organ. alleged victim and may need to be postponed to
Radiological techniques are required to confirm such a later examination. A chaperone must be offered
injuries. Blood tests and urinalysis may be useful if the examining physician’s gender is different
screens for such injuries. Routine examination of the from that of the patient. For more information,
cardiovascular system, lungs and abdomen should be see paragraph 283 above. See paragraphs 455–479
performed in the usual manner. Pre-existing respiratory below on sexual torture, including rape, and further
disorders are likely to be aggravated in custody and information regarding examination of victims of
new respiratory disorders frequently develop. sexual assault. Ultrasonography, kidney function
tests, urinalysis and dynamic scintigraphy can
4. Musculoskeletal system be used for detecting genito-urinary trauma.

414. Complaints of musculoskeletal aches and pains are 6. Central and peripheral nervous systems
very common in torture survivors. 422 They may be
the result of repeated beatings, suspension, other 416. The neurological examination should evaluate
positional torture or the general physical environment the cranial nerves, sensory organs and peripheral
of detention. 423 They may also be psychosomatic or nervous system, checking for both motor and sensory
somatic (see para. 507 below) in nature, but should neuropathies related to possible trauma, vitamin

422 Emma Baird and others, “Interventions for treating persistent pain in survivors of torture”, Cochrane Database of Systematic Reviews (2017).
423 Duncan Forrest, “Examination for the late physical after effects of torture”, Journal of Clinical Forensic Medicine, vol. 6, No. 1 (1999), pp. 4–13.
424 Michael S. Pollanen, “The pathology of torture”, Forensic Science International, vol. 284 (2018), pp. 85–96.

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