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

but only afterwards, when there is pain at the site accidents correspondingly decreases. The expected
or it is pointed out by the examining doctor. number of accidental injuries and their location is
also influenced by the person’s occupational history.
421. It may be that the cause of a particular finding cannot
be described, because individuals could not see clearly 423. Self-injury. Self-injury by cutting may be found in
due to multiple perpetrators around them or being a wide variety of anatomical locations, including
blindfolded or hooded, or because they were partially particularly the volar aspect (palm-side) of the wrist
or completely unconscious at the time, or have other or forearm of the non-dominant upper limb. It is
clinical reasons for impaired memory of the event. In often not the site but the nature and multiplicity that
these cases, the clinician may be able to indicate a level are relevant. The back is generally spared, but the
of consistency between the physical finding(s) and the forearms, upper arms, neck, chest, abdomen and thighs
likely cause of the finding(s). More commonly, with may be other typical sites for self-harm. Other parts
less characteristic findings that have no attribution, a of the body may also be injured in other ways, for
specific assessment of consistency may not be made, example the forehead if the person bangs their head
but general comment may be possible about the size, against the wall or a fist if punching a wall. The most
number and location of the finding(s) in terms of common form of self-harm injury is cutting and cuts
the characteristics of injuries from torture or other are usually superficial, multiple and closely grouped.
causes. There may be findings that are not specifically Self-inflicted burn injury with cigarettes or other
attributed to torture, but to falls while trying to evade heat sources may be found. Victims of torture may
perpetrators, for example. If the person was within the disclose these injuries readily and may explain that
control of the perpetrator at the time, then these still they self-inflicted these injuries in response to their
fall within the definition of torture injuries and should torture, as an expression of the pain of their torture
be assessed for consistency with the attribution given. or a way of coping with that pain. Other victims may
If there are findings attributed to other experiences find it very difficult to disclose self-harming, as it is
of assault, unrelated to the specific allegation of associated with shame and stigma. The most severe
torture under examination, such as domestic violence, self-inflicted injuries can be associated with more
child abuse, female genital mutilation, physical severe mental illness, such as psychosis. Deliberate
punishment, criminal assault or war- and conflict- injury for secondary gain is rare and such injuries tend
related violence, these can be assessed for consistency to be superficial, of a single mechanism of causation,
with the attribution given, where relevant for the legal on accessible body parts and poorly congruent with
procedure for which the medical report is required. the history, examination findings and timeline. Signs
of injuries in unusual locations and a diffuse spread
422. Accidental injuries. Accidental injuries are more of injuries all suggest torture, as does the finding of
commonly found on the extremities compared with multiple modalities of blunt force, sharp force and
the central parts of the body, 425 that is those parts of burn injury. The overall evaluation of all the physical
the body most often exposed rather than protected evidence, together with the psychological evidence,
by clothing and in first contact with a hard surface in the context of the account given is key to the
during a fall. Thus, the knees, shins, iliac crest, elbows, consideration of fabrication (see para. 348 above).
palms, bony spinal protuberance, forehead and crown
of the head are more common sites of accidental
injury. The central parts of the body – ears, cheeks, D. Conclusions and recommendations
eyes, mouth, upper arm, inner forearm, chest, genitals,
front of thigh, inner thigh, back of thigh, buttocks, 424. Clinicians should formulate a clinical opinion on
abdomen, backs of hands, shoulders and neck – are the possibility of torture or ill-treatment based on
more commonly associated with non-accidental all relevant clinical evidence, including physical and
injury. On the face, for example, it is not unusual for psychological findings, 426 historical information,
an individual to have one or two small scars from photographic findings, diagnostic test results,
accidental injuries, but as the number of such lesions knowledge of regional practices of torture, consultation
increases, so the chance of them all being due to reports etc., as stated in paragraphs 382–383

425 Terry Allen, Shannon A. Novak and Lawrence L. Bench, “Patterns of injuries: accident or abuse”, Violence against Women, vol. 13, No. 8 (2007), pp. 802–816.
426 Clinical evaluations that are conducted specifically to assess “physical evidence” may or may not include some “psychological findings”, for example, observations of
psychological distress during the interview and/or a report of psychological symptoms.

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