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

(a) Review of symptoms with the victim’s wishes. The duties of the physician
include obtaining voluntary informed consent for the
460. A thorough history of the alleged sexual torture or examination, recording all medical findings of torture
ill-treatment should be recorded as described earlier or ill-treatment and obtaining samples for forensic
in the present manual (see paras. 394–396 above). examination. Whenever possible, the examination
There are, however, some specific questions that should be performed by an expert in documenting
are relevant only to an allegation of sexual torture. sexual assault. Otherwise, the examining physician
These seek to elicit current symptoms resulting should speak to an expert or consult a standard text on
from a recent assault, for example bleeding, vaginal clinical forensic medicine. When the physician is of a
or anal discharge and location of pain, bruises or different gender from the victim, the victim should be
sores. In cases of sexual assault in the past, questions offered the opportunity of having a chaperone of the
should be directed to ongoing symptoms that same gender in the room. Given the sensitive nature of
resulted from the assault, such as urinary frequency, investigation into sexual assault, it is not appropriate
incontinence or dysuria, irregularity of menstruation, for this person to be a relative of the victim or the
subsequent history of pregnancy, abortion or vaginal interpreter (see para. 219 above). Physicians should
haemorrhage, problems with sexual function, including allow examinations to proceed at a pace dictated by
intercourse and anal pain, bleeding, constipation the alleged victims, minimizing exposure of their body
or incontinence of urine, flatus or faeces, and lower by examining one part at a time if they find this easier
abdominal pain. Patients may describe vomiting, to cope with. Physicians should observe the behaviour
retching and nausea on recall of oral rape. and emotions of the alleged victims and be ready
to stop if they become too distressed. A thorough
461. Ideally, there should be adequate physical and physical examination should be performed, including
technical facilities for appropriate examination of meticulous documentation of all physical findings,
survivors of sexual violation by a team of experienced including size, location and colour and, whenever
psychiatrists, psychologists, gynaecologists and nurses, possible, these findings should be photographed and
who are trained in the treatment of survivors of sexual evidence collected of specimens from the examination.
torture. An additional purpose of the consultation
after sexual assault is to offer support, advice and, 463. The physical examination should not initially be
if appropriate, reassurance. This should cover issues directed at the genital area. Any deformities should
such as sexually transmitted diseases, HIV/AIDS, be noted. Particular attention must be given to
pregnancy, if the victim is a woman, and permanent ensure a thorough examination of the skin, looking
physical damage, because torturers often tell victims for cutaneous lesions that could have resulted from
that they will never normally function sexually an assault. These include bruises, lacerations and
again, which can become a self-fulfilling prophecy. petechiae from sucking or biting. When genital lesions
Examination of anorectal injuries may need to be are minimal, lesions located on other parts of the body
performed under sedation, if symptoms indicate the may be the most significant evidence of an assault,
victim could not cope otherwise. The aim should be to especially, for example, those in forced contact with
do only one examination to minimize retraumatization, the ground, such as back, buttocks or knees. Even
with all necessary expertise and equipment present during examination of the female genitalia immediately
for evidence collection, swabs and treatment. after rape, injury is present in only a minority of
cases. Anal examinations of men and women after
(b) Examination following a recent assault anal rape similarly show injuries in a minority of
cases. In cases in which injury is present, most will
462. It is rare that a victim of rape during torture is released be healed within a few days. In situations in which
while it is still possible to identify acute signs of the relatively large objects have been used to penetrate the
assault. In these cases, there are many issues to be vagina or anus, the likelihood of identifiable damage
aware of that may impede the medical evaluation. increases, but absence of injury is not uncommon.
Recently assaulted victims may be troubled and
confused about seeking medical or legal help due to 464. In situations in which a forensic laboratory is available,
their fears, sociocultural concerns or the destructive the facility should be contacted before the examination
nature of the torture or ill-treatment. In such cases, a to discuss which types of specimen can be tested and,
doctor should explain to the victim all possible medical therefore, which samples should be taken and how.
and judicial options and should act in accordance Many laboratories provide kits to allow physicians to

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