Page 151 - ประมวลสรุปความรู้เกี่ยวกับพิธีสารอิสตันบูลและพิธีสารมินนิโซตา

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

(k) Type IV: all other harmful procedures to the female conditions of detention, where medical care may be
genitalia for non-medical purposes, for example: denied, late sequelae of this lesion may be observed.
pricking, piercing, incising, scraping and cauterization.
477. Individuals who were subject to scrotal torture may
474. A woman should be asked how the procedure suffer from chronic urinary tract infection, erectile
has affected her, and if she has had complications dysfunction or atrophy of the testes. Symptoms of
as a result. Acutely, women and girls can suffer PTSD are not uncommon. In the chronic phase, it
haemorrhage or overwhelming infection. Female may be impossible to distinguish between scrotal
genital mutilation/cutting is associated with long- pathology caused by torture and that caused by
term medical complications, including recurrent other disease processes. Failure to discover any
infections, cysts and abscesses, keloid scar formation physical abnormalities on full urological examination
resulting in pain, damage to the urethra resulting suggests that urinary symptoms, impotence or other
in urinary incontinence, complications of future sexual problems may be explained on psychological
childbirth (including increased risk of haemorrhage grounds. Scars on the skin of the scrotum and penis
and death), sexual dysfunction and psychological may be very difficult to visualize. For this reason,
trauma, including PTSD, anxiety and depression. the absence of scarring at these specific locations
In addition, infants born to women who have does not demonstrate the absence of torture. On
undergone female genital mutilation are more likely the other hand, the presence of scarring usually
to suffer perinatal morbidity and mortality. indicates that substantial trauma was sustained.

(f) Genital examination of males (g) Examination of the anal region

475. Men who have been subjected to torture of the genital 478. Penetration of the anus with an object or an erect
region, including the crushing, wringing or pulling of penis does not always result in injury. Initial pain and
the scrotum or direct trauma to that region, usually bleeding may be observed. Most injuries heal within
complain of pain and sensitivity in the acute period. a few days. Occasionally pain and bleeding can occur
Hyperaemia, marked swelling and ecchymosis can for days or weeks. This may lead to constipation,
be observed. The urine may contain a large number which can be exacerbated by the poor diet in many
of erythrocytes and leucocytes. If a mass is detected, places of detention. Haemorrhoids or a fissure may
it should be determined whether it is a hydrocele or arise secondary to the constipation. Gastrointestinal
haematocele, which could have resulted from torture and urinary symptoms may also occur. In the acute
or an inguinal hernia. In the case of an inguinal hernia, phase, any examination beyond visual inspection
the examiner cannot palpate the spermatic cord may require local or general anaesthesia and should
above the mass. With a hydrocele or a haematocele, be performed by a specialist. In the chronic phase,
normal spermatic cord structures are usually palpable several symptoms may persist and they should be
above the mass. A hydrocele results from excessive investigated. There may be anal scars of unusual
accumulation of fluid within the tunica vaginalis due size or position and these should be documented.
to inflammation of the testis and its appendages or Anal fissures may persist for many years, but it is
to diminished drainage secondary to lymphatic or not possible to differentiate by visual inspection
venous obstruction in the cord or retroperitoneal between those caused by torture and those caused
space. A haematocele is an accumulation of blood by other mechanisms, such as gastrointestinal
within the tunica vaginalis, secondary to trauma. disease. On examination of the anus, the following
Unlike the hydrocele, it does not transilluminate. findings should be looked for and documented:
Peyronie’s disease can arise secondary to trauma to
the penis (e.g. having a drawer slammed shut on it). (a) Fissures tend to be non-specific findings as they can
occur in a number of “normal” situations (constipation
476. Testicular torsion may also result from trauma to the or poor hygiene). However, when seen in an acute
scrotum. With this injury, the testis becomes twisted situation (i.e. within 72 hours), fissures are a more
at its base, obstructing blood flow to the testis. This specific finding and may be consistent with penetration;
causes severe pain and swelling and constitutes a
surgical emergency. Failure to reduce the torsion (b) Rectal tears with or without bleeding may be noted;
immediately will lead to infarction of the testis. Under

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