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ISTANBUL PROTOCOL VI. PSYCHOLOGICAL EVIDENCE OF TORTURE AND ILL-TREATMENT

narrative. Survivors may also exhibit impulse control (j) Psychotic symptoms
problems resulting in behaviours that they consider
highly atypical with respect to their pre-trauma 509. Cultural and linguistic differences, as well as flashbacks
personality. For example, a previously cautious and anxieties, may cause misinterpretation of psychotic
individual may engage in high-risk behaviour. symptoms. Before diagnosing someone as psychotic
(suffering from a mental disorder characterized by
(h) Physical complaints (somatic symptoms) a distorted perception or processing of reality), the
symptoms must be evaluated within the individual’s
507. Pain, headaches or other physical complaints, with unique cultural context. Psychotic reactions may
or without objective physical findings, are common be brief or prolonged, and the symptoms may
problems among torture survivors. Pain may be the occur while the person is detained and tortured or
only manifest complaint and may shift in location afterwards. The following findings are possible:
and vary in intensity. Somatic symptoms can be
directly due to the physical consequences of torture (a) Delusions;
or psychological in origin. For example, pain of
all kinds may be a direct physical consequence of (b) Auditory, visual, tactile
torture or of psychological origin. Typical somatic and olfactory hallucinations;
complaints include back pain, musculoskeletal pain
and headaches. Headaches are very common among (c) Bizarre ideation and behaviour;
torture survivors and may be due to torture-inflicted
injury (head and neck injuries are a common part (d) Illusions or perceptual distortions that may take
of torture), as well as being caused or exacerbated the form of pseudo-hallucinations and border on true
by poor sleep patterns, stress and anxiety. psychotic states. False perceptions and hallucinations
that occur on falling asleep or on waking are common
(i) Sexual problems among the general population and do not denote
psychosis. It is not uncommon for torture victims
508. Sexual dysfunction is common among torture to report occasionally hearing screams, their name
survivors, particularly among those who have being called or seeing shadows, but not to have florid
suffered sexual torture or rape, but not exclusively signs or symptoms of psychosis. Additionally, some
(see para. 470 above). Sexual problems include survivors report dissociative symptoms that can be
reduced or absent sexual interest/arousal/desire, mistaken for psychosis, such as feeling that the physical
erectile dysfunction, genito-pelvic pain, painful environment is not real, or that their body is altered or
intercourse, disgust or fear of intimacy and sexual disconnected. Vivid perceptual experiences may occur
involvement, flashbacks and dissociation triggered during a dissociative episode. Hallucinations may also
by sexual intercourse and concerns related to sexual occur in the context of traumatic loss. It is important
orientation, gender identity and fertility. Sexual to enquire about the origin and person’s understanding
violence may also lead to risky, self-destructive or of the symptoms. Many survivors recognize that these
reckless behaviour. Talking about sexual problems is experiences are not what other people are perceiving
often difficult due to feelings of worthlessness, shame them to be and that they are emanating from their
and guilt and additionally hampered by cultural, own mentation. This distinction can help distinguish
religious or gender taboos. If the perpetrator was dissociative from psychotic phenomena in which
male, anxiety from men is a frequent symptom. For individuals believe that others see the distortions in
male survivors, the sense of humiliation after sexual reality as they do. The distinction between a flashback
torture is often particularly deep, and they might also and hallucinations may not be easily drawn during
experience a crisis of sexual identity (i.e. concerns the experience but the dissociated individual can
about being gay after having been raped). They often later recognize that the experience does not represent
experience themselves as being weak, not strong current reality;
enough to defend themselves, rather than as a victim.
For men, it is therefore often extremely difficult to (e) Paranoia and delusions of persecution. As
disclose their experience with sexual violence. persecution, harassment and hostilities may be a reality
for torture survivors, clinicians should take special care
not to confound these real situations with paranoia
and delusions of persecution;

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