taking care torture victims

A recent review in JAMA, titled “Primary Care Management of Non-English-Speaking Refugees Who Have Experienced Trauma” contains a Table labeled “Physical Torture Techniques (August 7, 2013, Vol 310, Number 5).

Most of us have heard of some of these “techniques,” but when spelled out in a bland table in a medical journal, as it is in this article, it is simply appalling.  These are things that man does to his fellow man.  I think it is instructive to reproduce the list here because we need to know that these things happen to people that we clinicians care for in the everyday practice of medicine.


Physical Torture Techniques

Conditions of Detention:

  • Isolation
  • Containment in a cage
  • Deprivation of food and water
  • Deprivation of sanitary conditions (no toilet)
  • Crowded cells
  • No windows or ventilation

Methods of Physical Torture:

  • Beatings
    • Fists, kicks, canes, sticks, rifle butts
    • Head trauma
    • Falanga (beating to soles of feet)
      • Blunt trauma to soles of feet with batons, canes
      • Acute bruising, swelling, severe pain fractures
      • Chronic pain, neuropathy, deformities
      • Examination:  pain on palpation on ball of foot, heel pad destruction)
  • Burns
    • “Necklacing” – placement of gasoline-filled tire around neck and lighting it on fire [Although all these forms of torture are abhorrent, this one shocked me the most]
    • Cigarette
    • Hot liquids
    • Acid
    • Heated plastic
    • Lighters
    • Heated metal
  • Shaking
  • Dental trauma
  • Suspension (suspended from arms or legs)
  • Administration of electric shocks
  • Cutting wounds from knife, bayonet or other sharp instrument
  • Insertion of pins under nails
  • Simulated drowning- e.g., “waterboarding” or “submarino” (head placed in water that may be contanimated with substances such as feces)
  • Stress positions – forced unnatural positions for prolonged periods of time
  • Sensory deprivation
    • Prolonged isolation
    • Blindfolded
    • Earmuffs
  • Sensory stimulation
    • Temperature extremes (cold or hot)
    • Continuous loud noises
    • Continuous lights
    • Sleep deprivation
  • Sexual trauma
    • Female
      • Rape
      • Instrumentation
      • Female genital mutilation
    • Male
      • Rape
      • Sodomy with instruments
      • Direct genital trauma (blunt trauma, use of instruments such as pliers, weights applied to the scrotum)
      • Mental assaults (forced nakedness)
  • Forced to drink urine or human blood or eat human flesh

Nine academic references were cited as sources of this information – a number of them in a journal named simply “Torture.”


What PCPs need to know about torture

This article focused on primary care physicians taking care of non-English speaking refugees, but ordinary folks from the “civilized world” are also being subjected to these abuses – example:  the kidnapping victims of Ariel Castro.

The JAMA article has another table that is instructive – a list of medical conditions and symptoms related to torture and “ill-treatment.”  It ranges from chronic pain syndromes to sexually transmitted diseases to fractures and amputations.  Interestingly, PTSD and other mental health conditions and symptoms do not appear in this list although we know these sequelae are common.


Unanswered questions

There are many unanswered questions when it comes to the impact of violence on human health:

  • Why do we inflict violence on our fellow human beings?
  • Can we prevent it?  Are there effective methods of violence prevention that physicians and other clinicians ought to be applying?
  • How can we recognize when someone is a victim of violence, in particular, a victim of torture?
  • What are the short and long-term sequelae – both physical and psychological?
  • How can we intervene to help with relief of symptoms related to the torture?

I remember a young Vietnamese refugee I took care of in the Kaiser Permanente SanFrancisco Emergency Department years ago.  He lay rigidly on the gurney avoiding eye contact.  Even with an interpreter, it was difficult to make any sense out of his constellation of symptoms.  It wasn’t until I pulled back the sheet to do an exam and saw he was wearing his army boots that I had an inkling of what he had lived through.

Man’s inhumanity to man – all too common – is incomprehensible to most of us.


  1. In college, I did some research on the Spanish Inquisition and read about some of the medieval torture techniques, such as the rack, drawing and quartering, burning at the stake, etc. It was appalling and upsetting, as are all periods of torture. People have tortured one another since the beginning of time, but the most disturbing thing of all is that it continues. One would think that people would learn from twisted mistakes from the past, but we saw it go forth into the last century during two horrible world wars, and so many other conflicts, and it goes on to this very day. What makes a person so devoid of compassion, care, and humanity that they would ever do such things to other humans, or even to animals? How can they ever think that these things they do are justified? We live in a world that is so advanced in so many ways, from technology to medicine, architecture and design, education, science, the arts… but we can’t seem to wipe out this scourge. Perhaps some of the studies of the brain will begin to reveal something about the depraved or criminal mind that can be reversed or thwarted before it takes hold. If science could do something to change this behavior, think of how different and wonderful our world could be. No more mass shootings. No more serial killers. No more ill treatment by anyone in power, and perhaps no more war. To me, many wars simply boil down to aggressive, greedy, intolerant and cruel people in power who don’t have human empathy. If we could change the brains or DNA of these people, think of the possibilities of a kind and gentle world. With all the good things going on every day by so many people, we are still held hostage by those who would harm others. And of course, our country has to be ready to have a defense against those who would hurt us. But even within our own ranks, we have the rogue soldiers who go beyond the simple defeat of an enemy, which to me is so heartbreaking. I can barely stand to watch or hear the news when sad things occur. It is so disheartening and discouraging, it sometimes makes me wonder…. what is to become of this world? As a Christian, I’m convinced of my faith and my path to Heaven, but with so many lost souls out there, I pray that somehow this world will one day be rid of evil.

  2. Pat,
    These examples are extreme cases of humans cruelity. The opposite of this, KINDNESS, starts every say when we get out of bed. Are your thoughts positive and kind. Do you mindfully treat everyone you meet in a day with kindness and respect – even the most down and out. This all starts at home in our heart. Dealing with the worlds cruelty is too overwhelming for me. I can only deal with the cruelty in my own being.


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